Association between COVID-19 and sexual health: an umbrella review

Abstract

Purpose

We conducted this umbrella review to review the current evidence on the relationship between COVID-19 and sexual health in both men and women.

Methods

We conducted searches in Pubmed, Embase, and the Cochrane dataset for meta-analyses that met our pre-set inclusion criteria. We included studies with detailed information investigating the link between COVID-19 and sexual health in men/women. We did not limit the language.

Results

The results of the included studies frequently relied on the Female Sexual Function Index to assess sexual health in women. For men, the International Index of Male Function and hospital diagnoses were commonly used to assess sexual health. Currently, there is conflicting evidence regarding the impact of COVID-19 on sexual health. However, since most studies were observational in nature, additional study designs are necessary to draw definitive conclusions across different contexts.

Conclusion

Our findings highlight the importance of sexual health among COVID-19 patients and people affected due to COVID-19. Further critical studies should investigate the mechanism underlying the association between COVID-19 and sexual health.

Keywords:

• Covid-19
• sexual health
• umbrella review

Introduction

The first spread of the severe acute respiratory syndrome-related coronavirus type 2 (SARS-CoV-2) occurred in China in late December 2019 [1]. Out of all affected individuals, approximately 14% develop symptoms related to coronavirus Disease 2019 (COVID-19), while 5% experience severe discomfort and require intensive care [2]. Although the main prognostic feature is recovery, some patients continue to experience various symptoms long after the acute infection [3]. This condition has recently been named ‘post-COVID-19 condition’ by the World Health Organization (WHO) [4]. It is characterized by a wide range of persistent or new-onset symptoms, which can be continuous or fluctuating, lasting for more than 2 months after a microbiologically confirmed or suspected SARS-CoV-2 infection, and cannot be explained by an alternative diagnosis.

During the pandemic, many people experienced changes in their lives, such as illness and lower income, which reduced their recreational activities emotionally and physically and affected their frequency of sexual activity [5–8]. Sexual dysfunction refers to a diverse range of conditions which result in notable impairment of individual’s sexual response or their ability to derive pleasure from sexual experiences. These conditions include disorders related to low sexual desire, erectile dysfunction (ED), difficulties with orgasm and ejaculation, and painful experiences during genital-pelvic penetration [9]. This occurrence is widespread among the general population and is linked to various physical and psychological issues [10].

However, the association between sexual activity and COVID-19 remains unclear. Sexual activity can exacerbate SARS-CoV-2 spread [11,12]. As a result of implementing measures to prevent and control the COVID-19 pandemic, individuals may find themselves spending more time at home, which could lead to a higher occurrence of sexual activity. COVID-19, on the other hand, may affect sexual function and lead to decreased libido [13]. In particular, many researchers have found differences in sexual desire between the sexes. For example, a study in the UK showed that men generally had higher levels of sexual desire compared to women, with women experiencing a significant decline in libido during the lockdown period [14]. Similarly, another study discovered that around one-quarter of the participants reported a decrease in libido, with 18% of males and 8% of females reporting an increase [15].

In an era of an aging population and declining fertility, research on COVID-19 and sexual activity is needed to help public health policies and policymakers provide effective plans to improve the quality of sexual activity. With the availability of diverse results, umbrella review is needed to provide a comprehensive evaluation of available information on this specific topic based on systematic reviews and meta-analyses [16]. This umbrella review aimed to explore the link between COVID-19 and sexual function, aiming to summarize the present evidence from published studies on the impact of the COVID-19 on sexual activity and function.

Methods

Search methods and selection of the studies

In order to conduct an umbrella review, it is necessary to establish predetermined goals and inclusion criteria, use a transparent and comprehensive search strategy, evaluate the methodology employed, and summarize the available evidence succinctly. In this umbrella review, we included (1) only meta-analyses that studied the link between COVID-19 and sexual health in both men and women; (2) We did not limit language; (3) We excluded studies that only included lesbian, gay, bisexual, and transgender (LGBT) participants since it was beyond our research topic. To be clear, according to the Population, Intervention, Comparator, Outcome (PICO) rule, the search strategy is listed in Table 1. Several databases were searched to perform a thorough analysis, including PubMed, Cochrane, and Embase, for articles published until March 18, 2023. We conducted an umbrella review that revealed the association between COVID-19 and sexual health in men and women in detailed results. This umbrella review was registered in the International Prospective Register of Systematic Reviews (ID: 411584).

Table 1. Searching strategy till 18 March 2023.*

	Search strategy	PubMed	Embase	Cochrane
#1	‘sexual health’ OR ‘sexual function’ OR ‘sexuality’ OR ‘sexual development’ OR ‘sexual disorders’ OR ‘sexual dysfunction’ OR ‘sexual and gender disorders’ OR ‘sexual behavior’ OR ‘sexual activity’ OR ‘sexual activities’ OR ‘sexual quality of life’ OR ‘desire’ OR ‘anorgasmia’ OR ‘erectile dysfunction’ OR ‘libido’ OR ‘ejaculation’ OR ‘impotence’ OR ‘hypersexuality’ OR ‘sexual impulse control’ OR ‘arousal’ OR ‘vaginismus’ OR ‘orgasm’ OR ‘paraphilia’ OR ‘hyposexuality’ OR ‘priapism’ OR ‘sexual misconduct’ OR ‘sexual deviation’ OR ‘sexual motivation’ OR ‘sexual dissatisfaction’ OR ‘sexual intention’	27,3584	634,335	29,253
#2	‘2019-nCoV’ OR ‘covid-19’ OR ‘SARS-CoV-2’ OR ‘severe acute respiratory syndrome coronavirus 2’ OR ‘severe acute respiratory syndrome coronavirus’ OR ‘coronavirus’ OR ‘COVID’ OR ‘coronavirus’ OR ‘SARS-CoV’ OR ‘MERS-CoV’ OR ‘SARS-CoV-2’ OR ‘COVID-2019’ OR ‘2019 Novel Coronavirus’	35,9076	415,726	15,675
#3	‘meta-analysis’ OR ‘systematic review’	422,958	666,936	15,073
#4	#1 AND #2 AND #3	56	175	25

* Pubmed, Cochrane and Embase database used ‘all field’ as its searching ranges.

Data extraction

The search and screening processes were independently conducted by two authors (W. Y. L. and Z. L. J.). After removing duplicate studies, the two authors started screening according to the eligibility criteria and research purpose. In addition, the analyses included in the evaluation were assessed using the I² statistic, small-study effects, level of comparison, and random-effects summary. Furthermore, they collected data on the author, year, number of participants, patients’ diseases, outcome measurement tools, I² statistics, and study types. Any disagreements were resolved through discussions involving a third senior author (T.H.T).

Methodological quality

We further analyzed the quality of this umbrella review based on the A MeaSurement Tool to Assess

Systematic Reviews (AMSTAR-2) guidelines, which systematically grade evidence-based medical papers [17,18]. However, as a high score may overlook some significant limitations, no overall score was given [19]. The AMSTAR-2 method is considered a reliable and accurate approach for assessing the quality of systematic reviews and meta-analyses that involve both interventional and observational research [20]. In contrast to commonly used tools like risk of bias in non-randomized studies of intervention, AMSTAR-2 assesses the process of selecting study designs for inclusion, reasons for excluding studies, sources of primary study funding, and any conflicts of interest among the reviewers [21]. AMSTAR-2 is often employed in umbrella reviews [22].

Epidemiological credibility

High epidemiological credibility refers to having the strongest available evidence and no indication of significant variation or prejudice [23]. In addition, we characterized the studies included in our analysis as follows [24]:

1. ‘Persuasive’ – statistically significant per the random-effects model with a p-value of < 0.000001, > 1000 cases, low heterogeneity among the selected studies (I² < 50%), 95% CI (excluding the null value), and no evidence of small-study effects or significant bias.

2. ‘Highly recommended’ – statistically significant with a p of < 0.000001, > 1000 cases, with most studies indicating a significant effect.

3. ‘Recommended’ – > 1000 cases and significant effects at a p of < 0.001.

4. ‘Weak evidence’ – nominally significant associations (p < 0.05).

5. ‘Poor evidence’ – obtained from samples with < 1000 cases.

This umbrella review offered a broad perspective to evaluate existing literature and examine convergent and divergent research findings. Clinicians can benefit from umbrella reviews by gaining quick access to a comprehensive overview of a particular topic, facilitating evidence-based practice; therefore, we needed to show the quality of the included studies reasonably. Additionally, we assessed the presence of small-study effects, which is a phenomenon where smaller studies tend to show more significant treatment outcomes compared to larger studies [25]. This phenomenon is commonly resulted due to publication bias, as indicated by an Egger’s test p-value of < 0.10 [22,26]. The random-effects model is an approach in the meta-analysis that accounts for variability that cannot be attributed to chance. Although the fixed-effects model may have less control over factors that may affect outcomes, it typically results in less variability [27]. Nonetheless, the pooled estimates derived from the fixed-effects model were considered more dependable than those obtained from the random-effects model [24].

Results

Study characteristics

After excluding duplicates, meta-analyses were included to check eligibility further, and we finally included nine meta-analyses. The screening process is illustrated in Figure 1. All nine studies were published in 2022. We have presented characteristics of the included studies in Table 2, the average age is above 18 years in all included studies. Three of these studies examined the effects of COVID-19 on male sexual function [28–30], three of them only examined female sexual function [31–33], and the rest of the included studies included both men and women [34–36]. Based on the criteria and characteristics of each study, we classified them into several groups. The study by Zhang et al. [28], Mourikis et al. [34], Hessami et al. [31], and Pérez-López et al. [33] could be classified as ‘recommend’. The remaining five studies were classified as having ‘weak evidence’ [29,30,32,35,36]. In the review, only three studies used Egger’s test to detect the possibility of selection bias; therefore, we could not compare small-study effects.

Figure 1. Preferred reporting items for Systematic reviews and Meta-Analyses (PRISMA) flow chart.

Table 2. Characteristics of included studies.

Type/ Author, Year	Study design	Number of studies	Sample size	Mean age (Standard deviation)(study group)	Diagnosis of COVID-19	Outcome	Summary Effect Size	Largest effect size	Prediction 95% CI	I^2	Number of included participants	Statistical significance	Selection as most compre­-hensive	RCTs included	Prospective studies included	Study quality (AMSTAR rating)
Zhang et al. 2022	Retrospective/ Cross-sectional/ Case-control	8 studies	Study group: 250543; control group: 11907210	>18	ICD-10/ RT-PCR	Erectile dysfunction (ED)	RR: 2.64 (1.01, 6.88)	5.32 (4.54, 6.25)	(0.112, 60.931)	99.1%	COVID-19 patients (250,606) and control group (10,844,200)	p = 0.000	√	0	2	Moderate
Mourikis et al. 2022	Retrospective/ Cross-sectional/ Case-control	38 studies	31,558	>18	ICD-10/ RT-PCR	sexual function/dysfunction, activity, satisfaction	Standard mean difference: 0.76 (0.74,1.50) for females; 0.25 (−0.03,0.52) for males	2.64 (2.33, 3.04); 0.81 (0.47, 1.14)	(−1.644, 3.173); (−1.517, 2.047)	97%/90%	Total (31,911)	No significant/ p < 0.00001		0	0	Low
Hessami et al. 2022	Retrospective/ Cross-sectional	6 studies	1114	28.76 (8.28)	–	female sexual function index (FSFI)/ frequency of intercourse	Weight mean difference: total FSFI: −3.80 (−6.48, −1.12); desire: −0.15 (−0.40, 0.11); arousal: −0.75 (−1.09, −0.41); lubrication: −0.39 (−0.78, 0.01); orgasm: −0.65 (−1.03, −0.27); pain: −0.40 (−0.70, −0.10); satisfaction: −0.65 (−1.03, −0.26)	Total FSFI: −10.00 (−11.11, −8.89); desire: −0.60 (−0.90, −0.30); arousal: −1.20 (−1.50, −0.90); lubrication: −0.90 (−1.06, −0.74); orgasm: −1.45 (−1.77, −1.13); pain: −0.56 (−2.21, 1.09); satisfaction: −1.70 (−2.10, −1.30)	Total FSFI: (−1.644, 3.173); desire: (−1.517, 2.047); arousal: (−2.055, 0.582); lubrication: (−1.467, 0.684); orgasm: (−2.055, 0.759); pain: (−1.213, 0.404); satisfaction: (−2.174, 0.88)	96%	1114 female participants	Total FSFI: p < 0.00001; desire:p = 0.002;arousal : p < 0.0001; lubrication: p < 0.00001; orgasm: p < 0.00001; pain: p = 0.0009; satisfaction: p < 0.00001	√	0	3	Low
Masoudi et al. 2022	Retrospective/ Cross-sectional	21 studies	12,502	>18	ICD-10	FSFI and the ‘International Index of Erectile Function-5 items’ (IIEF-5)	Weight mean difference: −4.26 (−7.26, −1.25) for females; −0.66 (−0.99, −0.33) for males	(−16.528, 8.066); (−2.803, 1.485)	−10.00 (−11.11, −8.89); −1.13 (−1.91, −0.35)	–	2454 women and 3765 men.	p = 0.022/ p < 0.001/ p < 0.001/ p < 0.001		0	0	Low
Dashti et al. 2022	Retrospective/ Cross-sectional/	5 studies	217	27.59 (6.50)	–	FSFI	Weight mean difference: arousal: −0.58 (–1.29,0.13); desire: −0.04(–0.43, 0.35); desire: −0.04 (–0.43, 0.35); lubrication: −0.25 (–0.68, 0.18); Orgasm: −0.52 (–1.16, 0.11); satisfaction: −0.56 (–1.17, 0.04); pain: −0.24 (−0.72, 0.24); total: −3.20 (–7.23, 0.84)	Arousal: −1.20 (−1.41, −0.99); desire: −0.60 (−0.81, −0.39); lubrication: −0.25 (−0.68, 0.18); orgasm: −1.45 (−1.68, −1.22); satisfaction: −1.70 (−1.97, −1.43); pain: 0.70 (0.39, 1.01); total outcome: −10.00 (−10.80, −9.20)	(−3.333, 2.153); (−1.477, 1.366); (−1.897, 1.373); (−2.954, 1.886); (−2.883, 1.757); (−1.98, 1.476); (−19.046, 12.588)	91%/97%/91%/96%/96%/99%	1,233 participants	p = 0.27/ p = 0.2690/ p = 0.0486/ p = 0.2994/ p = 0.8716/ p = 0.0327/ p = 0.5319	√	0	1	Low
Klepinowski et al. 2022	Cohort/ case control	24 studies	Study group: 947; control group: 642	Study group: 35.6; control group: 34.1	RT-PCR	Sperm quality	sperm volume: −0.48(− 0.59, −0.36); sperm concentration: −16.23 (–25.56, −6.89); total sperm in ejaculate: −34.84(− 43.51, −26.17); progressive motility: −4.07 (−8.21, 0.08)	sperm volume: −0.60(− 0.75, −0.45); sperm concentration: −46.4 (–55.28, −37.52); total sperm in ejaculate: −64.00(− 108.93, −19.07); progressive motility: −13.3 (−24.81, −1.79)	sperm volume: convergence not achieved during tau2 estimation; sperm concentration: (−50.092, 15.931); total sperm in ejaculate :(−53.752, −18.458); progressive motility: (−10.114, −0.588)	14%/78%/87.1%	1589 subjects (947 in exposed arm and 642 in unexposed arm	p = 0.71/ p = 0.01/ p < 0.01/ p = 0.43/ p < 0.01	√	0	10	Low
Delcea et al. 2021	Quantitative	7 studies	6929	>18	–	Sexual activities	OR: 0.227 (0.097, 0.796)	2.739 (1.398, 5.368)	(0.001, 66.237)	98%	6,929 participants	p = 0.017		0	0	Low
Pérez-López et al. 2022	–	9 studies	1002	28.11 (8.21)	–	FSFI	FSFI score: −1.16 (−1.97, −0.35); arousal: −0.80 (−1.13, −0.48); orgasm: −0.66 (−1.07, −0.25); satisfaction: −0.59 (−0.97, −0.22); pain: −0.35 (−0.54, −0.16); desire: −0.18 (−0.48, 0.12); lubrication: −0.28 (−0.57, 0.01)	FSFI score: −2.64 (−3.04, −2.23); arousal: −1.19 (−1.51, −0.87); orgasm: −1.62 (−2.04, −1.20); satisfaction: −1.25 (−1.57, −0.93); pain: −0.48 (−0.58, −0.38); desire: −0.59 (−0.89, 0.29); lubrication: −0.57 (−0.67, −0.46)	FSFI score: (−6.126, 3.978); arousal: (−2.539, 0.921); orgasm: (−3.542, 2.19); satisfaction: (−2.631, 1.439); pain: (−1.077, 0.382); desire: (−1.941, 1.604); desire: −0.18 (−0.48, 0.12); lubrication: (−1.514, 0.946)	58% to 97%	1002 sexually active non-pregnant women	p = 0.005/ p < 0.00001/ p < 0.002/ p = 0.002/ p < 0.00004/ p = 0.06		0	0	Low
Pizzol et al. 2022	–	52 studies	1908	>18	–	ED	63.6% (20.3, 92.3%) for healthcare workers; 31.9% (19.5, 47.6%) for non- healthcare workers	Prevalence of ED in health care workers:82.4% (75.7%, 87.8%); non-healthcare workers: 50.0% (43.1%, 56.9%)	NA; (0, 91.7%)	97.75%/96.69%	a total of 1908 males, 1653 nonhealthcare workers	p = 0.569/ p = 0.024		0	0	Low

Note. FSFI: Female Sexual Function Index; ED: erectile dysfunction; ICD: International Statistical Classification of Diseases; COVID: coronavirus disease.

Outcome analysis

Zhang et al. included eight studies and found that COVID-19 was associated with a higher risk of ED [28]. Mourikis et al. included 11 studies and found that COVID-19 had an impact on female sexual function; in contrast, no significant effect was observed among males [34]. Hessami et al. also found a significant decrease in sexual function among females [31]. Masoudi et al. found that COVID-19-related restrictions were associated with lower sexual activity and decreased sexual functions [35]. Dashti et al. included five studies and found that female sexual function did not change significantly before and after the COVID-19 pandemic [32]. Klepinowski et al. observed significantly lower sperm volume, sperm concentration, and total sperm in male ejaculation [29]. Delcea et al. observed a significant reduction in sexual activity due to COVID-19 [36]. Perez-Lopez et al. concluded that there was a significant reduction in sexual function in females owing to COVID-19 [33]. Pizzol et al. found that the prevalence of ED was higher in healthcare workers than in non-healthcare workers [30].

Outcome measurement

The outcome measurements varied among the included meta-analyses. Zhang et al. measured ED using the International Coding of Diseases (ICD-10) and International Index of Erectile Function (IIEF-5) [28]. In a study by Mourikis et al. the Female Sexual Function Index (FSFI), IIEF-5, and structured questionnaires were used to quantify outcome diagnoses [34]. In the studies by Hessami et al. [31], Dashti et al. [32] and Pérez-López et al. [33], the total FSFI score with subtypes including desire, arousal, lubrication, orgasm, pain, and satisfaction was used to measure changes in sexual function. Masoudi et al. used the FSFI and IIEF-5 to study sexual function changes in females and males [35]. Klepinowski et al. used medical analyses to measure sperm quality and sexual function [29]. Delcea et al. mainly used questionnaires to measure changes in sexual behavior and sexual function [36]. Pizzol et al. did not specify how they measured the ED among healthcare workers [30]. Despite using various instruments, most of the included studies provided detailed descriptions of the measurement tools.

Publication bias

Zhang et al. used Begg’s (p = 0.71) and Egger’s (p = 0.006) tests to measure publication bias, which indicated the existence of publication bias, and they excluded five studies using the trim-fill method, after which the results did not change much [28]. Mourikis et al. used funnel plots to visualize publication bias, and asymmetry indicated the possibility of publication bias [34]. Hessami et al. revealed no significant publication bias based on Egger’s test (p = 0.722) or Begg’s test (p = 0.851) [31]. Masoudi et al. [35], Pérez-López et al. [33], Pizzol et al. [30] did not assess publication bias because the number of studies included was < 10. Dashti et al. observed publication bias when examining lubrication and pain; however, they did not detect publication bias in desire, arousal, orgasm, satisfaction, or total score.[32] Klepinowski et al. did not assess the publication bias in their analysis [29]. Delcea et al. did not observe a significant publication bias based on funnel plots or the results of the trim-and-fill analysis [36].

Residual confounding

Since all the meta-analyses included only observational studies, confounding and reverse causality were possible, and we could not conclude a causal relationship between COVID-19 and sexual function changes. Due to confounding and selection biases, we admit that the estimations of COVID-19 and sexual function may be biased.

Discussion

The studies included in the present review generally found that COVID-19 was significantly associated with sexual function in females; in contrast, the conclusions of the studies on relevant indicators of sexual function (including sperm volume, sperm concentration, and total sperm) in males were inconsistent. Therefore, it was important to explore the associations between these obscure results. This review summarizes the literature on COVID-19 and its impact on sexual function and provides evidence for treating sexual dysfunction.

Physiological effect

COVID-19 can cause respiratory diseases, such as coughing, difficulty in breathing, and hypoxemia [37,38]. A meta-analysis summarizing lung involvement in discharged patients with COVID-19 found a prevalence of lung function impairment > 40% 3 months after discharge [39]. A possible mechanism is the inflammatory response induced by COVID-19, specifically an increase in interleukin 6 [40]. Internal dysfunction of the pulmonary circulation capillaries may also induce lung injury, leading to ground-glass shadows and pulmonary fibrosis [39]. Low oxygen saturation caused by pulmonary fibrosis may also affect sexual health [41]. Nitric oxide, which allows proper erectile function, may have a negative effect due to insufficient oxygen intake [42]. Additionally, lack of oxygen intake may cause the patient to become less mentally active and have less energy to engage in sexual activity with a partner.

A study involving more than 80,000 individuals showed that COVID-19 is an independent risk factor for cardiovascular health [43]. Viruses can invade angiotensin-converting enzyme 2 and transmembrane serine protease 2 expressed by endothelial cells, leading to diffuse endodermatitis and affecting cardiovascular microcirculatory function [44–47]. Studies have shown that COVID-19 can cause acute vascular events and pulmonary embolisms [48,49]. SARS-CoV-2 may also cause other diseases through poor immune responses, such as abnormal coagulation function, viral myocarditis, and myocardial ischemia [50–52]. These affect motor function in young people, resulting in arrhythmias and postural tachycardia syndromes due to autonomic nervous system involvement, particularly common in young people [53–55]. These cardiovascular effects can affect sexual health [56]. These effects are independent of anxiety and depression as risk factors for sexual dysfunction [57,58]. Sex is a mild form of physical exercise, and myocarditis and arrhythmias can make intercourse uncomfortable and dangerous [59]. As a result, sweating and shortness of breath will likely occur during sex [60,61]. The clinical drugs used by patients with COVID-19, such as-β-blockers and diuretics, may cause temporary abnormal effects on sexual function [62,63].

COVID-19 may also be damaging to the endocrine system. ACE2, which viruses attack, is highly expressed in the hypothalamus, pituitary, thyroid, and testicular interstitial cells [64–66]. When ACE2 expression is impaired in hypothalamic, pituitary, and thyroid cells, thyroid dysfunction may occur, affecting sexual intercourse [67]. Some studies have reported examples of thyrotoxicosis following SARS-CoV-2 [68–70]. Impaired pituitary function may result in secondary endothelial dysfunction, clotting disorders, and increased blood flow due to underlying inflammation [71]. COVID-19 can also cause type 1 diabetes in susceptible individuals [72]. The accelerated development of type 2 diabetes may occur after an autoimmune response to beta cells, pancreatic inflammation, islet remodeling, and progressive beta cell dysfunction [73]. Testicular damage can lead to hypogonadism, affecting the immune and reproductive health and impairing male fertility [74–76]. An endocrine imbalance is a risk factor for sexual dysfunction [77–80]. Studies have shown that reduced testosterone levels in patients with COVID-19 may lead to hypogonadism and decreased sexual responsiveness [75,76,81]. Diabetes is also an independent risk factor for sexual dysfunction as it affects cardiovascular function and can lead to weight gain [82]. Decreased physical fitness may lead to other diseases, such as depression and insulin resistance, leading to decreased gonadotropin function [83].

Psychological effect

Several different outcomes may have resulted from prolonged isolation. First, isolation inevitably decreases the frequency of intercourse among non-cohabiting couples [84]. However, no clear evidence exists that long-term isolation directly affects sexual health, primarily through depression and anxiety. According to statistics, the prevalence of depression and post-traumatic stress disorder within 3 months after COVID-19 discharge is not low, both of which are > 15% [85,86]. Therefore, it is considered a possible risk factor for sexual dysfunction [87–89]. Second, the anxiety experienced by cohabiting couples who lose their jobs or spend too much time at home due to isolation may lead to less sexual communication between partners. Third, couples in good economic conditions can enjoy a cohabiting life without working for a long time; however, there is no study in the literature to prove this. In addition, studies have shown that cognitive deficits and sleep disturbances caused by COVID-19 lead to chronic fatigue, which may be associated with decreased sexual function [90–92].

Focusing on people who have COVID-19 or have recovered from COVID-19 may help reduce anxiety, thereby reducing its impact on sexual function. A Chinese study comparing patients with COVID-19 with healthy individuals found that the prevalence of ED in males was significantly higher at the first follow-up; however, it improved over time [93]. Other studies have found that COVID-19 may cause a loss of smell and taste, which could negatively affect sexual behavior because sensory sensations are very important during sex [37,38,94,95].

Gender gaps

Our study found that females had worse sexual satisfaction and functioning than males. For young females, sexual dysfunction may be less common; however, more likely to be the result of anxiety. Females are more likely to be anxious about important issues than males. Chronic stress associated with the COVID-19 pandemic can negatively affect females’ sex life [96]. In addition, studies have shown that persistent dyspnea caused by COVID-19 is more common in females, leading to a marked decline in sexual activity among females [97]. Studies have shown that male sex is a risk factor for sexual dysfunction at the pandemic’s beginning [98]. However, during a prolonged pandemic, all family members are at home due to restrictions and lockdowns, which increases the burden on females in their families and working lives. This might have had a wider impact on their sex lives [99]. In addition, studies have shown that the incidence of sexual partner violence against females during the COVID-19 pandemic was 26.6%, with psychological violence accounting for the highest proportion (13.3%), followed by physical violence (8.3%) and sexual violence (5.3%) [100].This indicates that females are a more vulnerable group in intimate relationships, contributing to low sexual satisfaction in females [101].

Strengths and limitations

This study aimed to investigate the impact of COVID-19 on sexual function systematically. Most included studies used objective tools to measure COVID-19 and sexual function with reliable results and high clinical value in real-world scenarios. Given that COVID-19 is the largest global pandemic in recent years, we believe this study is of great public interest.

Nevertheless, there were some limitations in this study. Firstly, due to the varying results and effect sizes in the studies included, it was not possible to calculate pooled results. Secondly, most of the included studies were retrospective and observational studies could not conclude causality. Thus, it is necessary to conduct other study designs to assess the causal effects of COVID-19 on sexual function. Thirdly, statistical heterogeneity was present due to differences in measurement tools, sample sizes, and other factors related to sexual dysfunction. Therefore, caution should be exercised when interpreting the results. Fourthly, future research should focus on summarizing the mechanisms through which COVID-19 impacts sexual health. Additionally, while our study only explored the link between COVID-19 and sexual function, we acknowledge that other conditions, such as reproductive ability, may also be associated with sexual function. Lastly, there was a lack of high-quality meta-analyses examining the relationship between COVID-19 and sexual dysfunction. Thus, it is crucial to conduct further high-quality meta-analyses that encompass all factors influencing sexual function, including sexual organ health.

Conclusion

This review provided an in-depth examination of the impact of COVID-19 on sexual function, expanding the clinical scope of this disease. This study also provided insight into the exact mechanisms of COVID-19 on sexual function and psychosexual disorders, understanding the natural history of the disease, developing the best methods for timely treatment, and minimizing the harmful effects of COVID-19 on sexual life. Regular follow-up visits with patients or recovered patients are strongly recommended to screen them for their physical and mental health and provide psychological support to help heal their mood changes and enhance their sexual capacity.

Author contributions

W-YL, ZL-J, C-CW and T-HT conducted the study and drafted the manuscript. W-YL and ZL-J participated in the design of the study and performed data synthesis. C-CW and T-HT conceived the study and participated in its design and coordination. All of the authors read and approved the final manuscript.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This study was partly supported by National Natural Science Foundation of China [ID: 72374157].