Why is COVID-19 more common in men?
January 9, 2021
Men are more likely to contract COVID-19 and be admitted to hospital. Compared to women, they are 40 % more likely to die from the disease.
Professor Mike Kirby, a specialist in urology and men’s health explains the reasons why – and points out that testosterone plays a key part.
As the COVID-19 pandemic spreads across the globe, the UK has been hit particularly hard. This difference in the number of men dying compared to women has been referred to as the ‘lethal gap’ by some.
The scale of the problem
- The death toll in August 2021 stood at 130,701 across Great Britain. Two-thirds were men.1
- Rates in patients younger than 85 are 50.6 per 100,000 for men. This compares to 25.5 per 100,000 for women.
- When considering broad groups of occupations, men who worked in elementary occupations (those involving simple, routine tasks which mainly requiring the use of hand-held tools and often some physical effort or caring, leisure and other service occupations) had the highest rates of death involving COVID-19.
- These shocking stats seem to be repeating a similar pattern from the SARS virus outbreak. Men had a higher case fatality rate of 21.9 % as compared to 13.2 % for females, and twice as many male-to-female deaths in the zero to 44-year age range. 4
- A large-scale global statistical analysis showed that whilst males and females are at equivalent risk of infection, men develop more severe disease. As a result, they are nearly three times more likely to end up in intensive care – and they are 40 % more likely to die.
Men are more like to already have underlying health risks
The following conditions have all been shown to increase the risk from COVID-19 – and they are more common in men:
- Type-2 diabetes
- Chronic kidney disease
- Heart failure
- Respiratory disease.
The role of testosterone
The fact that COVID-19 is associated with a fall in testosterone levels may increase the risk of dying.5
Low levels of testosterone is also associated with several age-related conditions, notably:
- Type 2 diabetes
- Coronary heart disease
- Heart failure
- Kidney disease
- Lung disease
- Long-term pain killers (codeine etc).
Men who contract COVID-19 with low testosterone are more vulnerable to the effects of the disease.
The problems with low testosterone:
- Association with an increased risk of dying prematurely.
- As there’s such differences in COVID-19 outcomes between men and women, and evidence points to testosterone as very important.
Why are men hit harder?
- There may be less virus entry into female cells because two X chromosomes protect them. Men only have the one. (Men XY, women XX).
- The virus gets into the testes but does not infect the ovaries in women.
- Female patients may be able to clear the virus significantly earlier than males, because the testes may be a reservoir.
Can COVID-19 affect future fertility?
Once again, we can compare to the earlier SARS virus outbreak. It was linked to infection of the testes and the prostate, inflammation of the testes, infertility and testicular tumours.
Because of the potential link between the virus and the health of the testes, there may be a long-term impact on fertility. The virus could also be transmissible in semen. Experts recommend that you should use precautions like condoms during intimacy until further research clarifies an answer.
If fertility is an issue, performing a sperm count could be a good idea
Treatment options for men could include medication for erectile dysfunction
The COVID-19 virus induces inflammation of the blood vessels in multiple organs. So, it makes sense that drugs that improve the health of arteries – like statins, blood pressure treatments and drugs like Viagra – could help men infected with COVID-19.
It’s worth noting that many of the vulnerable patients will already be on these drugs because of their previous medical problems. We know a combination of testosterone and drugs like Viagra are usually very effective in restoring erections in men with low testosterone who have not responded to Viagra alone.
Viagra-like drugs have a protective effect on the heart and blood vessels and other organs. If testosterone is low, replacing it reduces the risk of heart problems.7
It may be that a combination of Viagra and testosterone could help a significant COVID-19 infection.
The bottom line: Check testosterone levels
- The virus is associated with very low testosterone, which often occurs in addition to pre-existing low testosterone related to other chronic conditions.
- Multiple studies suggest that men admitted with COVID‐19 have significantly lower testosterone levels than with other acute hospital admissions.
- We should check testosterone levels in men affected by COVID-19. This is due to the known negative impact of low levels of testosterone on the circulatory system and heart failure.
- Men with low testosterone may be at high risk if they are infected, as testosterone reduces inflammation of the blood vessels.9
- In non-COVID-19 patients who have been treated with testosterone replacement therapy to restore levels, evidence shows a significant reduction in hospital admissions and death.
- Diabetes treatment involving testosterone may have a role in men who develop low testosterone with COVID-19 infection. It may also in those who develop Long Covid. 10
We’re missing a trick by not measuring testosterone. There’s now an opportunity for an intense testosterone treatment to boost men’s resistance to the acute inflammation associated with COVID‐19 infection.
There’s a pre-existing population of men with chronic medical conditions causing low testosterone. They may have survived the current pandemic but continue to be at considerable risk from a subsequent wave of infection, or future viral pandemics.
Current medical guidelines already recommend screening, diagnosing, and treating men with low testosterone in high-risk groups. These include those with diabetes who are overweight and men with erection problems.
Two recent reviews highlighted the cardiovascular and prostate safety of testosterone replacement therapy, together with a recent study demonstrating the safety in COVID-19 patients.11 Using steroids has also been very beneficial in seriously ill patients.12
Using drugs that improve the health of blood vessels and the heart, such as statins, blood pressure treatments, drugs like Viagra and Cialis and inappropriate patients anticoagulants could also be very important.
Prevention of COVID-19 is best
- Avoid exposing yourself to the virus (especially indoors)
- Stay fit and active
- And work hard on weight control.
If you think you may have low testosterone due to a medical condition or your symptoms e.g.:
- Low sexual desire
- Erection problems
- Muscle weakness
- Depression etc.
Check it out!
Coronavirus Disease Statistics. Available here.
Márquez EJ, Trowbridge J, Kuchel GA et al. The lethal sex gap: COVID-19. Immun Ageing. 2020;17(1):13.
Peckham, H, de Gruijter, NM, Raine C et al. Male sex identified by global COVID-19 meta-analysis as a risk factor for death and ITU admission. Nat Commun 11, 6317 (2020).
Ahmadzadeh J, Mobaraki K, Mousavi SJ et al. The risk factors associated with MERS-CoV patient fatality: A global survey. Diagn Microbiol Infect Dis. 2020;96(3):114876.
Schroeder M, Tuku B, Jarczak D. The majority of male patients with COVID-19 present low testosterone levels on admission to Intensive Care in Hamburg, Germany: a retrospective cohort study. medRxiv 2020. doi.org/10.1101/2020.05. 07.20073817.t
Wei X, Xiao Y-T, Wang J et al. Sex Differences in Severity and Mortality Among Patients With COVID-19: Evidence from Pooled Literature Analysis and Insights from Integrated Bioinformatic Analysis. arXiv (Preprint). 2020;
Aversa A, Duca Y, Condorelli RA et al Androgen Deficiency and Phosphodiesterase Type 5 Expression Changes in Aging Male: Therapeutic implications. Frontiers in Endocrinology published: 11 April 2019 doi: 10.3389/fendo.2019.00225
Shastri A, Wheat J, Agrawal S et al. Delayed clearance of SARS-CoV2 in male compared to female patients: High ACE2 expression in testes suggests the possible existence of gender-specific viral reservoirs. medRxiv (Preprint). 2020; 1–13.
Mohamad NV, Wong SK, Wan Hasan WN et al. The relationship between circulating testosterone and inflammatory cytokines in men. Vol. 22, Aging Male. Taylor and Francis Ltd; 2019. p. 129–40.
Yassin A. Haider A, Haider K, et al. Testosterone Therapy in Men With Hypogonadism Prevents Progression From Prediabetes to Type 2 Diabetes: Eight-Year Data From a Registry Study. Diabetes Care 2019;42(6):1104-11. doi. org/10.2337/dc18-2388.
Rambhatla A, Bronkema CJ, Corsi N et al. COVID-19 Infection in Men on Testosterone Replacement Therapy. J Sex Med 2021;18:215-218.
Lamontagne F, Agoritsas T, Macdonald H et al. A living WHO guideline on drugs for covid‐19. BMJ 2020;370. 10.1136/bmj.m3379.