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Exploring erectile dysfunction in gay, bisexual and other men who have sex with men

Thanks to the tremendous power of HIV treatment (antiretroviral therapy; ART), many people taking it will live well into their senior years. As the risk of life-threatening infections related to AIDS decreases for people who successfully use ART, other conditions become more of a concern. One such issue is erectile dysfunction (ED).

A team of researchers in the U.S. and at the University of Toronto analysed data from 625 gay, bisexual and other men who have sex with men (gbMSM), some of whom had HIV. Researchers were able to home in on risk factors for ED. They also were able to formulate recommendations for clinicians caring for gbMSM to help minimize the risk of ED in their patients.

Study details

Researchers analysed health-related information from 625 men who were part of a larger ongoing study in the U.S. called MACS (Multicenter AIDS Cohort Study). Participants were recruited from Baltimore, Los Angeles, Pittsburg and Washington, DC.

The average profile of the men at the time data were collected was as follows:

  • age – 62 years
  • HIV positive – 285 men (46%)
  • HIV negative – 340 men (54%)
  • main ethno-racial groups: White – 61%; Black – 26%; Hispanic – 13%
  • 58% had high blood pressure
  • 14% had diabetes
  • 95% were taking ART and had a suppressed viral load

Information about ED was captured on questionnaires that the men periodically answered.

Results

Statistical analysis found that men with HIV were 41% more likely to have ED than men without HIV.

Among HIV-positive men, factors that were linked to an increased risk for ED were as follows:

  • older age
  • being Hispanic (explained later)
  • having diabetes
  • using antidepressants

Among men without HIV, risk factors for ED were as follows:

  • tobacco smoking (the more years they smoked, the greater the risk)
  • older age

A closer look at some risk factors

Age

Some aging-related factors contribute to an increased risk for ED. One such factor is the gradual decline in testosterone levels. An increased risk for ED also may be connected to the gradual loss of cells in the penis that play a role in maintaining erections.

Diabetes and cardiovascular disease

Diabetes and cardiovascular disease are associated with changes to blood vessels that make them less flexible and reduce blood flow.

Mental health

Depression and anxiety can increase the risk of ED. Sometimes antidepressants can improve ED; however, in some cases antidepressants can also worsen ED.

Smoking

Smoking affects the health of arteries and reduces the flow of blood to organs and the penis.

A note about ethnicity in this study

The present study found a statistical link between being Hispanic and an increased risk of ED. However, the proportion of Hispanic men in the study was low and the link with ED may not be clinically meaningful because Hispanic men in the study may have had a cluster of underlying factors that increased their overall risk for ED. The apparent statistical link between ethnicity and ED may have occurred for reasons that had nothing to do with ethnicity.

What to do

The researchers encouraged healthcare providers to screen their gbMSM patients (regardless of HIV status) for ED. In addition, they encouraged screening for factors linked to ED, such as diabetes, cardiovascular disease, cigarette smoking and so on. This screening could uncover ED and its drivers and could allow clinicians to provide advice tailored to each patient so that these issues can be dealt with.

The researchers also recommended that healthcare providers screen gbMSM for depression and refer patients to receive counselling for help with mood-related issues. They encouraged doctors to prescribe “the lowest effective dose” of antidepressants. When ED appears to be caused by an antidepressant, the researchers encouraged doctors to switch to another class of antidepressant to reduce the risk of ED.

General risk factors for ED

According to the Mayo Clinic, the following general factors, some of which were found in the MACS study, can increase the risk for ED:

  • medical conditions, particularly diabetes or heart conditions
  • tobacco use
  • being overweight
  • certain medical treatments, such as prostate surgery or radiation treatment for cancer
  • injuries, particularly if they damage the nerves or arteries that control erections
  • medications, including antidepressants, antihistamines and treatment for high blood pressure, pain or prostate conditions
  • psychological conditions, such as stress, anxiety or depression
  • drug and alcohol use, especially if you’re a long-term drug user or heavy drinker

These issues should be discussed with a doctor or nurse and advice sought for dealing with them.

—Sean R. Hosein

Resource

Erectile Dysfunction Guidelines — Canadian Urological Association  

REFERENCES:

  1. Mustapha A, Polanka BM, Maini M, et al. Incidence of erectile dysfunction among middle-aged and aging sexual minority men living with or without HIV. Frontiers in Public Health. 2024 Jan 24; 12:1302024. 
  2. Guimaraes EL, Dias DO, Hau WF, et al. Corpora cavernosa fibroblasts mediate penile erection. Science. 2024; in press.