Abstract
Introduction: Cannabis is the most commonly used drug in the United States; however, the effects of cannabis use on male sexual function are poorly understood.
Aim: To characterize the contemporary landscape of cannabis use and to assess the associations between male sexual function and the frequency of use, the primary method of consumption, or cannabis chemovar (tetrahydrocannabinol or cannabidiol) among current users.
Methods: We surveyed adults who visited a single cannabis dispensary for baseline demographic information, medical history, cannabis use habits, and sexual function as assessed by the International Index of Erectile Function (IIEF). An IIEF-5 < 21 was considered erectile dysfunction.
Main Outcome Measures: The main outcome measure of the study was male sexual function via the IIEF domain scores.
Results: A total of 325 men completed the survey with a mean age of 46.7 years. 71.1% of the men were Caucasian and 52.6% were married. 13 men (4%) were never users; 29 men (8.9%) used 1–2 times/week; 51 men (15.7%) used 3–5 times/week, and 232 men (71.4%) used 6+ times/week. The average IIEF-5 score was 22.3 with 19.4% of the men having erectile dysfunction. In univariate analysis, men using cannabis more frequently had a higher overall IIEF (65.36 vs 60.52, P = .001), erectile domain (27.32 vs 25.74, P = .03), orgasm domain (9.08 vs 8.12, P < .001), intercourse satisfaction domain (12.42 vs 11.31, P = .006), and overall satisfaction domain (8.11 vs 7.05, P = .002). In multivariable analysis, compared to men who used cannabis 0 times/week, those who used 6 times/week had an increased overall IIEF (69.08 vs 64.64, P-value adjusted = 0.02), intercourse satisfaction domain (P-value adjusted = 0.04), and overall satisfaction domain (P-value adjusted = 0.02). The primary method of consumption (eg, smoking, edibles, etc.) and cannabinoid composition (eg, cannabidiol vs tetrahydrocannabinol dominant) were not associated with sexual function.
Conclusion: We report an association between the increased frequency of cannabis use and increased male sexual function. However, while the increased frequency of use was statistically significant with regard to the IIEF scores, the clinical significance of this is likely low, and selection bias may limit the generalizability of these findings. The method of consumption and cannabis chemovar were not associated with sexual function.
Key Words: CannabisOrgasmErectile dysfunctionSHIM
Discussion
In this study of over 300 men, we report, for the first time, evidence of a frequency-response relationship between cannabis use and sexual function, with increasing use associated with an increased overall IIEF score, intercourse satisfaction domain, and overall satisfaction domain. Similarly, more frequent cannabis use is associated with lower odds of ED. Importantly, the primary method of consumption, cannabis chemovar, and indication for use are not associated with sexual function.
While others have examined the association between male sexual function and cannabis use, most studies have not used validated measures of erectile function. Despite this, our findings of increased intercourse satisfaction domain and overall satisfaction domain with increased cannabis use are consistent with subjective reports of increased sexual satisfaction, sensitivity, and orgasm strength among most cannabis users reported by some studies.9,15 The largest survey of sexual health among male cannabis users was conducted by Smith et al in Australia and included over 4,000 men.7 Although the authors did not use a validated measure of erectile function, they found that subjectively there was no association between the frequency of cannabis use and self-reported trouble keeping an erection. The current report also found no change in erectile function; however, we did identify improvements in other domains of sexual function and a lower prevalence of ED with more cannabis use. Smith et al also found that daily cannabis use in men was associated with difficulty to achieve orgasm as desired. Although the authors did not discuss any potential mechanisms underpinning this association, it is possible that an altered cognitive state induced by cannabis consumption may contribute to difficulty in attaining orgasm. A recent qualitative survey of both men and women reported that some participants were unable to orgasm as desired on cannabis because of a lack of focus or altered mindset.16
To our knowledge, only one study, by Kumsar et al, has investigated male sexual health associations with cannabis using the complete IIEF survey.17 Here, the authors surveyed men with substance use disorder presenting to a dedicated substance abuse treatment center in Turkey. They found no differences in the overall IIEF score or any domain scores between cannabis users and nonusers. However, this study of 20 cannabis users had limited power to identify differences between the control population and was not able to identify the frequency of cannabis use.
A few studies have used the SHIM as an outcome measure, allowing for proper comparison with our results. In a survey of 2,507 Swiss men aged between 18 and 25 years, Mialon et al found that there was no association between cannabis use and ED in a bivariate analysis.18 However, the age of the population may limit the prevalence of sexual dysfunction. In contrast, Elbendary et al found that adult drug use, which mostly consisted of cannabis use in their cohort, was associated with increased odds of ED in multivariable analysis.19 However, the lack of granularity with regard to the type or frequency of use may have confounded the association between cannabis use and ED. Thus, the literature suggests that the effects of cannabis on sexual function can be either positive or negative and may vary by the dose and frequency of use.
Although we found statistically significant associations between the increasing frequency of cannabis use and increases in the overall IIEF, intercourse satisfaction domain, and overall satisfaction domain scores, the clinical significance of these results is unclear. The minimal clinically important difference for the erectile domain of the IIEF is widely considered to be an increase by 4 points.20 To our knowledge, however, no other studies have assessed what constitutes a minimal clinically important difference for the overall IIEF or other domain scores. Given the point increases conferred by the increasing frequency of cannabis by 6 additional uses per week ranged from a 4.44-point increase for the overall IIEF to a 0.68-point increase for overall satisfaction, it is likely that these modest increases in the IIEF scores are not clinically significant. At a minimum, these results suggest that the increasing frequency of cannabis consumption does not impair sexual function. Furthermore, our results must not be interpreted as implying a causal relationship between the increased frequency of cannabis use and improved sexual function; rather, the results of the present study simply identify a correlation.
Taken together, our findings suggest that there exists a relationship between the increasing frequency of cannabis use and slight sexual benefit to men in the realms of intercourse satisfaction and overall satisfaction, while the primary method of consumption and chemical composition are not associated with sexual function. The mechanisms underlying sexual enhancement from cannabis use are as yet poorly understood. It is postulated that the aphrodisiac-like properties of cannabis, including increased sensitivity, sexual satisfaction, and orgasm strength, involve altered perception of the sexual encounter and activation of cannabinoid receptors in the central nervous system.21 Indeed, a study of noncopulating male rats demonstrated that pharmacologic activation of the central nervous system's endocannabinoid network resulted in sexual behavior in 50% of the population.22 In humans, a study using functional magnetic resonance imaging revealed that cannabis intoxication modulates the response of the right nucleus accumbens to visual erotic stimuli.23 The nucleus accumbens is involved in the processing of the rewarding effects of sexual behavior, and activation of dopamine receptors in this brain region is shown to increase sexual motivation even among sexually satiated rodents.24,25 The cannabinoid composition of consumed cannabis may modulate the effect on sexual behavior, as well. In one study of male mice, chronic CBD exposure resulted in a decreased sexual behavior, as demonstrated by a reduced number of mounts and ejaculations, whereas THC exposure has been linked to a heightened sexual behavior in female mice.26,27 Ultimately, the effect of cannabis chemovar on sexuality is not well defined and should be further explored. Finally, cannabis use can induce an altered perception of time, potentially leading to artificially prolonged feelings of sexual pleasure and excitement.28
This study should be considered in the context of its limitations. First, our cohort is a population of men who made a purchase at a dispensary and represents a select population of cannabis users, which excludes individuals receiving cannabis through other means and therefore may not be generalizable. Indeed, the erectile function scores of men in the present study are higher than what would be expected of a typical cohort of men, roughly half of whom are at least 50 years old. Furthermore, the rates of use in the present study are high, with most men using 6+ times per week. Reassuringly, however, the population is geographically diverse and does not apply to a single region in the US, as can be seen from the home region data in Table 1. Second, there is inherent volunteer bias among men who chose to complete the surgery. Third, although we used a validated questionnaire for erectile function, the responses are still subjective and self-reported, as opposed to objectively measured. Fourth, it is possible that some of the self-reported responses, in particular cannabis chemovar, were inaccurate as the accuracy of self-reporting of chemovar is unknown. Fifth, while the frequency was assessed, the dose of the cannabis chemovar was not assessed in the survey; therefore, it is possible that less-frequent users may have been consuming higher doses. Sixth, the lack of a large, widely representative control group prevents robust comparison between heavy users and nonusers. Finally, although users were asked about their experiences in the last 4 weeks, we did not discriminate between new and chronic users.
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