Sex and COVID-19: How the Pandemic Affected Sexual Behaviour & Sexual Health

Edna Astbury-Ward

Disclosures

July 03, 2020

Pandemics are known to cause distress and an increase in poor mental health. Prolonged isolation resulting from lockdown's anti-contagion measures may lead to anxiety, depression, anger, boredom, frustration, and PTSD for some people. In addition, the decreased coping opportunities, less access to healthcare, less social and family support, and fewer leisure resources, creates situations that in turn may lead to an increase in sexual violence by people who lack emotional regulation, says Joana Carvalho, PhD – assistant professor, Universidade Lusófona de Humanidades e Tecnologias, Lisbon, Portugal.  She's concerned about what this means for those in lockdown.

Dr Carvalho took part in a recent webinar hosted by The International Society for Sexual Medicine (ISSM). The webinar gathered experts from across the world to discuss the challenges and changes to sexual health and behaviour during the COVID-19 pandemic 

The Hidden Side of COVID-19

Dr Carvalho says that increased distress and confinement may lead some "to uncontrolled pornography consumption as a result of negative moods". She referred to this as "sexualised coping behaviour". She pointed out that pornography consumption had increased in Europe during lockdown and so had sexual violence, and referred to a preprint German survey by Jung et al 2020, conducted during the height of lockdown measures in Germany from 1st April to 15th April 2020, which showed 5% of responders (n=3545) reported interpersonal violence (IPV). Prevalence of IPV during one month of lockdown confinement was equivalent to rates of IPV during one year in non-lockdown situations.

Dr Carvalho called for more comprehensive assessments that consider all the stressors that are emerging as a result of COVID-19. Specifically she highlighted unemployment, work/domestic overload, and the restructuring of family roles as specific triggers for negative thoughts and behaviours.

Dr Carvalho is not alone in being concerned about the impact of continued isolation during lockdown. Executive Director of UN Women, Phumzile Mlambo-Ngcuka said: "Confinement is fostering tension and strain created by security, health and money worries; and is increasing isolation for women with violent partners." She described the situation as "a perfect storm for controlling, violent behaviour behind closed doors". It is obvious that women are disproportionately vulnerable to interpersonal violence during the pandemic and that this is a global crisis. UN Secretary-General António Guterres is calling for measures to address a "horrifying global surge in domestic violence" directed towards women and girls, linked to lockdowns imposed by governments responding to the COVID-19 pandemic.

Gender Differences Impact Disease Severity

It is well documented that men are more disproportionately affected by COVID-19 than women. What is less well understood is why? There are theories that it may relate to occupational risk, smoking or lifestyle, but recently, research is focusing more on the biological differences between the sexes, specifically our chromosomal and hormonal makeup.

Dolores Lamb, PhD – vice chair, Department of Urology (Research) at Weill Cornell Medicine, New York, US discussed the role of testosterone and COVID-19 in the ISSM webinar. Dr Lamb presented data from the US Centers for Disease Control and Prevention-National Centre for Health Statistics. She highlighted the fact that younger men have a higher death rate from COVID-19 infection than older men, whereas for women the rate of death from COVID-19 remains relatively stable throughout their lifespan. It is not until men reach approximately 85 years of age that the death rate from COVID infection begins to even out in comparison with women. This, said Dr Lamb, "was reminiscent of the decline in testosterone levels in aging men" and she indicated that this fact was worthy of further exploration and research.

She pointed to Italian research which examined whether there was a protective effect against COVID-19 of androgen-deprivation therapy (ADT) [anti-androgens] used for the treatment of prostate cancer. The results showed that indeed prostate cancer patients receiving ADT appear to be partially protected from SARS-CoV-2 infections. There are a number of ongoing studies that are focusing on endocrine manipulation to impact COVID-19 disease severity. Dr Lamb said: "The jury is still out, so stay tuned because at the moment the data is incomplete, but it's encouraging." 

She then turned her attention to theories that coronavirus may affect the testes. She pointed out "that we know orchitis is a complication of SARS (an earlier version of the Coronavirus) but it is unclear what the effect of SARS-COV-2 has on the testis. It is also unclear whether direct damage to the testis was from the virus or the result of inflammation from the cytokine storm".  She added that, "detrimental effects to the testes resulting from high temperatures caused by fever associated with Coronavirus may adversely affect spermatogenesis". This has called for exploration of possible therapeutic approaches that may temporarily disrupt androgen receptor signalling, "which is associated with its own set of side effects, but obviously this would be a transient treatment as compared to men treated for advanced prostate cancer" said Dr Lamb.

Sperm Cryopreservation During the Pandemic

Because of the possible testicular effects and the impact on spermatogenesis there has been a lot of interest in sperm cryopreservation during the pandemic. Dr Lamb commented: "There is no good answer to this. It is widely known that there are a number of viruses that can be shed into the semen, sometimes long, long after symptoms abate. The Zika virus is a very good example of that. But so far the data suggests that the shedding of the SARS-COV-2 into the semen appears to be low, and there have been low titres of SARS-COV-2 at non-respiratory sites. Importantly, for sperm banking, the viruses are stable at ultra-low temperatures so SARS-COV-2 may remain stable after cryopreservation and thawing." She made clear that whilst there are no recorded cases of viral cross contamination between cryopreserved semen samples, the risk of cross contamination is thought to be "negligible, but not zero". Good practice would be to use safe and secure devices to protect the laboratory and to make sure that there's no cross contamination into the cryovials. She advised that cryovials containing semen from COVID affected men should be segregated for storage.

Sexual Behaviours and Differences Between Countries

A number of international research reports were discussed by the panel in the webinar, particularly a small UK study by Jacob et al 2020. 'COVID-19 Social Distancing and Sexual Activity in a Sample of the British Public' indicated that it was important to design interventions that promoted wellbeing during the COVID-19 pandemic, which focus on positive sexual health messages to mitigate detrimental consequences of self-isolation.

The Italians have their own take on the message and have a study published in the International Journal of Impotence Research called 'Love at the time of the COVID-19 pandemic: preliminary results of an online survey conducted during the quarantine in Italy' showing that more than 40% of the respondents reported an increased sexual desire during the quarantine but not a higher frequency of sexual intercourse. Dr Paolo Capogrosso, staff urologist, University Vita-Salute San Raffaele, Milan, Italy said: "Although social distancing due to the COVID-19 pandemic has led to an overall decrease in sexual activity, there is no convincing evidence showing an increase in sexual dysfunction during the lockdown phase."

Accessing Guidance on Sexual Behaviour During the Pandemic

In the UK it is very difficult to find specific government direction from a single access point regarding sexual behaviour during the pandemic, so the general public resort to trawling for information on the subject via a myriad of resources from various UK sexual health providers, such as the Faculty of Sexual & Reproductive Healthcare, Brook, British Association for Sexual Health and HIV (who have issued specific guidance) Sexwise, and many others.

In the US it is a different story. National organisations such as The Guttmacher Institute  publish regular updates on policy and research on the subject. Recent information from the New York City Health Department is clear on the subject of Safer Sex and COVID-19 stating:

  • The virus spreads through particles in saliva, mucus, and breath of those with COVID-19

  • The virus has been found in faeces and semen

  • You are your safest sex partner

  • Next safest sex partner is someone you live with

  • Limit sex with anyone outside your household

Risk of Viral Transmission of COVID-19 During Sex

The ISSM and International Society for the Study of Women's Sexual Health (ISSWSH) have produced statements outlining guidance around sexual activity and COVID-19 and advising on avoiding high risk sexual behaviours, which, during the time of COVID, now includes kissing. Dr Sharon Parish, professor of medicine in clinical psychiatry, professor of clinical medicine, Weill Cornell Medical College, New York, USA who also took part in the ISSM webinar added that in Coronavirus discordant couples "high risk individuals are those in terms of their work" ie, those whose areas of work expose them to high likelihood of infection.

Interestingly, Dr Capogrosso, stated in the webinar that: "There is conflicting evidence regarding the presence of SARS-CoV-2 in seminal or vaginal fluid." The ISSWSH position statement goes further stating: "It is now known that the virus is present in the urine, and the semen of men both acutely ill and recovering from COVID -19 infection… it is not known for how long the virus remains present in the semen nor whether the semen carries transmission risk."  Dr Lamb said that regarding the risk of viral transmission via semen "the data is still incomplete and studies that have been done have been on small sample sizes".

As the Coronavirus pandemic continues, emerging evidence regarding the impact on human sexuality, sexual health and sexual behaviours will be interesting to follow. It is clear from the experts speaking in this webinar that there is still lots to learn about how COVID-19 affects the genders differently in terms of psychosocial, biological and behavioural aspects of their lives.

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