Sexual Behavior in the Days of COVID-19

Coronaviruses comprise a very large family of viruses, many of which have been identified to cause minor and major illnesses in humans and animals. In humans, several coronaviruses can cause symptoms resembling the common cold. However, 2 coronaviruses are responsible for more severe respiratory illnesses: Severe Acute Respiratory Syndrome (SARS) and Middle-East Respiratory Syndrome (MERS). The coronavirus that is responsible for the current pandemic has been named SARS coronavirus 2 (SARS-CoV-2); this virus causes coronavirus disease 2019, abbreviated as COVID-19. ¹

COVID-19 started in Wuhan, China, and has now been identified in all parts of the world. As of July 04, 2020, more than 11 million people have tested positive for the virus and more than 525,000 patients have died of the disease. Countries in North America and Europe were initially the worst affected, but now Brazil and India have moved up on the list.

Almost every medical journal now contains articles on COVID-19; in some issues of some general medical journals, articles on the disease outnumber articles on all other subjects combined. Specialty journals, such as psychiatry journals, discuss the immediate and delayed impact of COVID-19 on their respective fields.^{2, 3} In this context, not COVID-19, per se, but the lockdown imposed to limit the spread of COVID-19 is likely to impact sexual behavior, as we will examine in the rest of this article.

Lockdown refers to government-placed and government-enforced restrictions on citizen movement. Total lockdown in China was responsible for the containment of the epidemic in that country. Following the same model, total lockdown was imposed in India on March 24, 2020. Less harsh versions of lockdown have been set in place in other parts of the world, as well.

Lockdown, and especially total lockdown, forces couples into prolonged, inescapable proximity. For some, this could present favorable opportunities. For example, there are couples today who work in different cities, or who work in the same city but in different shifts, or who work in the same city and in the same shift but are too tired by the end of the day for intimacy. For all these couples, therefore, lockdown could be an opportunity for improving intimacy. This could improve the quality of marital and sexual relationships and could also result in a spurt in the pregnancy and abortion rates.^{4, 5}

The prolonged proximity could have an adverse impact, too. Nobody is perfect, and no relationship is perfect, and so imperfections and interpersonal frictions could increase during lockdown, because couples in prolonged, forced proximity have ample time and opportunity to observe weaknesses in each other and in their relationships. This could result in quarrels that escalate into martial disharmony that could impair the quality of sexual relationships. Disharmony could reduce partner sexual attractiveness and result in partner-specific sexual dysfunction. And, of course, disharmony could later cause a spurt in the divorce rates. It should not be forgotten that disharmony associated with inescapable proximity could also result in intimate partner violence.^{6, 7}

Time hangs heavily on one’s hands during lockdown, even if one works from home. This could result in increased viewing of visual entertainment on internet-connected devices such as smartphones, tablets, laptops, and desktops, and on cable television. This could, in particular, result in increased time and opportunity to view online pornographic materials. Excessive viewing of pornography could overtly change partner expectations in terms of sexual performance and behavior; if the partner is unwilling to or incapable of exhibiting the desired change, this could result in stressed relationships. Expectations could also be changed unconsciously, as in wanting a picture-perfect or idealized partner; because this is never possible in real life, dampened expectations could also adversely affect the quality of sexual and emotional relationships. ⁸ It is also possible that there will be a rise in porn addiction as a special form of internet addiction. ⁹

During lockdown, increased viewing of entertainment channels, such as movies on television, could be accompanied by increased eating. Compounding this is the lack of opportunity for exercise when one is not permitted to leave home. As a result, weight could increase. This would have long range adverse effects on the risks for overweight and obesity, diabetes, hypertension, and cardiovascular disease, all of which are associated with impaired sexual functioning, most especially with erectile dysfunction. ¹⁰ Who would imagine, 2 to 3 decades in the future, that new onset sexual dysfunction had a pathophysiological contribution from the COVID-19 lockdown imposed in 2020. ³

Lockdown, forced proximity, anxiety about work and finances, and other stresses could trigger new onset psychiatric disorders and worsen the existing ones. Psychiatric disorders and many psychopharmacological interventions are well known to be associated with sexual disturbances. For example, D2 dopamine receptor antagonist drugs elevate serum prolactin and decrease libido. Drugs with anticholinergic action impair erection and drugs that block alpha adrenergic receptors impair ejaculation. Drugs that inhibit the reuptake of serotonin delay or prevent ejaculation. Sedating drugs have a generally dampening effect on sexual functioning; a sleepy subject is unlikely to be interested in sex. Thus, a large number of antianxiety, antidepressant, and antipsychotic drugs used in the treatment of psychiatric disorders triggered by lockdown and other COVID-19 stresses may result in sexual dysfunctions such as decreased libido, erectile dysfunction, and ejaculatory delay or anorgasmia.^{11, 12}

In this context, it should be remembered that, even in the absence of a psychiatric diagnosis, stress is itself related with disturbances in sexual functioning, and so lockdown-related stressors can result in such disturbances even in persons who are psychiatrically stable.

The bottom line is that healthy sexual functioning is not something that arises in isolation. Healthy sexual functioning requires a sound mind, a sound body, and (as we now learn) a sound environment, and not merely a sound reproductive system!