Abstract
Background:
Intimacy during sexual contact with a person with symptomatic or asymptomatic COVID-19 disease carries the risk of its transmission. COVID-19 has been therefore found to adversely impact the sexual behavior in people in various countries. A discussion on sexual health is often tabooed in India, leading to less research evidence from India.
Aim:
We tried to study and compare the impact of COVID-19 pandemic on the sexual behavior of urban- and rural-based eligible couples.
Methods:
Eligible couples were randomly selected from the urban and rural field practice area of a Medical College of West Bengal (India). They were interviewed using a data collection schedule for their sexual practices adopted during the pandemic. Urban vs rural sexual behavior was compared using chi-square test.
Results:
Majority didn’t report any change in sexual desire compared to prepandemic days. However, scope of sexual contact had significantly reduced among urbanites (P = .036); fear of contracting COVID-19 during sexual intimacy was more among them as well (P = .047). The rural respondents reported significantly higher desire for parenthood (P = .018), though their contraceptive behavior was not significantly different from the urban counterparts. Many used means other than sexual intercourse for sexual gratification, which had remained similar to the prepandemic times.
Conclusion:
The sexual behavior of urban and rural participants was found to be significantly different on many fronts, probably due to better COVID-19 awareness among urban residents as well as other prevalent social stigma and restrictions that were less commonly encountered in rural participants.
Introduction
Global health bodies recommend personal preventive measures and social isolation to prevent dissemination of COVID-19.1–3 In-person sexual activity probably carries risk of SARS-CoV-2 transmission, as close contact with asymptomatic individual or a person of unknown disease status comes with the risk of getting infected with the virus.4–7 Due to this dilemma, the public might experience a change in their intimate and sexual behavior. Among those married or living together, social isolation might variably impact sexual behavior. 5
There is limited evidence on the impact of COVID-19 on sexual behavior of people, especially from developing countries like India and Nepal, where an open-minded discussion about intimacy is often considered a taboo. An Italian research has concluded that during the ongoing pandemic, episodes of sexual intercourse had declined amongst women belonging to the reproductive age group, with significantly raised Female Sexual Distress Scores. 8 Another study reported that use of contraceptive methods had declined among women during the pandemic; participants had significantly better Female Sexual Function Index scores before the pandemic compared with scores during the pandemic, leading to decreased quality of sexual life. 9
In this study, we assessed and compared the impact of COVID-19 pandemic on the sexual behavior of urban- and rural-based eligible couples and thereby tried to bridge the gap in existing knowledge and generate new evidence in this context.
Materials and Methods
Study Type and Study Design
This was a field-based observational study of cross-sectional design.
Place and Duration of Study
The study was conducted in the urban and rural field practice areas of a Medical College based in Kolkata, West Bengal (India), over a period from August to November 2021, after the second wave of the pandemic eased out from the state.
Sample Size and Sampling Method
The sample size was calculated by the formula n0 = z2pq/e2. The sample size obtained was further corrected, since the population was finite, using the formula n = n0/[1+{(n0–1)/N}]. 10 Considering proportion (p) of couple in productive age group whose sexual behavior was affected by the pandemic to be 50.0% (due to scarcity of available data), n0 = sample size before correction, z2 = 3.84 (at 95% confidence interval), N = total number of line-listed eligible couples in respective field practice areas = 178 in urban area (UA) and 971 in rural area (RA), q = 1–p, and e = 10% of p, sample size (n) was calculated to be 122 and 276 in UA and RA, respectively. Assuming 20% for nonresponse, final sample size was 147 for UA and 331 for RA. Respective number of eligible couples from UA and RA were selected from the available list randomly.
Methods of Data Collection
For the purpose of data collection, a pretested schedule was administered on each selected couple. When both counterparts of a selected eligible couple were available for data collection, the husband was selected for the interview. In other cases, the available counterpart was interviewed. Informed consent was taken from all the participants. The schedule contained questions on sociodemographic profile and sexual practices adopted during the COVID-19 pandemic. Female participants were interviewed in the presence of the local Accredited Social Health Activist worker or another female member of the family.
Ethical Approval and Patient Consent
The Institutional Ethics Committee of the Medical College gave permission to conduct the research (ref: MC/KOL/IEC/NON-SPON/1236/12/21). Anonymity of all participants was maintained.
Inclusion and Exclusion Criteria
Selected eligible couples who were willing to participate were included in the study. However, couples who were unavailable after 3 attempts on consecutive days of data collection were excluded. Finally,132 couples were included from the UA and 309 from RA.
Statistical Analysis and Software Used
Data was analyzed using Statistical Packages for Social Science (SPSS)® (SPSS Inc) version 16.0. Results were reported as ratios and proportions. Chi-square test was performed to check for necessary statistical associations.
Results
Most of the respondents were aged between 26 and 35 years (45.4% in UA and 43.4% in RA) and were females (UA: 65.2%, RA: 60.5%). Most were educated till secondary level in UA (35.6%) and primary level in RA (43.7%); 49.2% in UA and 45.6% in RA were homemakers. About a fifth, that is, 19.7% and 22.3% in UA and RA had chronic comorbidities, respectively, while history of COVID-19 was reported by 25.8% (UA) and 22.0% (RA) of the respondents. Of participants, 74.2% in urban area reported that some of their neighbors and/or relatives suffered from COVID-19 while this proportion was 36.2% for rural area. Social media and mass media like television, radio, and social media was the source of knowledge for majority among respondents (UA: 80.3%, RA: 76.4%) regarding COVID-19. In the urban area, posters, banners, and mic campaigns contributed largely as a source of information (90.2%). About 60.6% of the urban respondents faced stigma and discrimination from neighbors during the pandemic compared to 33.0% among their counterparts (P < .001). Recent unemployment during the COVID-19 pandemic was significantly more in UA (25.0%); it was 14.6% in RA (P = .008). Tobacco use was the most common substance of addiction (UA: 43.2%, RA: 47.9%), followed by alcohol (UA: 12.1%, RA: 14.2%) (Table 1, Figure 1).
Sociodemographic Detail of Study Participants.
Maximum number of participants reported no change in sexual desire during the pandemic compared to before (UA: 84.8%, RA: 88.0%; P = .175); however, a higher proportion of individuals from RA reported increased sexual desire compared to their urban counterpart. Fear of contracting COVID-19 during sexual acts was significantly higher in urban participants (UA: 70.4%, RA: 60.5%; P = .047). Scope of sexual contact was affected more among urban residents compared to rural (UA: 31.8%, RA: 22.3%; P = .036) and desire for parenthood was significantly more in the rural population (UA: 12.9%, RA: 22.6%; P = .018). No significant difference in contraceptive use behavior was noted, as 66.7% from UA and 60.9% from RA reported no apparent change in their use (P = .248). Majority of the participants used means other than sexual intercourse for gratification as well (UA: 76.5% RA: 70.2%)—among them, watching porn was the most common form of sexual gratification reported (UA: 50.8%, RA: 51.4%) (Tables 2, Figure 2).
Sexual Behavior of Participants During COVID-19 Pandemic.
Discussion
Sexual activity is an important factor in maintaining quality of life. Poor physical and psychological health conditions like diabetes, depression, and so on have severe impact on sexual health. The unprecedented measures taken due to the COVID-19 pandemic, like lockdown, quarantine, and mandatory social distancing, have affected all social and economical facets of life including sexual behavior. However, the impact on sexual health has been ignored and less discussed as it is often tabooed in India.
Sexual behavior is dependent on trust, intimacy, and ability to perceive and express interpersonal emotions. Studies have concluded that due to restrictions like quarantine, people become anxious about human-to-human contact and interpersonal distrust increases as a result.8, 11, 12 Heightened scope of interpersonal conflicts and emotional stress could also negatively affect the facilitation of sexual intimacy. 13 Chance of spread of COVID-19 through saliva during kissing and sexual acts makes the matter of sexual health complicated.8, 11, 12 In case of any acute health condition, people try to prioritize safety over sexual pleasure and avoid sexual contact even with the safest sexual partners. But avoiding sex for the whole duration of the 20-month-long pandemic could have started to hamper psychological health, in turn resulting in poor quality of life. This is a matter of concern as it adds to the factors like posttraumatic stress, death perception, and disruption of normal recreational activities that were already present during the pandemic, making healthy living difficult.8, 11, 12 Another burning question regarding sexuality is whether desire for offspring has reduced due to the impending stressful pandemic situation or has it increased due to home confinement and reduced scope of outside entertainment. What might have seemed obvious amidst the COVID-19 pandemic is therefore not so clear any more.
In this study, though most people reported no change in sexual desire and there was no significant difference in this regard between the rural and urban population, a higher proportion of respondents from the rural population felt an increase in sexual desire. Decreased desire was proportionately higher among the urban population compared to their rural counterpart. It is also evident from the result that fear of contracting COVID-19 was significantly higher among urban population. Possible reasons behind this rural-urban mismatch include significantly higher unemployment, more sources of health knowledge, a greater proportion of participants knowing COVID-19 patients, and significantly higher percentage of those facing stigma from the neighbors among the urban participants. All these point toward stronger negative impact of COVID-19 in UA than in the RA. Diverse knowledge source indicates that in urban areas people were more likely to know that COVID-19 can spread during sexual activities. Unemployment and stigma lead to a sense of fear and insecurity due to COVID-19. More participants knowing COVID-19 patients might have created a sense of vulnerability among the urban participants, even if most of them didn’t suffer from the disease. Also, as more people live in relatively smaller space in the urban areas leading to lack in privacy, reduced scope of sexual contact during the lockdown and similar restrictions can be explained. This in turn may have led to a stronger fall in sexual desire and sexual activity among the urbanites. A similar study from India, Nepal, and Bangladesh has stressed on the issue of privacy to negatively affect sexual intimacy during the pandemic. 13
In spite of all these factors, it was seen that majority of the study population, both urban and rural, had unaltered sexual desire. Majority of our participants reported no change in scope of sexual contact, compared to pre-COVID times. These point out that there were many balancing factors too, in favor of sexual intimacy. Longer free time due to lockdown leading to greater scope for emotional bonding as indicated by a previous multinational study done in countries including India and Nepal could have been an important factor. 13 This also negates the perspective mentioned in studies from some other countries where apprehension to bear child amidst the pandemic was an important contributing factor toward decreased sexual activity.11, 12 Culture in the Indian subcontinent is notably different from the Western world. Here, the values of family and offspring(s) are utmost and important determinants in social structure.14, 15 Therefore, even during the pandemic, desire for parenthood was noted both in urban and rural areas and no increase in contraceptive use compared to the prepandemic times was reported. It could be because of greater influence of the Western culture on urbanites that desire for parenthood was lower in them. Significantly higher desire of parenthood among rural residents can be explained by the relatively lesser negative impact of COVID-19 on them.
Studies conducted all over the world showed varied result regarding sexual behavior. In Italy, a study showed significant decrease in sexual desire and quality of life during the pandemic, whereas a Turkish study indicated a significant increase.8, 9 In our study, no significant change in sexual desire was seen; however, respondents reporting increased sexual desire was more than those who indicated a decrease. A previous online survey in India also pointed out increased desire to parenthood and sexuality among females. 11 A study done in India, Nepal, and Bangladesh reported no significant change in sexual activity as well, and it even went on to show an increased sexual activity amongst some of its participants. 13 Findings of our study also suggest that desire for offspring and use of other sexual gratifications like watching porn continued during the pandemic. An international study reported increased consumption of pornography during the pandemic. 12 Not having access to other forms of entertainment during COVID-19 induced movement restrictions and alcohol ban may have led to an increase in such desire in some. The India Child Protection Fund report showed a disturbing finding that online child pornography traffic during the COVID-19 pandemic lockdown in India increased by 95% compared to the average before the lockdown. 16
Conclusion
As established by previous researches, the COVID-19 pandemic has had variable impact on the sexual behavior in the public. While some studies especially from the Western world have indicated a negative effect, research from parts of Asia mostly reflect otherwise. Significant differences in the sociodemographic pattern and societal norms could be the most prominent reason behind such differences. However, evidences from developing countries like India and Nepal in the subject concerned are mostly lacking, and this study therefore bridges this gap in the existing knowledge.
Better knowledge about modes of spread of COVID-19, loss of job, and apprehension of it caused relatively more decrease of sexual desire among the urban population than the rural. In spite of these stressors across urban and rural populations, sexual behaviors largely remained unaltered and desire to extend family even increased in rural areas. All these point out a limited effect of COVID-19 on sexual behavior in the Eastern Indian scenario.
This being a sensitive issue which does not often allow open-minded communication in societies like that in India, a qualitative study like in-depth interview after establishing a rapport is required to gain deeper insights into the issue.
Limitation
Sexual behavior is a sensitive matter in the Indian context. So, as a limitation of this study, its subjects might have opted for socially appropriate response during interview, as it is a difficult domain for open-minded communication in societies like that in India owing to associated taboos.
Footnotes
Acknowledgements
The authors thank Mr Satyajit Gupta, ACMA for his assistance in developing the conceptual framework of this study.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Ethical Approval and Patient Consent
The Institutional Ethics Committee of the Medical College gave permission to conduct the research (ref: MC/KOL/IEC/NON-SPON/1236/12/21).