Benefits of Sexual Activity on Psychological, Relational, and Sexual Health During the COVID-19 Breakout

Abstract

Background: The COVID-19-related lockdown has profoundly changed human behaviors and habits, impairing general and psychological well-being. Along with psychosocial consequences, it is possible that sexual behavior was also affected.

Aims: With the present study, we evaluated the impact of the community-wide containment and consequent social distancing on the intrapsychic, relational, and sexual health through standardized psychometric tools.

Methods: A case-control study was performed through a web-based survey and comparing subjects of both genders with (group A, N = 2,608) and without (group B, N = 4,213) sexual activity during lockdown. The Welch and chi-square tests were used to assess differences between groups. Univariate analysis of covariance, logistic regression models, and structural equation modeling were performed to measure influence and mediation effects of sexual activity on psychological, relational, and sexual outcomes.

Outcomes: Main outcome measures were General Anxiety Disorder-7 for anxiety, Patient Health Questionnaire-9 for depression, Dyadic Adjustment Scale for quality of relationship and a set of well-validated sexological inventories (International Index of Erectile Function, Female Sexual Function Index, and male-female versions of the Orgasmometer).

Results: Anxiety and depression scores were significantly lower in subjects sexually active during lockdown. Analysis of covariance identified gender, sexual activity, and living without partner during lockdown as significantly affecting anxiety and depression scores (P < .0001). Logistic regression models showed that lack of sexual activity during lockdown was associated with a significantly higher risk of developing anxiety and depression (OR: 1.32 [95% CI: 1.12 - 1.57, P < .001] and 1.34 [95% CI: 1.15 - 1.57, P < .0001], respectively). Structural equation modeling evidenced the protective role of sexual activity toward psychological distress (β_males = -0.18 and β_females = -0.14), relational health (β_males = 0.26 and β_females = 0.29) and sexual health, both directly (β_males = 0.43 and β_females = 0.31), and indirectly (β_males = 0.13 and β_females = 0.13).

Clinical translation: The demonstrated mutual influence of sexual health on psychological and relational health could direct the clinical community toward a reinterpretation of the relationship among these factors.

Strengths and limitations: Based on a large number of subjects and well-validated psychometric tools, this study elucidated the protective role of sexual activity for psychological distress, as well for relational and sexual health. Main limitations were the web-based characteristics of the protocol and the retrospective nature of prelockdown data on psychorelational and sexual health of subjects recruited.

Conclusions: COVID-19 lockdown dramatically impacted on psychological, relational, and sexual health of the population. In this scenario, sexual activity played a protective effect, in both genders, on the quarantine-related plague of anxiety and mood disorders. Mollaioli D, Sansone A, Ciocca G, et al. Benefits of Sexual Activity on Psychological, Relational, and Sexual Health During the COVID-19 Breakout. J Sex Med 2021;18:35-49.

Keywords: COVID-19; Psychological Distress; Quarantine; SARS-Cov-2; Sexual Activity; Sexual Health.

Figure 1

Sex@COVID study flowchart. Flowchart from the creation of the questionnaire web-based platform to the subdivision of the sample in 3 study groups. Criteria for exclusion: (i) age below 18 years; (ii) missing informed consent; (iii) uncompleted questionnaire. Basing on self-referred sexual activity during lockdown, study sample was subdivided in 2 groups: (group A) subjects sexually active during lockdown (N = 2,608); (group B) subjects reported no sexual activity during lockdown (N = 4,213). Figure 1 is available in color online at www.jsm.jsexmed.org.

Figure 2

Sexually active subjects during lockdown show lower anxiety and depressive symptoms. Factorial analysis of covariance was computed to evaluate differences in anxiety (F_{(7, 6,813)} = 86.69, P < .0001, Cohen’s F [95% CI] = 0.24 [0.22, 0.27], 0.15 [0.12, 0.17] and 0.08 [0.06, 0.11] for gender, sexual activity during lockdown and living without partner during lockdown, respectively) and depression (F_{(7, 6,813)} = 73.71, P < .0001, Cohen’s F [95% CI] = 0.19 [0.17, 0.21], 0.16 [0.14, 0.18], and 0.11 [0.09, 0.13] for gender, sexual activity during lockdown and living without partner during lockdown, respectively) scores among subjects sexually active during lockdown (group A) and subjects reported no sexual activity during lockdown (group B). Data expressed as means ± SE; detailed outputs of the models, including coefficients and effect sizes for interaction terms, are available in Supplementary Table 1. GAD = Generalized Anxiety Disorder scale; PHQ = Patient Health Questionnaire. Figure 2 is available in color online at www.jsm.jsexmed.org.

Figure 3

Odds ratio for anxiety and depression in the study population. Results from logistic regression models identify, among other variables, that cessation of sexual activity during lockdown is associated with higher risk of developing both anxiety and depression (OR 1.32 [95% CI: 1.12–1.57, P = .0035] and 1.34 [95% CI: 1.15–1.57, P = .0001], respectively). Full outputs for both models are reported in Supplementary Table 2.

Figure 4

Correlation matrices for variables included in structural equation model (SEM). Correlation plots depicting the measure of correlation between variables included in SEM. Spearman’s correlation coefficients are given in the lower triangle, whereas colored circles indicate statistically significant correlations in the upper triangle. Red represents positive and blue negative correlations, while size and color intensity of the circles are related to the correlation coefficients. (A) Male sexuality: Frequency of sexual activity (FSA) is weakly correlated with GAD-7 (ANX) and PHQ-9 (DEP) scores and with sexual domains (from weakest to strongest): Orgasm (ORG), Erectile function (ERE), Desire (DES), Male Orgasmometer (ORGINT), Overall Satisfaction (OSAT) and Intercourse Satisfaction (ISAT). Moreover, FSA is weakly correlated with dyadic satisfaction (DAS-SAT) and moderately with dyadic cohesion (DAS-COH). (B) Female sexuality: Frequency of sexual activity (FSA) is weakly correlated with GAD-7 (ANX) and PHQ-9 (DEP) scores and with sexual domains (from weakest to strongest): Coital Pain (PAI), Lubrication (LUB), Orgasm (ORG), and Arousal (ARO), Female Orgasmometer, (ORGINT), Desire (DES) and Sexual Satisfaction (SAT). Moreover, FSA is moderately correlated with dyadic cohesion (DAS-COH) and dyadic satisfaction (DAS-SAT). Figure 4 is available in color online at www.jsm.jsexmed.org.

Figure 5

Frequency of sexual activity is related to lower psychological distress and better relational and sexual health. Red arrows indicate positive paths, whereas blue ones indicate negative paths. Arrow widths are scaled to reflect the magnitude of path coefficients. Structural equation model showing that frequency of sexual activity is associated with both lower anxiety and low depressive symptoms (expressed in the psychological distress latent variable) and higher levels of dyadic cohesion and satisfaction (expressed in the relational health latent variable) in both genders. Frequency of sexual activity is also associated with better female and male sexual function and self-perception of orgasmic intensity (expressed in the sexual health latent variable), both in direct and indirect way. (A) Graphical representation of the structural equation model for the male gender. (B) Graphical representation of the structural equation model for the female gender. Figure 5 is available in color online at www.jsm.jsexmed.org.