Safe Sexual Practices in the COVID-19 Pandemic Period

Introduction

The coronavirus disease 2019 (COVID-19) pandemic is a public health emergency caused by the 2019 novel coronavirus. The strategies to prevent against COVID-19 involve respiratory hygiene, hand hygiene, social isolation, physical distancing, and quarantine, along with contact tracing that seems to be more likely to achieve control of COVID-19 pandemic transmission.¹ So far, it is unknown whether there is a relationship between sexual practices and the risk of spreading severe acute respiratory syndrome coronavirus 2 (SARS-COV-2). Therefore, the guidelines regarding sexual life during the pandemic are based on expert opinion, and some proposed that sexual practices should be avoided because of the risk of COVID-19 infection.² However, some evidences has been emerged, which may guide physicians to talk about sex with their patients (Table 1).

Table 1.

Highlights regarding SARS-COV-2 and sex practices during the COVID-19 pandemic

Available evidences

There was no study evaluating the risk of sexual intercourse in the COVID-19 pandemic period.

The patients remained positive for COVID-19 in feces after pharyngeal swabs turned negative.

Vaginal transudate is free of SARS-COV-2.

It is unknown whether there is a relationship between sexual practices and the risk of spreading SARS-COV-2.

For futures studies

It is crucial to investigate the patients' sexual habits during the COVID-19 pandemic.

It is crucial to know when the viral load remains negative in the convalescent period.

To verify if COVID-19 is transmissible by secretions other than nasal or salivary means.

There is a need for qualitative and quantitative studies on the mental health and the quality of sexual life, during the COVID-19 pandemic.

Possible scenarios for sexual practices

In the case of isolated partners at home, same partners, known absence of contamination in both partners, with no history of contacts, no symptoms of COVID-19: sexual practices should be recommended according to couples' preferences. Specific measures such as washing hands (and any sex toys) with soap and water for at least 20 seconds should be recommended before and after sex to prevent contamination.

Measures to prevent nonplanned pregnancy and sexually transmitted infections should be offered.

In the scenario when the exposure of a partner is known, one (or both) partner is infected, with or without symptoms, and one partner is suspicious of infection, the isolation is recommended and shared sexual relations must be suspended. Thus, in this case, the physician should suggest solitary sexual practices such as sexual fantasies, autoerotism, masturbation, and sexual toys as a way to reach sexual pleasure. It is important to emphasize that kissing can easily pass COVID-19 infection, and this practice should be avoided.

Practices that can be maintained for all couples and casual partnership, and for those in the recovering period: considering that sexual practices involve physical, visual, and auditory stimuli and psychological stimuli that do not depend on physical contact, the use of media and bibliotherapy can be help build sexual fantasies and autoerotic practices for those who are prevented from physical contact when in quarantine.8

There is no evidence to support recommendations for sexual practices with casual partners. However, the use of mask is recommended, and avoiding kisses is a practice to avoid contact with saliva and nasal and eye secretions, which is crucial to prevent contagion through these routes.

Because COVID-19 has been found in feces of people who are infected with the virus, anal sex may be a way of transmission and should be avoided. It is recommended to have sex with people close to yourself9,10

COVID-19 = coronavirus disease 2019; SARS-COV-2 = severe acute respiratory syndrome coronavirus 2.

The main route of COVID-19 transmission is through respiratory droplets, aerosols, and person-to-person contact through cough, sneeze, droplet inhalation transmission, and contact transmission, such as the contact with oral, nasal, and eye mucous membranes.³ The risk of sexual transmission is still unanswered, and it is unknown whether persons with sexually transmitted disease are at a greater risk of contracting COVID-19. However, a Chinese study showed a reduction in risky sexual behaviors,⁴ and this may reduce the risk of contracting sexually transmitted diseases.

The viral load of SARS-COV-2 may remain high in convalescent patients.⁵ The SARS-COV-2 was detected in the semen of both symptomatic and convalescent patients,⁶ and this may pose a risk for infection of the sexual partner. In addition, the presence of SARS-COV-2 in feces suggests the possibility of transmission via the fecal-oral route.⁷ This may explain the rationale for avoiding oral sex that can pose a risk, as viral shedding can also occur from the anus and hence contaminate the genitals. The risk of transmission between asymptomatic individuals through kisses, hugs, and physical proximity is known. Thus, these practices should be avoided for those who do not live in the same household.

The casual sexual encounters may reduce, whereas couples may be confined in the same space for hours, days, or even months, and that closeness may increase sexual activity in these couples. However, the impact of COVID-19 on sexual practices is controversial with studies showing both a decrease⁸ and an increase⁹ in the frequency of sexual intercourse during the pandemic. The challenge is to provide strategies for safe and pleasurable sexual practices during the COVID-19 pandemic based on scientific evidences because of the lack of data regarding partner's contamination during sexual practices.

Given the paucity of scientific evidence on contagion in sexual relations, it causes concern and uncertainties on how to provide safe guidance recommendations on sexual practices in COVID-19 pandemic times. Although it may be reassuring to know that the vagina does not appear to shed SAR-COV2, it is hard to conceptualize a vaginal sex encounter as safe once this practice includes proximity sufficient to put both partners at risk from droplets from the oropharynges. In theory, sexual practices such as kissing, oral sex, and anus-oral sex need to be restricted in times of the COVID-19 pandemic.¹⁰ To offer adequate safe sex counseling in times of the COVID-19 pandemic, further studies are needed on the risk of contagion of COVID-19 through sexual intercourse. Thus, the sexual activity involving intimate physical contact should consider several scenarios as shown in Table 1.

Statement of authorship

Lucia Alves da Silva Lara: Conceptualization, Methodology Development Validation Verification, Formal Analysis Investigation Data Writing – Original Draft Preparation, Writing – Review & Editing Preparation, Visualization Preparation, Supervision; Carmita Helena Abdo: Validation Verification, Supervision; Flávia Fairbanks Lima de Oliveira Marino: Conceptualization, Methodology Development Validation Verification, Data Writing – Original Draft Preparation, Writing – Review & Editing Preparation, Supervision; Sandra Cristina Poerner Scalco: Conceptualization, Methodology Development Validation Verification, Data Writing – Original Draft Preparation, Writing – Review & Editing Preparation, Supervision; Jaqueline Brendler: Conceptualization; Sidney Glina: Conceptualization; Rosana Maria Reis: Conceptualization, methodology, supervision.