Sexuality, sexual well being, and intimacy during COVID-19 pandemic: An advocacy perspective

Abstract

The coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome (SARS)-CoV-2, has emerged as a global public health threat. The implications are much beyond just health crisis, and it has long-lasting psychosocial and economic implications. Although the psychological offshoots such as depression, anxiety, posttraumatic stress, and sleep disturbances are being studied in-depth, there is a dearth of literature on the sexual well-being and sexual practices during this pandemic. Considering the physical distancing; travel restrictions; the high human–human transmission rate; misinformation and uncertainty about the sexual routes of transmission for SARS-CoV-2; and fear about intimacy, sexuality, and safe sexual practices have increased significantly. This is more prominent in newly settled or distanced couples and the frontline health workers, with increased risk exposure to the virus. For them, guilt and distress associated with sexual relationships might increase primary psychiatric and sexual disorders. This, in turn, impacts relationships and emotional bonding in couples and affects healthy coping during the pandemic crisis. Although sexual abstinence is the safest practice to prevent transmission, it is not practically feasible in all cases. Risk reduction counseling, sex with quarantined partners, and digital sex are other options that are worth exploring. There are additional concerns of digital safety, unhealthy use of technology, cyber-crimes, and online extortion. Keeping this in the background, this advocacy article glances through the effects of past outbreaks on sexuality, reviews the current recommendations, and proposes methods and approaches for sexual well-being during the COVID-19 pandemic, which is vital for overall public health.

INTRODUCTION

The Coronavirus disease 2019 (COVID-19) crisis

Over the last few months, the world has seen the emergence of a new public health threat. The coronavirus disease 2019 (COVID-19) caused by the novel coronavirus severe acute respiratory syndrome (SARS)-CoV-2 has brought the world down to its knees. The medical and psychosocial implications of this large-scale outbreak can potentially long outlast the pandemic itself. Till date, more than three million people have been affected globally and nearly three lakh people have been succumbing to the infection, and the numbers are rising by the day.[1] The widespread chaos regarding the uncertainty and source of infection has led to fear, panic, apprehension, and mass-hysteria. Grief for loved ones, bereavement, and isolation as a measure of “social distancing” is keeping billions segregated from their loved ones.[2] Due to the international lockdown imposed on many cities, either the families have got separated for long times or people are having a new experience of staying with their spouses or families, like never before. Physical intimacy and proximity can significantly influence the dynamics of interpersonal relationships and mend them for the better or worse.[3] The unprecedented changes imposed by COVID-19 and the containment measures have changed the living structure of millions, impacting their relationships and mental health. Research done in China during the first phase of infection shows an increase in acute stress, depressive disorders, obsessive-compulsive disorders, anxiety, panic symptoms, and insomnia. The long-term sequelae are posttraumatic stress, pathological grief, and adjustment disorders, which tend to be chronic.[4] Social interaction, intimacy, and relationships have shown to boost well-being and serve as critical coping factors during such disasters. The quarantine and travel restriction measures during the COVID-19 pandemic can trigger loneliness and negativity, which prevent healthy coping with the crisis.[5] Although literature related to this pandemic and mental health is increasing, there is a dearth of discussion on a vital aspect, the sexual and reproductive health. Sexual relations and sexuality have been important determinants of relationships and general well-being.[6] COVID-19 being a contagious infection has generated a plethora of fears related to couple intimacy, the guilt of transferring the infection to the partners (especially for the frontline workers), altered sexual dynamics and performance in newly married couples or in those who are not used to cohabiting for long periods, and also the serious concerns of domestic abuse and intimate partner violence (IPV).[7] Pandemics like this can have critical implications on sexual and reproductive health at all levels: individual, systems, or society.

In the absence of enough literature during COVID-19, the authors write this article as an advocacy document based on their clinical experience and relevant research related to past outbreaks. It will discuss the effects that infectious disease outbreaks can have on sexual health and intimacy, with perspectives from the past and present pandemics, and reviews recommendations for ensuring sexual well-being during these times of crisis.

PANDEMICS AND SEXUAL HEALTH: REVISITING THE “PESTILENCES”

”A loveless world is a dead world. The plague makes us crave more for love and the arms of our loved ones.”

– Albert Camus, The Plague (La Peste), 1948.[8]

Since the classical bubonic plague of the 13^th century, the world has faced pandemics time and gain, disrupting social structures. Surprisingly, much literature has focused on the psychosocial constructs of sexuality during this deadly disease. Tsiamis et al.[9] in “Poetic description of the plague” mentions “fear of infection disrupting love and lives.” They mention couples being separated in rooms, not even allowed to talk. The segregation was more for the higher social classes, with separate living arrangements and dining altogether. Cantor[10] mentions the social perceptions that immorality and illicit sexual relationships were causative of the plague, and physicians advised “physical distancing” and abstinence from all forms of sexual intimacy as it was related to “bad air,” then believed to be responsible for the infection. However, there are also mentions of increase in incest, prostitution, and coercive sexual practices in Europe during those days of the plague.[11] It seems surprising that when a deadly infection was sweeping off one-thirds of the European population, what is the importance of discussing human relationships. However, contrary to the popular ideas, sexuality and physical intimacy has long been involved in social theories surrounding the classical “black death” in medieval Europe. German physicians advised against jealousy and promiscuity as they open the mind to “bad emotions.”[12] Religious connotations were attached by the Church as homosexuals were accused of spreading the infection against the “Divine will,” and “sanitary legislation” was proposed based on “moral” laws to have them either publicly flogged or put out of the country.[13] Salisbury et al.[11] wrote about incest increasing significantly during the bubonic plague. The authors hypothesized that due to the widespread mortality, exogamy (marrying outside the clan or community) turned improbable. Hence, consanguineal marriages increased to preserve the patrimony, especially in the royal families, as many were on the verge of extinction. In Land, Kinship and Life-Cycle,[14] Smith pointed out the increase in the severity of fines for fornication during the middle of the plague period (1349–1350). It is interpreted as a punishment for acts that were seen as morally improper. The Courts blamed the fornicators, as “sexuality” was considered to be a potent medium for infection spread. The idea of sex and intimacy being responsible for all forms of pathogenic spread has been increasing even before the outbreak of plague and peaked in the Victorian era.[15] This was related to the social taboo, prejudice toward sexuality, and religious antagonism of sexual practices through moral standards. Ironically, there was a spur in the industry of prostitution as the plague waned off. People considered intimacy and sex to be critical coping factors for the pandemic aftermath. Sex-parlors and “royal safeguards” were built to promote safe and consensual sex.[13] Some consider this as a revolt against the orthodox blame put by the Medieval Church on the society. It has an existential angle too. Hatcher, while describing plague in England, mentioned increase in sexual practices between newly married and elderly couples to deal with the stress.[16] This was postulated to arise from the uncertainty of life and togetherness during and post the crisis times.

Unfortunately, though social research in pandemics peaked during the “black death,” literature related to sexual health and pandemics declined. The changing public health priorities and more “biological” focus to disease control might be the probable reasons. Furthermore, in the words of Cohn and Cohn,[17] people were self-stigmatized to consider an immoral topic of sexuality in the face of much more serious issues such as death and disability, though frustration and distress over physical distancing from the partners have played an active role in the social reaction to these pandemics. During the Spanish flu of 1918, social-distancing measures were considered to be oppressive by many.[18] As the administrative line, “You are your safest sexual partner” gained popularity, so was the common quote, “We want to be quarantined together” by couples that established itself as a landmark romantic comment in many books and movies later in time. Sex steroids for enhancing sexual potency and pregnancy were considered to be risk factors for the influenza outbreak while birth control methods gained importance.[19] There were reports of discrimination against sexual minorities and increase in violence and abuse in families.[20] With an increase in the understanding of molecular biology and pathogenesis, fear has grown more about sexual transmission of infections and the degree of permissible intimacy during the outbreaks. There have been debates about the same during the SARS and the Middle East respiratory syndrome (MERS) outbreaks. Chua et al.[21] while studying the psychological effects of the SARS outbreak reported an increase in sexual dysfunction, decreased arousal, and increased marital discord over issues of intimacy. Long-term psychosocial and occupational outcomes of health-care workers dealing with SARS patients showed a rise in erectile dysfunction (ED), premature ejaculation (PME), lack of sexual satisfaction in partners, and heightened performance anxiety. This contributed to the burnout, work stress, absenteeism, substance abuse, and depressive disorders. Substance use also had a positive relationship with sexual dysfunction, anxiety, and partner violence and an inverse relationship with perceived sexual satisfaction in the couples.[22] SARS and MERS had led to adverse pregnancy outcomes such as miscarriages, abortions, intrauterine growth retardation, and maternal deaths, which is proposed in COVID-19 as well, which generates fear among sexually active couples.[23] New infections with unknown pathways of transmission always tend to create considerable apprehension about pregnancy and vertical routes of transmission. Hence, the implications of safe sexual practices and sex education become paramount during these times. Ebola outbreak in Africa had a possible sexual mode of spread, which led to significant discrimination based on race, ethnicity, and sociocultural status.[24] The lesbian, gay, bisexual, transgender (LGBT) community were stigmatized as “carriers” for the same. The psychological models adopted for the Zika outbreak in Brazil and Nipah infection in India involved sex education about the viral transmission among partners, social connectedness, and focusing on alternative forms of expressing love and intimacy, while observing physical distancing.[25,26] This becomes vital as sexual well-being has been linked with positivity, hope, personal growth, and overall health, especially at times of disasters.

CORONAVIRUS DISEASE 2019, SEX, AND SEXUALITY

Literature related to sexual health and current COVID-19 pandemic is still in their infancy. The global lockdown has led to marked “physical and social” distancing, and the implications are chronic. Unfortunately, sexual well-being is often neglected at the face of more significant immediate concerns. Given the importance of sexuality in people's lives and its relationship with quality of life, and psychiatric disorders, physicians need to stay sensitive to this issue, routinely ask or screen for sex-related complaints, and incorporate primary sex education tailored to the present outbreak in their patient counseling. Considering the social stigma attached behind sexuality and the varied sociocultural expression, the dictum that holds true clinically is that “You don't ask, and they don't tell.” The summary of the present evidence on COVID-19 suggests that any form of close human–human contact can spread the virus.[27] The SARS-CoV-2 is much more contagious than its earlier congeners, which is the proposed reason for such speedy global spread. The virus gets easily carried by aerosol and fomites, can remain viable in air for up to 3 days, and survive on various inanimate objects for 2–3 weeks. This further generates fear and frustration related to intimacy. It is all the more for frontline workers against COVID-19 who self-quarantine themselves to prevent interaction with their families. Those who return to their spouses have expressed marked guilt, fear, and apprehension.[28] This eventually affects the interpersonal relationship, closeness, sexual practices, and an overall lead to discord and emotional distancing in couples.[29] Looking from the other side, recreational sex when billions are stranded at home, without family planning measures, can lead to increased abortions and population boom with time. Such consequences are unprecedented. Like human rights, sexual and reproductive rights also need to be safeguarded during such biological disasters. Singh and Adhikari while studying the age-structured impact of social distancing on the COVID-19 epidemic in India, have mentioned the emotional distress of the adolescents and younger adults due to separation.[30] Sentiment analysis from Twitter has shown the lockdown in India to instigate fear, disgust, and stigma. People have reported concerns about physical distancing and traveling to their partners, more so in those who have recently started relationships or got engaged.[31] Keeping in mind the social situations that might arise due to this pandemic and lockdown, the possible ways in which sexual lives and relationships can get affected are summarized in Table 1.

Table 1.

Probable sexuality and intimacy-related issues during the coronavirus disease 2019 pandemic

Effect on sexuality/sexual practices	Contributing factors
Sexual abstinence	Fear related to intimacy
	Travel history of partners
	Uncertainty about transmission
	Physical distancing
Coercive sexual practices/IPV/incest	History of IPV
	Marital discord/disharmony
	Couples stranded together away from family (more contact time)
	Substance abuse Increased pornography use
	Crowding in joint families (less supervision)
Noncompliance to precautions/lockdown	Frustration and distress associated with prolonged sexual abstinence
	KAP gap about healthy sex
Increase in paraphilias	History of sexual deviations
	Fear/restriction of conventional sexual acts
Disinterest in sex	Chronic stress
	Anxiety, uncertainty related to pandemic
	Depression, PTSD, and adjustment disorders
	Guilt
	Loneliness and isolation
Unhealthy use of technology (pornography addiction, use of dark web)	Isolation/quarantine
	History of substance abuse, externalizing personality traits, ADHD
	Compulsive use of technology
	Lack of partners/social support
Interpersonal issues	Lack of intimacy
Extramarital relationships	Prolonged sexual abstinence
Marital discord/disharmony	Physical distancing
	Increased sexual appetite/sex addiction
The rise in sexual disorders (erectile dysfunction, premature ejaculation, arousal disorders, etc.)	Preexisting sexual problems
	Chronic stress
	Depression, anxiety, psychoses (new onset or exacerbation)
	Chronic abstinence
	Interpersonal issues
	Heightened performance anxiety (fear of infection)
	Decreased self-esteem
High-risk sexual behaviors	Personality traits
	The psychological impact of lockdown
	Poor knowledge about sexual risks and contraception matters
Increased viral spread	Indiscriminate sexual practices without understanding the transmission risk

IPV – Intimate partner violence; KAP – Knowledge-attitude-practice; PTSD – Posttraumatic stress disorder; ADHD – Attention deficit hyperkinetic disorder

SEXUAL ABSTINENCE: A FEASIBLE SOLUTION?

Sexual abstinence is the practice of voluntarily refraining from some or all aspects of sexual activity. It can arise from deliberate ideological or philosophical reasons (chastity and celibacy) or situational reasons (prevention of infection and conception), lack of suitable partners, or to conform to legal provisions.[32] In infectious disease outbreaks, abstinence is considered to be the safest practice to prevent spread. For decades, the psychological effects of sexual abstinence have been debated in all age groups. The traditional association of abstinence and better “vitality of nerves and brain” has not been scientifically proven.[33] There are other views related to chastity and puritanism about sexual abstinence, which are beyond the scope of this article. In this discussion, we will stick to the situational need for abstinence during the pandemic, and not refer to the moral or religious connotations of it. Sex is often considered to be a stress reliever and an indicator of well-being in couples. It also forms an essential parameter of relationship dynamics.[34] It is vital to understand the difference between asexuality and celibacy. Any obligation to stay abstinent involuntary sexual lives can cause distress. For sexually active couples, not being able to be intimate due to physical distancing or fear of infection can be traumatic. Many might be stranded alone, feeling lonely in the absence of their partners. This becomes more concerning in couples who have just moved in together. Here, by abstinence, we also mean a lack of any form of intimacy, including foreplay, which can impact the self-esteem and well-being of couples. Preexisting marital issues can be amplified as there might be discordance of opinion related to sexual practices between the partners. Sexual frustration and loss of affection are other offshoots. Chronic sexual repression has shown to affect performance anxiety and sexual confidence, which can eventually lead to arousal disorders, anorgasmia, PME, and ED. It can also increase the risk of chronic diseases such as diabetes, hypertension, and cardiovascular illness.[35] Studies related to the prevalence of these disorders as the aftermath of pandemics are, however, scarce. Fear of intimacy can lead to emotional distancing from the partner, which leads to loneliness, poor coping, and sleep disturbances, all of which are independent risk factors for depression and anxiety. Although masturbation is often considered to be a replacement for partnered sex, there are significant differences between the emotional processing and perceived satisfaction from both.[36] Sex has been termed as “emotionally binding,” and it increases the sense of emotional closeness among couples.[34] Although some studies have shown beneficial effects of abstinence on self-control, spirituality, and well-being, they were on individuals who practiced abstinence as a voluntary lifestyle.[37] During infectious disease outbreaks, it is more of an “imposed abstinence” to prevent the spread. Bogart et al.[38] studied 1917 adolescents, recruited from mid-school, and assessed them periodically. They found a relationship between sexual abstinence among females and better mental health, which no longer existed once educational variables, family bonding, and conventionality factors were accounted for. In another study, sexually abstinent men were compared with those with high-risk sexual behavior having HIV, and the authors reported that the two groups had similar prevalence of depression, burnout, anxiety, and insomnia.[39] HIV, however, having entirely different social dynamics and established routes of sexual transmission will be different from other infectious diseases. Psychological distress and sexual abstinence have been shown to share a bi-directional relationship, as increased stress can also induce people to avoid sexual activities altogether. This factor becomes vital during disasters such as COVID-19 as the financial crisis, unemployment, fear of infection, health anxiety, travel restrictions, and uncertainty all can contribute to the collective stress and hence the varied sexual behavior.[29] Prolonged sexual abstinence might also lead to the emergence of high-risk sexual behavior, substance abuse, gambling, and compulsive self-gratification as harmful coping strategies.[40] Sexual oppression at the time of emergencies has led to adverse physical and psychological consequences. Considering these factors, total sexual abstinence alone might not be an effective measure to promote sexual well-being during pandemics.

SAFETY OF SEXUAL PRACTICES DURING CORONAVIRUS DISEASE 2019: REVIEWING THE RECOMMENDATIONS

SARS-CoV-2 is present in respiratory secretions and has aerosolized droplet spread. Data so far suggest that the virus can be transmitted through respiratory droplets to the skin and personal objects, from which it can infect the sexual partner.[27] Hence, any form of in-person sexual activity carries the potential risk. Data related to other routes of sexual transmission are sparse. The virus was not detected in semen or vaginal samples in two small studies.[41,42] However, another study detected SARS-CoV-2 by reverse transcriptase-polymerase chain reaction in semen samples of six patients.[43] Even the detection of the virus in urine samples is equivocal.[44] Saliva has also been considered to be potential media for cross-contamination in dental practice, and recommendations of testing saliva for viral particles have been suggested.[45] To summarize, the pathophysiology and epidemiology of COVID-19 are yet extensively studied. Considering the large-scale spread of the infection, it is clinically prudent to consider all of these modes as a source of potential contamination, unless proven otherwise with clear evidence. Many individuals might feel too stressed for sex and prefer to delay it till situation normalizes. It is a normal stress reaction, and their partners need to accept it. Stress responses during pandemics can vary widely.

SAFETY ABOUT SEX/INTIMACY DURING THE CORONAVIRUS DISEASE 2019

The Center for Disease Control and Prevention (CDC) recommends a minimum distance of 6 feet to avoid transmission, which is impossible for intimate relationships.[46] As mentioned before, any in-person contact carries the potential risk for infection. However, total isolation is not necessary in all cases. Case-by-case safety assessment and decision-making is better. If both the couples are asymptomatic, have been practicing precautions, and have no history of travel or exposure, touching, hugging, kissing, and intercourse are likely to be safe. Sharing the bed with partner and dining together can also be done. After community transmission in many countries, asymptomatic carriers are rising. That always carries a potential risk, which cannot be negated.

SEX/INTIMACY WHEN A PARTNER IS SYMPTOMATIC

Of late, any flu-like symptom generates panic, as it can mimic COVID-19. Although the clear-cut distinction is difficult, high fever, sore throat, respiratory distress, and history of exposure (might not always be present) are useful cues.[47] The WHO and Indian Council of Medical Research have standard protocols for testing and quarantine, which need to be followed. Ideally, based on CDC recommendations, if any partner is a suspect, self-quarantine is necessary without bed-sharing or any form of intimacy till at least 7–14 days after the symptoms started, or till full resolution of all symptoms, or at least up to 72 h of being fever free without any medications.[48] For hospitalized patients, negative testing for severe infections is recommended before discharge. A study from Shenzhen, China, had reported 15% transmission in household contacts, which can be minimized using strict hand and respiratory hygiene.[49]

SEX/INTIMACY FOR FRONTLINE HEALTH WORKERS

Health-care staff, police personnel, delivery executives, or other people involved in essential services have an added vulnerability. Many tend to self-isolate themselves from their spouses, adding to the psychological distress. The most important thing is keeping the partner informed about the risk, using adequate hygiene measures, using a separate set of clothes, having different room for occupational requirements, etc. Based on the degree of risk, isolation can be discussed and decided upon by both the partners. Unilateral decision-making can harm intimacy and relationships. If the partner at risk is asymptomatic, the decision about sexual activities is personal and can be tailored based on mutual preferences and convenience, as there are no evidence-based guidelines for the same. Partner consent is vital in these cases.

There are many who have newly entered relationships or just got married. Many of their partners might be away. For these couples, the challenges might be much more, and the need for continuation of intimacy and digital sexual practices becomes essential. Masturbation, phone or video sex, pornography, and sex toys might be helpful measures.[50] However, the unhealthy use of technology, pornography addiction, personal and digital safety, and cyber-crimes are often the concerns. Research points out that although pornography can be a self-gratifying replacement for in-person sex, it also tends to be compulsive, can distort ideas about sex, and contribute to partner violence.[51] The inner anxiety of the pandemic, sexual abstinence, and the resultant psychological distress might contribute to sexual disorders in the postpandemic period. Physicians of all specialties need sensitization and awareness for detecting these problems, offering appropriate sex counseling, and initiating referrals if necessary. Special attention needs to be offered to the sexual minorities, adolescents, and the elderly to prevent them from stigma and prejudice during this pandemic – people who are sexually active need to be advised about contraception and risks to pregnancy if infected. The various sexual approaches during the pandemic (most least to most risky) are summarized in Table 2.

Table 2.

Proposed sexual approaches during the coronavirus disease 2019 pandemic

Sexual practice/methods	Details
Abstinence	Ideal and safest, not always practically feasible
Masturbation/self-gratification	Low risk for transmission
	Safe masturbation tips as followed in STD[52](washing hands before touching genitals, clean sex toys, not sharing sex toys, using new condoms each time, nonirritant, and safe lubricant)
Digital sex	Appropriate and mutual consent
	Sociocultural acceptance
	Risks of data leakage and theft
	Sexual extortion
	Sexual details/images of minors can have legal consequences
	Risk of cyber harassment and online sexual predation
	Special counseling for children and adolescents
Sex with a self-quarantined partner	Least risk to others
	Asymptomatic carriers pose a potential risk
	Increased risk of multiple sexual partners
Continuation of usual sexual activities	Risk reduction counseling[53] Reducing the number of sexual partners
	Risk of infection and transmission routes, sex education
	Awareness about performance anxiety, sexual frustration, and symptoms of sexual disorders
	Identifying COVID-19 symptoms and avoid sexual contact if present
	Wearing mask, hand and respiratory hygiene before and after intercourse
	Cleaning of the place of sexual intimacy
	Avoiding sexual behaviors that can lead to orofecal contact
	Minimum contact intimacy and regulated frequency of sex, if a suspected risk
Miscellaneous	Informed decision-making
	Emotional support and bonding
	Spending quality time
	Communication; sharing hope and joy
	“COVID-” free time

STD – Sexually transmitted disease; COVID-19 – Coronavirus disease 2019

ENSURING HEALTH SEXUALITY AND SEXUAL WELL-BEING: THE WAY FORWARD

Total abstinence and self-gratification can be the safest measures, but not always practically feasible. Abstinence-only approaches have been shown to induce guilt, decrease self-esteem, and increase noncompliance to recommended legal provisions.[54] Human needs for intimacy need to strike an appropriate balance with personal safety and infection control. The health-care workers need to be empathic and nonjudgmental in these discussions with the couples, as for many, it might be a sensitive and stigma-inducing topic. Many might be hesitant to express it at all. Minors can tend to withhold valuable information (suicidality, high-risk sexual behaviors, abuse, sexual bullying, etc.), if not interviewed in confidence. People can be encouraged to engage in digital sex (such as sexting or video sex), with an eye for the safety concerns. The mutual consent of the partners is, however, an essential consideration. Digital theft has increased during the pandemic, especially with specific platforms such as Zoom, which can lead to leakage of personal data and sexual extortion.[55] Encrypted and password-protected digital platforms are safer. The risks and legal implications need to be informed and discussed. The administration also needs to be aware of the increased use of digital forums for intimacy and change in cyber security monitoring and policies as necessary. For some minors and others with limited technology access and practice, digital intimacy might not be possible, and other avenues might need to be explored. Telephonic expression of affection can help closeness and relationships. Being dismissive of the sexual needs during such a crisis might be counter-productive for both the clinicians and the clients. It is especially important to identify any signs of abuse or IPV at the earliest and steps to be taken immediately. The national mental health helplines related to COVID-19 can liaise with related services by the Ministry of Health and Family Welfare, Government of India.[56] The women, child and elder helplines can also be integrated to help and counsel abuse victims, catering to their safety.

Another safe approach is to self-quarantine with partners if exposure has already occurred with an acceptable degree of risk. In that case, sexual practices can be feasible.[57] Those who cannot engage in this might continue their sexual relationships in a controlled frequency, with risk reduction counseling. This has helped in reducing the transmission of sexually transmitted diseases (STDs). Indiscriminate sexual practices without understanding the risk of transmission can enable a much faster spread of COVID-19. Unwanted pregnancies need to be prevented and education on the use of contraceptive measures and protection from STDs need to be incorporated in the counseling modules. People affected with HIV form a susceptible section of the population, and the CDC gives particular guidelines about SARS-CoV-2 infection in HIV.[58] Preexposure prophylaxis needs to be diligently followed. Widespread misinformation has turned COVID-19 into an “infodemic,” which is an added burden to public health. Myths related to sexual transmission can further impair safe sexual practices. Community health workers need to be active for sexual health counseling and exploring the emotional needs during the pandemic; socioculturally appropriate and multilingual infographics providing information-education-communication about sexuality during COVID-19 can help at the primary level. Active liaison of health care with media is necessary for increased penetration at all levels; mainly social media can be a uniquely equipped tool in this field for sexual health communication and promotion.[59] Authentic sources such as the WHO and CDC are best used for reference. Few websites have useful counseling guidelines for discussion with children about online sexual risk during the pandemic.[60]

Beyond all the other aspects of intimacy, emotional bond between partners is vital during a global crisis. Sexuality is much beyond just foreplay or intercourse. It involves holistic closeness and emotional bonding between partners. This becomes all the more critical during such pandemics, with various restrictive measures in place. Communication is the key, and informed mutual decision-making can help relationships progress. The lockdown has led many couples to be stranded together for a long time, a chance that was long due. This time can be used for generating love and intimacy, to mend strained relations, and fostering new avenues of trust and hope, that can last long beyond the pandemic threat. Spending quality time together, sharing happiness, staying away from “information overload,” and cherishing “COVID-” free time every day, can help regenerate the intimacy.[2] Any form of abuse needs immediate reporting, as otherwise, it tends to become a vicious and recurrent pattern. Another vital issue is the sociocultural acceptance of sexual practices in our country. Traditionally, from the descriptions of Kamasutra to the modern-day literature, intimacy has always been viewed in terms of “personal touch,” and cyber closeness thus becomes a culturally dissonant concept.[61] Digital sexuality has often been equated with “obscene” or “inappropriate” based on traditional ideas, for which it might be difficult to adapt it even at such times of crisis.[62] In that context, even with the use of technology for psychosexual well-being, the partners need to discuss and tailor it according to their beliefs, values, and ideals. A discordance in this area can be further damaging.

CONCLUSION

Sexual health and well-being have been extensively spoken about in the early days of “pestilences” and since then, fallen neglected during pandemics, subsumed by other health priorities. New advances might emerge with the innovative use of technology for both social and sexual connectedness. Digital intimacy can be an effective way of closeness in relationships; however, the authors do not intend to advocate that it is mandatory. It is an option that the couples can mutually choose for sexual well-being. Given the many facets of “digital sexuality” discussed above, it is more of a tailored choice and not a generic recommendation.

Antibody testing used to have a prime role in the detection of sexual risk for HIV,[63] and similar hopes can be expected in COVID-19 too. Antibodies to the causative novel coronavirus might render someone safe as a sexual partner. As research progresses in this field, sexual medicine needs to be integrated into public health as an integral indicator of psychosocial well-being. Mental health counseling at all levels needs adequate sex education tailored to the needs of pandemics. Awareness and knowledge-attitude-practice among the health-care professionals can improve beyond the stigma, prejudice, and taboo related to the discussion about the sexual matter.

Cross-sectional and longitudinal studies need to estimate the prevalence and risk factors of sexual disorders and their sociocultural differences and predictors of the same during a pandemic. Qualitative studies are much-needed assets to understand the in-depth and lived experiences of sexuality in couples and their practices of intimacy and unmet needs. Sexual counseling can be specialized for children, adolescents, the elderly, and LGBT community, who are more vulnerable to social and sexual stigmatization. Sexuality has moved beyond just an emotional requirement to a “rights-based” approach. Lessons learned now might help psychological preparedness and ensure psychosexual health during futuristic crises. It is high time we discard the “moral” veil of sexuality and start considering it as a natural indicator of human well-being, which needs to be nurtured for healthy relationships. In that sense, COVID-19 might be another chance for us to integrate sexual well-being into broader public health practices for the greater good.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.