Abstract
Aim:
This study aimed to evaluate the impact of lockdown on sexual functioning in India. In addition, impact of lockdown on relationship with the partner and mental health was evaluated.
Materials and Methods:
An online survey was conducted using changes in sexual functioning questionnaire, Patient Health Questionnaire-4, and a self-designed questionnaire.
Results:
The mean age of the participants was 41.5 (standard deviation: 11.2; range: 22–77; median: 39.5) years, with the majority being males 385 (85.6%). The participants reported that lockdown led to reduction in the frequency of sexual intercourse and also touching the partner (fondling, caressing, touching, or kissing) when not indulging in sexual intercourse. Majority of the participants reported improvement in the overall relationship, communication with the partner, and interpersonal conflicts. About two-fifths of the participants reported engaging in sexual intercourse more than twice a week or more. About one-fifth screened positive for psychiatric morbidity, with 14.2% screened positive for anxiety, 14.8% screened positive for depression and 8.7% screened positive for both. In both genders, presence of depression and anxiety were associated with lower sexual functioning in all the domains.
Conclusion:
Lockdown led to a reduction in the frequency of sexual intercourse, and reduction in the frequency of intimacy in the form of fondling, caressing, touching, or kissing partner when not doing sexual intercourse. However, lockdown led to the improvement in overall relationship and communication with the partners and a reduction in interpersonal conflicts.
Keywords: COVID-19, lockdown, sexual dysfunction
INTRODUCTION
Novel coronavirus 2019 (nCoV/SARS-CoV-2/COVID-19) outbreak has posed extreme challenges for survival to humanity. To deal with the COVID-19 infection, most of the countries went through a phase of “lockdown” and are now gradually unlocking. During the initial phase, “lockdown” led to no entry/exit movements, and the persons were required to stay wherever they where. Lockdown was considered as both preventive strategies and an emergency strategy to save the lives of the vulnerable or at-risk persons. Government of India implemented “lockdown” with effect from March 25, 2020, across the country to control the spread of COVID-19.[1] Lockdown had a significant negative impact on the mental health and overall functioning of the person.[2] Additional strategy which was recommended to tackle the spread of COVID-19 infection included social distancing, which possibly impacted the interaction with others.
Lockdown for a man meant staying at home for a longer duration of period and availability of longer time to interact with the spouse.[3] Lockdown for women meant an increase in the workload for women, because of everyone being at home throughout the day, higher work pressure, more chances of domestic violence, and interpersonal relationship issues.[3] Considering the impact of lockdown on domestic violence, the World Health Organization issued an advisory against domestic violence.[3] However, despite increase in the workload, the “lockdown” gave women more opportunity to spend time with their spouses.[4]
Lockdown possibly provided more opportunity for sexual intimacy for the couples.[4] Few studies from different parts of the world have evaluated the impact of social distancing, quarantine, and lockdown on sexual activity.[5,6,7] An online survey from the United Kingdom, which involved 864 participants showed that, during the period of self-isolation/social distancing, about two-fifth (39.9%) of the participants engaged in sexual activity at least once per week. The presence of sexual activity was associated with being a male, of younger age, taking alcohol, being in a marital relationship or a domestic partnership, and longer duration of self-isolation/social distancing.[8]
Another study from Turkey, which evaluated the sexual functioning of 58 females, showed that, compared to 6–12-month period of prepandemic time, the frequency of sexual intercourse during the pandemic increased significantly, and there was a significant improvement in the female sexual functioning index score, compared to that during the time before the pandemic. However, when compared before a pandemic, there was a significant reduction in the use of contraception and desire to become pregnant during the pandemic. In addition, this study showed that there was an increase in menstrual disorders during the pandemic.[7] A study from Italy evaluated the sexual satisfaction of 1515 respondents who were quarantined. This study showed a reduction in the frequency of sexual intercourse during the period of quarantine, compared to the earlier. However, the majority of the participants reported sexual desire to be similar (39.2%) or more than (40.66%) to the previous times. A majority of the participants (78.88%) reported indulging in autoerotism, and this was similar (29.44%) to or more than 39.74% than earlier. There was an increase in the consumption of pornography and marked reduction in sexual satisfaction during the period of being quarantined. It was also seen that sexual dissatisfaction in men was associated with age, whereas in females, it was associated with age, a higher level of depression, and knowing people positive for COVID-19.[5]
Little is known about the impact of the COVID-19 pandemic on sexual functioning in people from India. Over the period, many myths have also emerged related to sexual intercourse (such as sexual intimacy with partner can lead to spread of COVID infection) and pregnancy (transmission of COVID infection from mother to the newborn during the process of birth) during the COVID times.[9] These can influence the sexual intimacy. Accordingly, there was a need to evaluate the impact of lockdown on sexual functioning. This online survey evaluated the impact of lockdown on sexual functioning, which had not been determined yet in the Indian context. In addition, impact of lockdown on relationship with the partner and mental health was evaluated.
MATERIALS AND METHODS
This was an online survey conducted using Survey Monkey® platform through a link which was sent to people using either Whattsapp® or E-mail, using the nonprobability snowball sampling. Initially, the links were circulated by the researchers to thier contact and the people receiving the survey link were requested to forward the link further. People receiving the survey link were at freedom to participate or not to participate in the survey. Similarly, there was no compulsion to forward the survey link to others on those receiving the survey link. These were ensured by the nonprobability snowball sampling in that after the initial circulation of the survey link, the direct involvement of the researcher was absent.
The survey invitation mentioned that the participants would have the right not to participate in the survey, and participation in the survey would imply providing informed consent. The participants were also informed that the responses will be anonymized, and there was no chance of them getting identified. The survey link was circulated during the period of May 14 to June 6, 2020. To be included, the participants were required to be aged more than 18 years. The survey was carried out using bilingual (English and Hindi) questions.
Clicking on the invitation link implied providing consent for participation in the study.
The Ethics Committee of the Indian Psychiatric Society approved the study, and the survey was conducted under the aegis of Research, Education, and Training Foundation of the Indian Psychiatric Society.
Instruments used
Changes in Sexual Functioning Questionnaire (CSFQ):[10] The CSFQ is a reliable and valid measure of sexual functioning, which is useful in both clinical and research settings. This is a structured questionnaire designed to measure illness- and medication-related changes in sexual functioning. The scale has separate male and female versions, both of which have 14 items, with each item rated on a 5-point Likert scale. English and Hindi version of the scale, which were available, were used. Permission was sought from the original author of the scale, for use.
A self-designed questionnaire was used to evaluate the effect of lockdown on the relationship with the partner and frequency of sexual intimacy in the past and during the lockdown.
Patient Health Questionnaire-4 (PHQ-4):[11] The PHQ-4 is a self-administered questionnaire, which has the depression and the anxiety modules, to screen for depression and anxiety, respectively. This questionnaire has excellent reliability and validity, sensitivity and specificity of 88% for major depression.
Data were analyzed using SPSS 20.0 (IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp., 2011), and the descriptive analysis in the form of frequency, percentages, the mean and standard deviation (SD) was calculated. Comparisons were made by using t-test and Chi-square test.
RESULTS
During this survey period of May 14 to June 6, 2020, 514 responses were received. All the responses which were received from outside the country, verified using the IP addresses were excluded. Similarly, responses received from people below 18 years were also excluded. Responses which were incomplete were not considered for the final analysis. The entries were also checked for duplicacy, and in case of doubt, such responses were excluded. Out of the response received, 26 responses were incomplete, 1 was from a participant <18 years, 6 were from outside India, and 31 were from those who did not have a partner. All these responses were deleted. Finally, 450 responses were found to be complete in all aspects and were analyzed. Majority of the participants were male, married, and postgraduates. The mean age of the participants was 41.5 (SD: 11.2) years. Small proportions of the participants were suffering from chronic physical illness and were on any regular medications. Majority of the participants were spending more than 1 h/day on the screen media [Table 1].
Table 1.
Sociodemographic profile of the participants
| Variables | Frequency, n (%)/mean (SD) |
|---|---|
| Age (years) and range (median) | 41.5 (11.2), 22-77 (39.5) |
| Number of participants aged>65 years | 20 (4.4) |
| Sex | |
| Male | 385 (85.6) |
| Female | 65 (14.4) |
| Marital status | |
| Married and living with spouse | 389 (86.4) |
| Married and living away from spouse | 35 (7.8) |
| Umarried but in a live-in relationship | 4 (0.9) |
| Divorced | 4 (0.9) |
| Single | 17 (3.8) |
| Others (did not specify) | 4 (0.9) |
| Education level | |
| Up to matric | 2 (0.4) |
| Intermediate | 4 (0.9) |
| Graduate | 143 (31.8) |
| Postgraduate | 301 (66.9) |
| Occupation | |
| Student | 2 (0.4) |
| Business | 27 (6.0) |
| Housewife | 12 (2.7) |
| Professional | 260 (57.8) |
| Self-employee | 155 (34.4) |
| Retired | 13 (2.9) |
| Type of family set-up | |
| Husband and wife only | 76 (16.9) |
| Husband, wife, and children | 172 (38.2) |
| Husband, wife, children, and parents | 158 (35.1) |
| Joint/extended family | 40 (8.9) |
| Did not response | 4 (0.9) |
| Do you have a personal bedroom | |
| Yes | 410 (91.1) |
| No | 40 (8.9) |
| Are you suffering from any chronic physical illness | |
| Yes (for example-hypertension, diabetes mellitus, chronic obstructive pulmonary disease, asthma, and rheumatoid athritis)# | 68 (14.8) |
| Are you receiving any regular medication for any illness | |
| Yes | 33 (7.2) |
| Time spent watching television, using social media, laptop, facebook, whatsapp, twitter, etc. | |
| Up to 1 h/week | 53 (11.8) |
| 1-3 h/day | 165 (36.7) |
| 3-6 h/day | 150 (33.3) |
| 6-9 h/day | 55 (12.2) |
| 9-12 h/day | 15 (3.3) |
| >12 h/day | 12 (2.7) |
#Hypertension (n=11), diabetes mellitus (n=6), diabetes mellitus and hypertension (n=3), hypothyroidism (n=2), chronic pain (n=16), PCOS (n=1), coronary artery disease (n=1), chronic kidney disease with asthma (n=1), depression (n=1). SD=Standard deviation, PCOS=Polycystic ovary syndrome
To understand the impact of lockdown on sexual functioning, the participants were asked to keep the month of December 2019 in mind (to give the responses for the time before lockdown), while responding the questions enquring about prior sexual functioning. Lockdown led to reduction in the frequency of fondling, caressing, touching, or kissing partner when not indulging in sexual intercourse and reduction in the frequency of sexual intercourse [Table 2].
Table 2.
Comparison of sexual activities before and during the lockdown period
| Prior to lockdown (n=450), n (%) | During the lockdown (n=450), n (%) | Chi-square test (P) | |
|---|---|---|---|
| Time spent in watching porn/reading erotic material per week | |||
| Nil | 181 (40.2) | 178 (39.6) | 12.263 (0.092) |
| <15 min/week | 101 (22.4) | 82 (18.2) | |
| 15-30 min/week | 76 (16.9) | 64 (14.2) | |
| 30-60 min/week | 39 (8.7) | 47 (10.4) | |
| 1-2 h/week | 31 (6.9) | 38 (8.4) | |
| 2-3 h/week | 6 (1.3) | 19 (4.2) | |
| 3-6 h/week | 8 (1.8) | 10 (2.2) | |
| >6 h/week | 8 (1.8) | 12 (2.7) | |
| Frequency of masturbation and sexual self-pleasuring acts | |||
| More than once per day | 11 (2.4) | 15 (3.3) | 4.578 (0.333) |
| Once per day | 27 (6.0) | 33 (7.3) | |
| Few times in a week | 113 (25.1) | 109 (24.2) | |
| Few times in a month | 169 (37.6) | 144 (32.0) | |
| Never | 130 (28.9) | 149 (33.1) | |
| Frequency of fondling, caressing, touching or kissing partner when not doing sexual intercourse | |||
| More than once per day | 118 (26.2) | 124 (27.6) | 9.883 (0.042*) |
| Once per day | 66 (14.7) | 54 (12.0) | |
| Few times in a week | 142 (31.6) | 115 (25.6) | |
| Few times in a month | 84 (18.7) | 94 (20.9) | |
| Never | 40 (8.9) | 63 (14.0) | |
| Frequency of sexual intercourse | |||
| More than once per day | 14 (3.3) | 21 (4.7) | 2.163 (<0.001***) |
| Once per day | 42 (9.6) | 46 (10.2) | |
| Few times in a week | 175 (39.1) | 168 (37.3) | |
| Few times in a month | 188 (41.5) | 143 (31.8) | |
| Never | 31 (6.5) | 72 (16.0) |
*P<0.05; ***P<0.001
When enquired about the impact of lockdown on the overall relationship with their partner, the majority of the participants reported improvement in the overall relationship, communication with the partner, and interpersonal conflicts [Table 3].
Table 3.
Impact of lockdown on the relationship with the partner
| Variables | Very much improved, n (%) | Somewhat improved, n (%) | Not changed, n (%) | Somewhat worsened, n (%) | Very much worsened, n (%) |
|---|---|---|---|---|---|
| Overall relationship with my partner during lockdown period | 129 (28.7) | 124 (27.6) | 156 (34.7) | 33 (7.3) | 8 (1.8) |
| Level of communication between you and your partner during the lockdown period | 155 (34.4) | 119 (26.4) | 146 (32.4) | 24 (5.3) | 6 (1.3) |
| The interpersonal conflicts between you and your partner during lock-down period | 98 (21.8) | 119 (26.4) | 187 (41.6) | 40 (8.9) | 6 (1.3) |
Majority of the participants reported lack of privacy issues (54.1%) during the lockdown period. However, one-third of the participants reported some privacy issue (32.8%) and a small proportion of them reported significant privacy issues (13%). In terms of availability of contraception, a majority (76.7%) reported no worries related to the availability of contraception; a small proportion reported worries related to contraception “somewhat (17%)” and “very much (6.3%).”
As per the assessment of PHQ-4, 14.2% screened positive for anxiety, and 14.8% screened positive for depression. A small proportion (8.7%) screened positive for both, and overall prevalence of psychiatric morbidity (depression, anxiety, or both) was 20.4%.
As is evident from Table 4, less than half of the participants of either gender reported, “much” or “great” enjoyment or pleasure in their sexual activity at the time of assessment. Only about two-fifths of the participants reported engaging in sexual intercourse more than twice a week or more. Other details are shown in Table 4. Similarly, only a small proportion of the females reported indulging in various sexual activities. The mean CSFQ score for males was 44.9 (SD: 9.5), and that for females was 40.2 (SD: 11.8). Overall, female had significantly lower scores on all the domains except for the pleasure domain [Table 4].
Table 4.
Sexual functioning as assessed by change in sexual functioning questionnaire
| Variables | Male frequency, n (%)/mean (SD) (n=385) | Female frequency, n (%)/mean (SD) (n=65) | Chi-square test/t-test (P) |
|---|---|---|---|
| Compared with the most enjoyable it has ever been, how enjoyable or pleasurable is your sex life right now? | |||
| No enjoyment or pleasure | 46 (11.9) | 10 (15.4) | 1.234 (0.873) |
| Little enjoyment or pleasure | 56 (14.5) | 11 (16.9) | |
| Some enjoyment or pleasure | 109 (28.3) | 18 (27.7) | |
| Much enjoyment or pleasure | 101 (26.2) | 14 (21.5) | |
| Great enjoyment or pleasure | 73 (18.9) | 12 (18.5) | |
| How frequently do you engage in sexual activity (sexual intercourse, masturbation, etc.) now? | |||
| Never | 40 (10.4) | 11 (16.9) | 13.541 (0.009**) |
| Rarely | 51 (13.2) | 12 (18.5) | |
| Sometimes (more than once a month, up to twice a week) | 110 (28.6) | 25 (38.5) | |
| Often (more than twice a week) | 140 (36.4) | 9 (13.8) | |
| Everyday | 44 (11.3) | 8 (12.3) | |
| How often do you desire to engage in sexual activity? | |||
| Never | 25 (6.5) | 6 (9.2) | 3.888 (0.421) |
| Rarely | 42 (10.9) | 11 (16.9) | |
| Sometimes (more than once a month, up to twice a week) | 103 (26.9) | 19 (29.2) | |
| Often (more than twice a week) | 132 (34.3) | 19 (29.2) | |
| Everyday | 83 (21.6) | 10 (15.4) | |
| How much now frequently do you engage in sexual thoughts (thinking about sex, sexual fantasies)? | |||
| Never | 11 (2.9) | 7 (10.8) | 29.973 (<0.001***) |
| Rarely | 51 (13.2) | 16 (24.6) | |
| Sometimes (more than once a month, up to twice a week) | 91 (23.6) | 26 (40.0) | |
| Often (more than twice a week) | 127 (32.9) | 9 (13.8) | |
| Everyday | 105 (27.35) | 8 (12.3) | |
| Do you enjoy books, movies, music or artwork with sexual content? | |||
| Never | 53 (13.8) | 8 (12.3) | 11.136 (0.025**) |
| Rarely | 88 (22.9) | 23 (35.4) | |
| Sometimes (more than once a month, up to twice a week) | 110 (28.6) | 23 (35.4) | |
| Often (more than twice a week) | 81 (20.9) | 9 (13.8) | |
| Everyday | 53 (13.8) | 2 (3.1) | |
| How much pleasure or enjoyment do you get from thinking about and fantasising about sex? | |||
| No enjoyment or pleasure | 28 (7.3) | 7 (10.8) | 6.459 (0.167) |
| Little enjoyment or pleasure | 63 (16.4) | 17 (26.2) | |
| Some enjoyment or pleasure | 108 (28.1) | 18 (27.7) | |
| Much enjoyment or pleasure | 122 (31.7) | 13 (13.8) | |
| Great enjoyment or pleasure | 64 (16.6) | 10 (15.4) | |
| How often do you have erection related or unrelated to sexual activity (male)/how often do you become sexually aroused? (female) | |||
| Never | 62 (16.1) | 5 (7.7) | 11.092 (0.026*) |
| Rarely | 60 (15.6) | 19 (29.2) | |
| Sometimes (more than once a month, up to twice a week) | 90 (23.3) | 19 (29.2) | |
| Often (more than twice a week) | 88 (22.9) | 10 (15.4) | |
| Everyday | 85 (22.1) | 12 (18.5) | |
| Do you get an erection easily? (male)/are you easily aroused? (female) | |||
| Never | 18 (4.7) | 7 (10.8) | 37.558 (<0.001***) |
| Rarely | 29 (7.5) | 18 (27.7) | |
| Sometimes (more than once a month, up to twice a week) | 71 (18.4) | 17 (26.2) | |
| Often (more than twice a week) | 96 (24.9) | 11 (16.9) | |
| Everyday | 170 (44.2) | 12 (18.5) | |
| Are you able to maintain an erection (male)/do you have adequate vaginal lubrication during sexual activity (female)? | |||
| Never | 17 (4.4) | 7 (10.8) | 21.537 (<0.001***) |
| Rarely | 37 (9.6) | 10 (15.4) | |
| Sometimes (more than once a month, up to twice a week) | 61 (15.8) | 19 (29.2) | |
| Often (more than twice a week) | 111 (28.8) | 19 (29.2) | |
| Everyday | 159 (41.3) | 10 (15.4) | |
| How often do you experience painful, prolonged erection? (male)/how often do you become aroused and then lose interest? (female) | |||
| Never | 256 (66.5) | 31 (47.7) | 10.822 (0.029*) |
| Rarely | 78 (20.3) | 20 (30.8) | |
| Sometimes (more than once a month, up to twice a week) | 23 (5.9) | 9 (13.8) | |
| Often (more than twice a week) | 21 (5.4) | 4 (6.2) | |
| Everyday | 7 (1.85) | 1 (1.5) | |
| How often do you have an ejaculation? (male)/how often do you experience an orgasm? (female) | |||
| Never | 45 (11.7) | 3 (4.65) | 23.879 (<0.001***) |
| Rarely | 46 (11.9) | 21 (32.3) | |
| Sometimes (more than once a month, up to twice a week) | 85 (22.1) | 19 (29.2) | |
| Often (more than twice a week) | 137 (35.6) | 13 (20.0) | |
| Everyday | 70 (18.2) | 9 (13.8) | |
| Are you able to ejaculate when you want to? (male)/are you able to have orgasm when you want to? | |||
| Never | 27 (7.0) | 17 (26.2) | 57.228 (<0.001***) |
| Rarely | 42 (10.9) | 22 (33.8) | |
| Sometimes (more than once a month, up to twice a week) | 81 (21.1) | 12 (18.5) | |
| Often (more than twice a week) | 139 (36.1) | 7 (10.8) | |
| Everyday | 95 (24.7) | 7 (10.8) | |
| How much pleasure or enjoyment do you get from your orgasms? | |||
| No enjoyment or pleasure | 21 (5.5) | 5 (7.7) | 22.899 (<0.001***) |
| Little enjoyment or pleasure | 36 (9.4) | 18 (27.7) | |
| Some enjoyment or pleasure | 86 (22.4) | 16 (24.6) | |
| Much enjoyment or pleasure | 142 (36.9) | 11 (16.9) | |
| Great enjoyment or pleasure | 100 (25.9) | 15 (23.1) | |
| How often do you have painful orgasm? | |||
| Never | 281 (72.9) | 9 (13.8) | 87.946 (<0.001***) |
| Rarely | 57 (14.8) | 28 (43.1) | |
| Sometimes (more than once a month, up to twice a week) | 27 (7.1) | 17 (26.2) | |
| Often (more than twice a week) | 11 (2.9) | 8 (12.3) | |
| Everyday | 7 (1.8) | 3 (4.6) | |
| Mean score for the pleasure domain | 3.2 (1.3) | 3.3 (1.2) | 0.788 (0.431) |
| Mean score for the desire (frequency) domain | 6.1 (2.2) | 6.8 (2.1) | 2.423 (0.016*) |
| Mean score for the desire (interest) domain | 10.0 (2.7) | 8.6 (2.9) | 3.970 (<0.001***) |
| Mean score for the arousal (excitement) domain | 11.1 (3.1) | 9.4 (3.2) | 4.203 (<0.001***) |
| Mean score for the orgasm (completion) domain | 10.7 (2.9) | 8.7 (3.2) | 5.010 (<0.001***) |
| Mean total CSFQ score | 44.9 (9.5) | 40.2 (11.8) | 3.557 (<0.001***) |
*P<0.05; **P<0.01; ***P<0.001. SD=Standard deviation, CSFQ=Changes in Sexual Functioning Questionnaire
In both the genders, presence of depression and anxiety were associated with lower sexual functioning in all the domains [Table 5].
Table 5.
Correlation of sexual functioning with psychological morbidity
| Variables | Anxiety | Depression |
|---|---|---|
| Females | ||
| Pleasure | −0.307 (<0.001***) | −0.341 (<0.001***) |
| Desire (frequency) | −0.130 (0.006**) | −0.114 (0.017*) |
| Desire (interest) | −0.147 (0.002**) | −0.149 (0.002**) |
| Arousal (excitement) | −0.174 (<0.001***) | −0.141 (0.004**) |
| Orgasm (completion) | −0.209 (<0.001***) | −0.166 (0.001**) |
| Total CSFQ score | −0.196 (<0.001***) | −0.167 (0.001**) |
| Males | ||
| Pleasure | 0.315 (<0.001***) | −0.345 (<0.001***) |
| Desire (frequency) | −0.215 (<0.001***) | −0.177 (<0.001***) |
| Desire (interest) | −0.109 (0.022*) | −0.077 (0.103) |
| Arousal (erection) | −0.155 (0.002**) | −0.133 (0.009**) |
| Orgasm (ejaculation) | −0.237 (<0.001***) | −0.214 (<0.001***) |
| Total CSFQ score | −0.230 (<0.001***) | −0.211 (<0.001***) |
CSFQ=Changes in Sexual Functioning Questionnaire. *P<0.05; **P<0.01; ***P<0.001
DISCUSSION
This online survey evaluated the sexual functioning of the people during the lockdown period using a self-designed questionnaire and CSFQ. Findings of the present study suggest that lockdown due to COVID-19 pandemic has led to a reduction in the frequency of sexual intercourse, and reduction in the frequency of intimacy in the form of fondling, caressing, touching, or kissing partner when not indulging in sexual intercourse. Further, the present study suggests that lockdown led to an improvement in overall relationship with the partners, communication with the partner, and reduction in the interpersonal conflicts. In terms of psychiatric morbidity, the present study suggests that the prevalence of psychiatric morbidity is about 20.4%, with 8.7%, fulfilling the diagnosis of both depression and anxiety. On CSFQ, less than half of the participants reported enjoyment or pleasure in their sexual activity. About two-fifths of the participants reported engaging in sexual intercourse more than twice a week or more. When the findings of the present study are compared with an online survey from the United Kingdom, which reported the frequency of sexual activity of once per week in 39.9% of participants during the period of self-isolation/social distancing, it can be said that the frequency of sexual intercourse in participants from India was higher than that reported from United Kingdom,[8] despite participants in the present survey reporting reduction in frequency of sexual intercourse. These differences could be attributed to various psychosocial factors, demographic factors, personal/individual differences, timing of the survey with respect to the pandemic, availability of the partner, and possibly giving socially desirable answers. Our findings are also supported by the survey conducted in Italy, which also reported a reduction in the frequency of sexual intercourse during the period of quarantine, compared to the earlier.[2] This study also showed that majority of the participants indulged in autoerotism, similar to or more than the earlier; increase in consumption of pornography and marked reduction in sexual satisfaction during the period of being quarantined.[2] However, in our study, there was no significant change in the frequency of masturbation and sexual self-pleasuring acts or time spent in watching pornography or reading erotic material per week. Our findings also do not support the findings from Turkey, which evaluated females and reported an increase in the frequency of sexual intercourse during the pandemic.[7] In fact, we found that higher level of dysfunction in females. These similarities and differences in sexual behavior during the period of lockdown/self-isolation and quarantine in different countries can be attributed to a difference in cultural factors, which possibly influence sexual behavior. Besides these other factors, such as individual/personality factors, timing of the survey, sampling technique, and socially desirable responses could have influenced the frequency of sexual intercourse. In addition, the prevailing myths and incorrect beliefs in the society, with respect to the sexual intercourse and spread of COVID-19 infection.[12] The reduction in the frequency of sexual intercourse or avoidance of sexual intercourse may also be attributed to the fear of spreading the infection or contracting infection to or from the asymptomatic partner. The present study also suggests that a lower score on various domains of CSFQ was associated with higher severity of depression and anxiety scores. However, this should not be interpreted as a cause and effect relationship, as psychiatric morbidity may be a cause or effect of reduced sexual functioning. Previous studies have also reported a negative impact of psychiatric morbidity on the sexual functioning.[13]
The present study suggests that lockdown led to an improvement in the relationship with their partner. This improvement can be attributed to a possible reduction of the stress and availability of time. A previous survey from India, which evaluated the psychological impact of lockdown, also reported a positive impact on the relationships.[2] There are also reports of increase in domestic violence and worsening of relationship between couple during the lockdown period.[14,15] Hence, considering this negative impact of lockdown, it can also be said that the improvement in relationship, as noted in the present study could have been influenced by sampling bias and those with actually relationship issues, possibly not participating in the survey.
However, the prevalence of depression and anxiety in the present study was lower than that reported in the previous survey from India, which was conducted about a month before the current survey.[2] This difference could be due to the use of a brief version of PHQ in the present study, which could have led to lower prevalence of psychiatric morbidity. Other possible reason could be the fact that, at the beginning of the pandemic, there was a significantly higher level of stress, which possibly reduced with passing time and hence led to a reduction in the prevalence of psychiatric morbidity. Accordingly, it can be said that lockdown has not led to only negative consequences for the general population but has also led to some of the positive consequences in terms of improvement in the communication between the couple. Accordingly, while evaluating patients presenting with various psychological issues, it is important to enquire about both and negative aspects of lockdown, and making the patients aware about the positive aspects may help in dealing with patients who only talk about the negative consequences and the associated distress.
Findings of this survey must be interpreted in light of its limitations. The response rate was limited, and the survey was conducted by using the snowballing sampling technique. In view of this, the findings cannot be generalized to the entire country. The demographic profile of the study sample is not representative of the demographic profile of the nation; hence, the findings can not be generalized to the country. Further, the psychiatric morbidty ascertained in this survey was assessed by PHQ-4, and the same was not confirmed using any diagnostic interview by a psychiatrist. The Hindi version of the CSFQ has not yet been validated. It is possible that some of the participants would have given socially desirable answers. The survey was limited to those able to read either English and/or Hindi. The survey was also limited to those with a smart phone with internet connection or those with a valid e-mail address. In future, attempts must be made to overcome these limitations.
CONCLUSION
To conclude, this survey shows that lockdown led to a reduction in the frequency of sexual intercourse and reduction in the frequency of intimacy in the form of fondling, caressing, touching, or kissing partner when not doing sexual intercourse. However, lockdown led to an improvement in overall relationship with the partners, communication with the partner, and reduction in the interpersonal conflicts. These findings overall imply that lockdown led to improvement in the communication between the couple but led to reduction in sexual intimacy. This suggests that possibly lockdown led to improvement in relationship. Accordingly, in future, there is a need to evaluate the role of stress in day-to-day life on the relationship between couple. Further, there is a need to evaluate the role of stress management techniques in couples facing relationship issues.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
- 1.PM Narendra Modi Announces a National Lockdown for 21 Days Starting Midnight of 24-25 March-Health News, Firstpost. [[Last accessed on 2020 Sep 03]]. Available from: https://www.firstpost.com/health/pm-narendra-modi-announces-a-nationallockdown-for-21-days-starting-midnight-of-24-25-march-8185961.html .
- 2.Grover S, Sahoo S, Mehra A, Avasthi A, Tripathi A, Subramanyan A, et al. Psychological impact of COVID-19 lockdown: An online survey from India. Indian J Psychiatry. 2020;62:354–62. doi: 10.4103/psychiatry.IndianJPsychiatry_427_20. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.World Health Organisation. COVID-19 and Violence against Women. What the Health Sector/System Can Do. WHO; 2020. [[Last accessed on 2020 Sep 03]]. Available from: http://www.who.int/reproductivehealth/publications/vaw-covid-19/en/ [Google Scholar]
- 4.Banerjee D, Rao TS. Sexuality, sexual well being, and intimacy during COVID-19 pandemic: An advocacy perspective. Indian J Psychiatry. 2020;62:418–26. doi: 10.4103/psychiatry.IndianJPsychiatry_484_20. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Cocci A, Giunti D, Tonioni C, Cacciamani G, Tellini R, Polloni G, et al. Love at the time of the Covid-19 pandemic: Preliminary results of an online survey conducted during the quarantine in Italy. Int J Impot Res. 2020;32:556–7. doi: 10.1038/s41443-020-0305-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Shindel AW, Rowen TS. Challenges in the practice of sexual medicine in the time of COVID-19 in the United States. J Sex Med. 2020;17:1216–9. doi: 10.1016/j.jsxm.2020.05.011. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Yuksel B, Ozgor F. Effect of the COVID-19 pandemic on female sexual behavior. Int J Gynaecol Obstet. 2020;150:98–102. doi: 10.1002/ijgo.13193. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Lovehoney. Lockdown Lust. Lovehoney Survey Uncovers More than Half (54%) of American Couples Have Become More Sexually Adventurous during the COVID-19 Crisis. 2020. [[Last accessed on 2020 Sep 03]]. Available from: https://www.prnewswire.com/news-releases/lockdown-lust-lovehoney-surveyuncovers-more-than-half-54-of-american-couples-have-become-moresexually-adventurous-during-the-covid-19-crisis-301082179.html .
- 9.Sahoo S, Pattnaik JI, Mehra A, Nehra R, Padhy SK, Grover S. Beliefs related to sexual intimacy, pregnancy and breastfeeding in the public during COVID-19 era: A web-based survey from India. J Psychosom Obstet Gynaecol. 2020:1–8. doi: 10.1080/0167482X.2020.1807932. (online ahead of print) [DOI] [PubMed] [Google Scholar]
- 10.Clayton AH, McGarvey EL, Clavet GJ. The Changes in Sexual Functioning Questionnaire (CSFQ): Development, reliability, and validity. Psychopharmacol Bull. 1997;33:731–45. [PubMed] [Google Scholar]
- 11.Kroenke K, Spitzer RL, Williams JB, Löwe B. An ultra-brief screening scale for anxiety and depression: The PHQ-4. Psychosomatics. 2009;50:613–21. doi: 10.1176/appi.psy.50.6.613. [DOI] [PubMed] [Google Scholar]
- 12.Sahoo S, Padhy SK, Ipsita J, Mehra A, Grover S. Demystifying the myths about COVID-19 infection and its societal importance. Asian J Psychiatry. 2020;54:102244. doi: 10.1016/j.ajp.2020.102244. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Basson R, Gilks T. Women's sexual dysfunction associated with psychiatric disorders and their treatment. Womens Health (Lond) 2018;14 doi: 10.1177/1745506518762664. 1745506518762664. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Chandan JS, Taylor J, Bradbury-Jones C, Nirantharakumar K, Kane E, Bandyopadhyay S. COVID-19: A public health approach to manage domestic violence is needed. Lancet Public Health. 2020;5:e309. doi: 10.1016/S2468-2667(20)30112-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Vora M, Malathesh BC, Das S, Chatterjee SS. COVID-19 and domestic violence against women. Asian J Psychiatry. 2020;53:102227. doi: 10.1016/j.ajp.2020.102227. [DOI] [PMC free article] [PubMed] [Google Scholar]