Dear Editor:

COVID-19 is having a tremendous impact on the healthcare and economic systems worldwide, as well as on human behavior, negatively affecting both personal and social relationships. COVID-19 is an acute respiratory illness caused by the SARS-COV2, with transmission that occurs via droplets or direct contact with contaminated objects (i.e., fomites).1 As such, first-line preventive strategies are the increase of social distances and of all the general prevention measures focusing on infective respiratory diseases (i.e., droplets barriers and contact isolation).1 

The lockdown period, as well as all the other preventive measures (including isolation) carried out to face the COVID-19 diffusion, has dramatically changed sexual behavior and the sex life of couples. Theoretically, the more available private time might help couples to reconnect at an intimate level and improve their sexuality. Nonetheless, a recent study on a large sample of quarantined couples has shown that the majority of them experienced a reduction in sexual intercourse per week, due to poor household privacy and lack of psychological stimuli; on the contrary, reduced autoeroticism was not reported.2 Besides, a reduction in the number of sexual partners per single subject and in the frequency of fortuitous sexual intercourse has been reported, as well as a concomitant reduction of risk behaviors for sexually transmitted infections (STIs).3–5 

These findings might be related to fears of the COVID-19 pandemic implications affecting either the lives of couples or the lives of friends and relatives, with the production of feelings of anxiety and panic. Sometimes, these feelings can degenerate into further negative psychological reactions, including adjustment disorder and depression, negatively affecting sexual health.6 

It has been shown that adolescent sexual minorities expressed worry about COVID-19, and nearly all of them reported physical distancing, which adversely impacted mental health by reducing their sense of social connectedness.7 Confinement, as well as the illness itself, are both causes of stress. Indeed, there is no doubt that most people would experience some degree of emotional distress following isolation, social distancing, loss of relatives and friends, difficulties in securing medications, as well as the obvious economic consequences of lockdown. Sexual activity is closely associated with mental and psychological health, and it is, therefore, unsurprising that sexual desire and sexual intercourse frequency have declined in both sexes during this pandemic.

Moreover, the association between higher levels of mental distress, being single, and having casual sex during the imposed isolation due to the COVID-19, highlights the burden of loneliness.7 This latter is a main indicator for low levels of well-being and a risk factor for mental disorders, such as depression, anxiety, and adjustment disorder, negatively affecting sexual health. 

However, poor knowledge of the potential sexual transmission of SARS-COV2 might play a pivotal role on such an avoidant sexual behavior. In fact, the presence of SARS-COV-2 has been reported in feces, as well as in seminal fluids of male individuals, including those who did not present symptoms and signs of the disease, indicating that COVID-19 could be an STI.8

Though this concern might cause a reduction of sexual intercourse in most people, there are still some categories that are at higher risk of STIs, including men who have sex with men (MSM), that represent an important public health challenge during the pandemic.5 The fear for a potentially fatal disease, likely to cause death in a short period of time, could lead to the avoidance of sexual activities, such as kissing, soft sex, or oral sex. On the other hand, the MSM indifference to high-risk sexual behaviors could determine an increase of unprotected fast sex, especially anal intercourse.5 

A recent online survey administered to MSM showed that participants who violated social-distancing restrictions sought to minimize physical contact with their sexual partners, and modified their sexual behaviors (e.g., by avoiding kissing their partner), in the attempt to reduce their exposure to the virus.9 They also reduced their intake of drugs or alcohol and used condoms or pre-exposure prophylaxis (PrEP) more often. Surprisingly, although human immunodeficiency virus (HIV) is a life-long condition, and its health outcomes in younger patients without medical treatment are usually worse than those of COVID-19, participants, were more scared of COVID-19 than acquired immunodeficiency syndrome (AIDS). This could be due to the uncertainty surrounding COVID-19 in the absence of an effective vaccine or medical treatment, added to its distressing news on the media.

This is why more information on sexuality and COVID-19 is needed for both stable pairs and STIs high risk groups, including adolescents and MSM. The principles of human rights can help us find ways to try and solve this important concern: 1) fostering community participation; 2) focusing on nondiscrimination with an open dialogue on hot topics; 3) working to ensure the availability, accessibility, acceptability and quality of services; 4) providing access to information, ensuring transparency and accountability in the response to the pandemic.10 

As a multidisciplinary approach integrating medical, psychosexological, behavioral, and social perspective is therefore necessary to provide people with the right information on sexuality in the COVID-19 era, telemedicine could be helpful. Telecounseling exists in the psychological service performed online, which provides individuals, couples, or groups with psychological support and/or psychotherapy. This is as effective as conventional therapy, and it is well accepted by both healthcare professionals and patients. Digital tools minimize direct contact with vulnerable populations, without compromising assistance or methodological rigor. In fact, the implementation of telepsychology during the COVID-19 pandemic can help protect participants and operators from the infection, and it also allows for specific psychological interventions to reduce the long-term psychological effects of social isolation.11 In particular, using psychological telesupport, clinicians, including sexologists and psychotherapists, should provide individuals with clear information on sexual health in the COVID-19 era. 

Guidelines regarding sexual life during the pandemic are based on expert opinion, and some authors proposed that sexual practices should be avoided because of the risk of COVID-19 infection. The main route of COVID-19 transmission is through respiratory droplets, aerosols, and person-to-person contact through cough, sneeze, droplet inhalation, and transmission and contact transmission (such as the contact with oral, nasal, and eye mucous membranes). The risk question of sexual transmission is still unanswered, as it is unknown whether people with STIs are at a greater risk of contracting COVID-19. The fact that the virus has been found both in semen and feces might explain the rationale for avoiding oral sex, as viral shedding can also occur from the anus and contaminate the genitals. Given that the risk of transmission between asymptomatic individuals through kisses, hugs, and physical proximity is known, these practices should be avoided for those who do not live in the same household.12 Moreover, social distancing is still the best measure to be taken; partners who live separately should reinvent loving and sexual relationships, whereas strengthened intimacy is recommended to those who live together.13 Indeed, a high-quality relationship is beneficial for physical, mental, and sexual well-being, as negative relationships generally induce deeper responses to stress and worsen mental and sexual health.11,12 Nonetheless, as physical proximity and contact are seen with much discomfort and physical contact is still discouraged, advising on new forms of intimacy, including cybersex, is of great importance for sexual health in this dramatic period. This latter advice is particularly important to high-risk groups for STIs, as they need a further support to better deal with these issues. In fact, for these people, telepsychology could be the best solution to overcome social and physical barriers.

In conclusion, because the COVID-19 pandemic is still unfolding, and it is difficult to predict how long it is going to last, it is highly necessary to provide proper and scientific evidence-based information, including telepsychology, to overcome the prevailing unrealistic beliefs and myths concerning COVID-19 infection and sexual health.


The author wishes to thank Prof. Agata Grosso for English editing.


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With regards,

Rocco Salvatore Calabrò, MD, PhD

IRCCS Centro Neurolesi, “Bonino-Pulejo”, in Messina, Italy

Funding/financial disclosures. The authors have no conflict of interest relevant to the content of this letter. No funding was received for the preparation of this letter.