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Sexual relationships during the lockdown: Adjusting sex counselling and therapy to the restriction of quarantine

Evie Kirana
Member of the ESSM Educational Committee
Executive co-Director of International Online Sexology Supervisors (IOSS)

Francesca Tripodi
Member of the ESSM Educational Committee
Executive co-Director of International Online Sexology Supervisors (IOSS)

Sexual relationships during the lockdown: adjusting sexual counselling and therapy to the restriction of quarantine

Introduction

Since the World Health Organization (WHO) has declared a pandemic over a new coronavirus which causes an illness known as COVID-19, we have gradually learned that the virus can spread to people who are within 6 feet (2 meters) of an infected person when he/she coughs or sneezes (respiratory droplets), or through direct touch with an infected person or object. Many countries asked their citizens to remain in their houses, close businesses and all events that may involve a gathering of people. Lockdown policy went into effect to avoid spreading the virus.

The pandemic with the consequent lockdown was, therefore, a period characterized by social isolation, uncertainty and stress. We still have a lot to learn about COVID-19 and sex. Coronavirus has been found in semen (1), feces (2) and urine (3) of people with COVID-19, but not in vaginal fluids. However, the relevance regarding sexual transmission remains unknown. Until this is better understood, specialists suggest considering these secretions potentially infectious (4). Anyhow, these data are moot, given that any in-person contact results in substantial risk for disease transmission owing to the virus’ stability on common surfaces and propensity to propagate in the oropharynx and respiratory tract.

The broad guidance regarding physical distancing had substantial implications for sexual well-being. We still don’t have enough data about the impact on the intimate relationships or the sexual life of people. Most of the health agencies recommended the following which led to a change in people’s sexual behavior:

  • Singles who are self-isolated should not have sex with people who do not live with them;
  • People can have sex with someone they live with and shows no symptoms if they both feel well and avoid contact with people outside their household.

Because many COVID-19–infected people are asymptomatic, Health Care Providers (HCPs) were left with little to offer beyond guidance to not engage in any in-person sexual activity.

In this article, we are sharing some thoughts and speculations about the challenges that this pandemic and lockdown period possibly brought to people’s relationship and sex life. Moreover, leading a project on online clinical supervision for HCPs from all over the world (www.sexologysupervisors.org), we met the needs of many professionals about guidance and support in counselling patients in this difficult time. We take the occasion to participate in the current debate about treatment challenges and opportunities for sexual therapy during the quarantine.

Dealing with stress and emergency

During the pandemic, people varied in the way they dealt with stress and emergency. For example, some people felt the need to binge on the news and read every article on the web, while others preferred to set boundaries and strictly select the information they process. A feeling of emergency and fatality overwhelmed some people, while others were focused on maintaining a stable daily routine. Some people adopted a proactive coping style and others adopted a passive coping style. Some individuals focused on problem-solving while others focused on the emotional regulation of their anxiety. As with every stressor, people have their own coping styles. Within the couple, when partners don’t share a common coping style conflict may arise. However, it is also an opportunity to increase mutual understanding and acceptance of each other’s way to manage life burden. On the other hand, some couples feel more efficient and skilled when it comes to working together towards a common goal, compared to having fun or having sex together. For these couples, this external stressful situation may increase the feeling of being united and enhance appreciation of each other’s presence. This stressful period probably didn’t affect all couples in the same way. Those that were skilled to manage important stressors, even if the coping styles varied, were more likely to navigate through this period while maintaining a feeling of connectedness.

Loss of social relationships

If we think of the people that are involved in one’s life beyond the primary partner and the children, then we can easily see the gap that was experienced during the lockdown.

People experienced a sudden loss of contact with their close friends, the broader social network, those involved in childcare or housework, professional colleagues, various service providers (psychotherapist, physiotherapist, trainer, etc.), and some people also lost contact with their extramarital relationships. However, this broad social network has an important function for the primary relationship. It serves to cover needs that are not covered within the dyadic relationship. For example, the need for play, need for inspiration, for attention, for care, etc. But during the lockdown, these relationships were on halt. This increased reliance and expectations from the primary partner (e.g., share childcare and housework, have fun time together, cope with stress, share professional concerns, share erotic moments). Individuals that expected their partner to substitute all the above roles probably experienced disappointment. Individuals that focused on how they can contribute positively to their own needs and to the relationship instead of focusing solely on the contribution of the partner adopted a more productive and fruitful role. For example, if instead of blaming the other for being boring one tried to find ways to be creative himself while respecting the other’s need for being quiet, the home was likely to become a space where all needs were covered instead of space where only one’s needs are valued.

Loss of daily routine and structure

During the lockdown, usual routines were disrupted. Children were going to bed much later than usual, parents were working on the dining table or falling asleep on the couch watching a movie, weekends were similar to weekdays, family time was merged with individual time. Actually, in a period of chaos and feelings of not being in control, many homes felt messy because of loss of structure. But what impact did it have on erotic relationships? The loss of structure makes the present feel less important. It takes away the sparkle of the moments. For example, eating on the dinner table by just putting the laptop and stationery aside to fit the plates instead of setting the dinner table in a way that makes it a special moment. Or going to bed at 04.00 am after having fallen asleep on the couch instead of going to bed after sharing a drink with the partner on the balcony. Flashes seem more unique when they are different from other situations and they have our full attention. Family time is special when it is separated from working time. Weekends are special when they are different from weekdays. Intimacy moments are special when they are different from individual time. A loss of structure can take away the enthusiasm and exclusiveness of one’s moments. Some couples created a structure in their daily routines and were able to preserve the reward of their moments. Others were overwhelmed by non-structure and felt that they lost the sparkle of their days including their occasions of eroticism and intimacy.

Loss of the ability to walk away

During the lockdown, couples weren’t able to walk away when they got into an argument. They weren’t able to go somewhere when they felt fed up with each other. This could increase the amount of attention placed on the argument and thus prolong or intensify conflict. Distancing can help people understand their negative emotions and healthily express them without losing control. This is not about suppressing the negative feelings; it’s about increasing understanding of one’s own feelings and needs. During the lockdown, couples that were used to healthy management of their negative emotions could communicate their needs and didn’t necessarily need to walk away. Distancing could occur by just going to another room or just not being present. On the contrary, couples that were used to being aggressive and insulting when feeling negative emotions lost the ability to walk away from violent behavior. The UN reported that domestic violence during the lockdown was intensified (5). In France, domestic violence had increased by 30% since March 17th; during the first two weeks of lockdowns in Spain, the emergency number for domestic violence received 18 percent more calls; helplines in Singapore have received 30 percent more calls. As NBC News reported, law enforcement agencies across the U.S. have seen domestic violence cases rise to 35 percent in recent weeks.

Infidelity and flirting

Internet communication allows people to feel a host of emotions without requiring any physical connection. People can feel sexual desire; they can feel wanted, understood, funny, special through online communication. This can happen at almost all times of the day and from every corner of the house. It is possible to flirt and chat with many people without even getting off the couch. It is possible to have an online affair while the primary partner is in the same room. Online communication can bring feelings of bonding or intimacy even during the lockdown. So, the pathways that could cover needs for intimacy and sexual expression where still there, thanks to technology. A lot of sexual activity moved online causing an increase of cybersex, phone sex, sexting, online sex parties, online affairs, as well as dating apps during the lockdown, compared to before. According to the Economist, in April the average number of messages sent daily across Match products, including OkCupid, PlentyOfFish, Tinder, Hinge and Match.com, was up by 27 per cent compared with the last week of February. During the worst week of China’s epidemic, in late February, the average user of TanTan, a Chinese app, spent 30 per cent longer on the app than normal. As a matter of fact, the available time for that could have increased during the lockdown. Between late February and late March, the average length of a conversation on Tinder, one of the most popular apps, surged by 25 per cent. Therefore, online pathways allowed flirting, intimate relationships and sexual expression when physical mobility was restricted.

Sexual behavior during the lockdown

The empirical data on the sexual behavior of the population during the pandemic and the lockdown is still very limited. NBC News is conducting a poll to measure how coronavirus has impacted people’s sexual life (6). Currently, over 11.000 participated: 22% answered the outbreak had positively affected their sex lives, 28% were neutral, while 50% declared it had affected them negatively. A British study presented data from a cross-sectional epidemiological online survey (7). In this sample of 868 UK adults self-isolating owing to the COVID-19 pandemic, the prevalence of sexual activity was lower than 40%. Sexual activity was defined as sexual intercourse, masturbation, petting, or fondling, so it was not restricted to partnered sex. Therefore, about 60% of the study population reported no sexual activity, including masturbation. In another study that was conducted on a convenience sample of 270 men and 189 women living in a Chinese epidemic area, 25% of the participants experienced a reduction in sexual desire, while only 18% of men and 8% of women experienced increased sexual desire (8). A subanalysis of married individuals showed that 49% of married men and 29% of married women reported a decrease in the number of sexual partners, and 36% of married men and 28% of married women reported a decrease in the frequency of sexual activities. According to this study, during the COVID-19 outbreak, 32% of men and 39% of women experienced a reduction in sexual satisfaction. Some data were also obtained by a cross-sectional study conducted among individuals of three south-east Asian countries (Bangladesh, India & Nepal) from 3rd April 2020 to 15th April 2020 (9). The sample consisted of people that were cohabiting with their partner. Most of the participants said they had sexual intercourse with their spouse 1 to 5 times a week before the lockdowns, and this was mostly unchanged during the lockdowns. Only about 3.3% of the participants indicated that sexual activity had increased from 1 to 5 times a week to more than five times a week after being locked down. This increase could be the result of seeking intimacy and reassurance, or simply having more time to spend with their partner, but this is just an assumption. Different results to these studies were obtained by a Turkish study on female sexual activity (10). Interestingly, this study reported an increase in sexual desire and sexual activity of women. Also, there was a decrease in sexual satisfaction, a decrease in FSFI scores and more menstrual disorders. These studies provide some preliminary data on the sexual activity of the general population. However, they do not provide a good understanding of the factors that explain the sexual activity reported. For example, the contribution of mood states or relationship quality were not assessed. It could be assumed that the role of such factors moderated the influence of the pandemic on sexual activity and behavior during this period.

Sexual dysfunction and concerns as a result of the lockdown

The effect of the lockdown and the pandemic on the prevalence of sexual dysfunctions has not been reported until today. As most definitions of sexual dysfunctions require the problem to be present for at least 6 months, then we could assume that it is still early to have evidence for an increase on these disorders because of the pandemic and the lockdown. For example, a decrease in sexual desire doesn’t necessarily indicate a dysfunction if it is not present for a significant amount of time and if it is not experienced with significant distress. Besides, an increase in masturbation practices does not indicate a compulsive sexual behavior disorder. As a matter of fact, as scientists, we need to be especially cautious of mistakenly interpreting situational adaptations of sexual behavior to one’s mood or priorities as sexual disorders and dysfunctions. In addition to the above, we have no data about the impact of the lockdown and the pandemic on the course of sexual dysfunctions that were pre-existing.

We already know that general mood states, relationship quality and the sexual context are factors that influence sexual function and satisfaction. To the extent that the pandemic had a negative impact on these factors, we could assume that there was a higher risk for developing or maintaining a sexual problem. On the contrary, if the pandemic had a positive influence on these factors, we could suppose that there was a positive influence on sexual function. For example, for couples that experienced more time together, less daily stress and more intimacy we could imagine that sexual functioning was improved. For couples that experienced negative mood, conflict and less privacy, we could infer that sexual problems were experienced or exacerbated.

Adjusting sexual counseling and therapy to lockdown

Tip 1

Given the important role of sexuality in most peoples lives, HCPs should consider opening up a conversation with patients on this topic whenever possible

Sexual expression is a central aspect of human health but is often neglected by HCPs. Messaging around sex being dangerous may have insidious psychological effects at a time when people are especially susceptible to mental health difficulties. Sex can be a great stress reliever, but dating – casual or not – is indefinitely on hold for many people around the world. That is why facilitating brief conversations and referrals to relevant resources can help patients maintain sexual wellness during the pandemic. During all talks, HCPs should express a nonjudgmental stance to encourage comfortable discussion and minimize shame. This is particularly important with minors because the fear of judgment can lead them to withhold information about sexual risk behaviors (4).

It should be considered that this is an unprecedented and stressful time for HCPs as well; changes in working time, setting, and habits, different priorities, few or no guidelines on how to manage the patients’ needs due to the lockdown, several challenges in their private life, these are all factors continuing to impact the way they work.

Here below there are some suggestions we found useful in orienting colleagues on sexual counseling and therapy during this period.

Tip 2

As we continue to fight the pandemic, HCPs should consider counseling on safe sexual practices and risk reduction as the first-line approach during the quarantine.

Fig. 1: Range of sexual practices organized from least to most risky

Adapted from: The NYC Health Department (nyc.gov/health) (6) and Turban et al., 2020 (4).

Abstinence is the lowest-risk approach to sexual health during the pandemic. Given that abstinence-only recommendations, however, are likely to promote shame and unlikely to achieve intended behavioral outcomes, sex-positive recommendations regarding maintaining the sexual activity are optimal during the pandemic, balancing human needs for intimacy with personal safety and pandemic control. Therefore, although suggested by some health agencies, we strongly advise not to counsel patients on this approach.

Masturbation is an additional safe recommendation for patients to meet their sexual needs without the risk for COVID-19 infection. “You are your safest sex partner”: this is a motto we can use in counselling patients to satisfy their sexual needs through self-stimulation. The lockdown could be a good period to explore sexual fantasies and discover different ways to give pleasure to our own body. HCPs can suggest reading/watching/listening erotica, trying sex toys, experience different stimulations by modifying a rigid pattern.

Sexual activity via digital platforms can be a good alternative in time of quarantine. Patients can be counseled to engage in sexual activity with partners via telephone or video chat services. Privacy concerns could be an issue, so good advice is to use secure encrypted platforms. Clear consent is mandatory; therefore, patients should be warned about the risk of others taking screenshots of conversations or videos and sexual extortion. Minors should be counseled on potential legal consequences if they own sexual images of other minors.

Sex with someone you live with is the safest approach for those who complete abstinence from in-person sexual activity is not an achievable goal. For couples who are quarantining in the same house, this could be the best option, and even an opportunity to improve their sexual life. Patients should be counseled about the risk for infection from the sex partner if they have been exposed while outside the home or from an asymptomatic COVID-19–infected partner.

Sex with anyone outside your household is the riskiest approach in pandemic time. Patients should be counseled on the risk for infection from partners who didn’t follow a strict quarantine, as well as risk reduction techniques that include:

  • minimizing the number of sexual partners
  • avoiding sex partners with symptoms consistent with COVID-19
  • avoiding kissing and sexual behaviors with a risk for fecal–oral transmission or that involve semen or urine
  • wearing a mask
  • showering before and after sexual intercourse
  • cleaning of the physical space with soap or alcohol wipes

Tip 3

HCPs should inform about taking care measures during pandemic.

Simple and clear instructions can guide the patients on how to enjoy sex and to minimize the spreading of COVID-19:

  • Avoid kissing anyone who is not part of your small circle of close contacts. Kissing can easily pass the virus.
  • Condoms and dental dams can reduce contact with saliva, semen or feces during oral or anal sex
  • Wear a face covering or mask
  • Make it a little kinky, finding positions or putting “barriers” to reduce intense physical contact
  • Masturbate together with the partner, and reduce face to face proximity
  • Washing up before and after sex is more important than ever:
    • Hands
    • Toys
    • Keyboards and touch screens
  • Skip sex if you or your partner is not feeling well:
    • Closely monitor yourself for symptoms 
    • Take precautions to interact with people at risk (over 65 years of age or with serious medical conditions)
  • If you have sex with multiple partners, pick partners you trust if possible. Talk about COVID-19 risk factors, just as you would discuss PrEP, condoms, and other safer sex topics. Ask them about COVID-19 before you hook up. Consider the following:
    • Limit the size of your guest list
    • Pick larger, more open, and well-ventilated spaces 
    • Wear a face covering, avoid kissing, and do not touch your eyes, nose, or mouth with unwashed hands 
    • Bring an alcohol-based hand sanitizer 
  • If you usually make a living by having sex, consider taking a break from in-person dates. Video dates, sexting, subscription-based fan platforms, sexy “Zoom parties” or chat rooms may be options for you.
  • Prevent HIV, other sexually transmitted infections (STIs) and unplanned pregnancy.

Tip 4

HCPs should consider different settings in providing their services. Lists of walk-in Health Services should be spread as much as possible trough call centres and media.

Online sexual predation and gender-based violence have increased since the pandemic began. Moreover, limited access to Health Care Services put sexual and reproductive health and rights at risk. Children, women and sexual minorities should be considered very carefully during the lockdown, especially those people who may benefit from immediate counseling, medical care and support. Health Services and professionals should be available finding new ways to be reached. In Tab.1 a list of what we think could be the setting options and the essential services we should provide in pandemic time.

Tab.1: Settings and services during the lockdown

SettingsServices
HotlineHIV-STIs (PrEP-PEP, treatment)
Online consultationUnintended pregnancy
Online chatEmergency Contraception
Email counsellingFertility and Prenatal Care
Mobile counsellingViolence and abuse
Social mediaCancer Screening

Tip 5

For health services to be immune to future lockdowns, digital technology needs to be endorsed as a tool that has a central role in sex therapy. Legal, technological and scientific regulations are needed and require special attention.

During the lockdown, most sex therapy sessions were moved online. However, to our knowledge, the request for sessions was significantly decreased in the first 2 months. This could be because some patients were not familiar and didn’t feel comfortable with online consultations. Some people didn’t have enough privacy to talk freely from their house. In addition, some people placed less importance to their sexual problem during the pandemic. Some people had lost their job, some had lost a friend or relative, some were highly concerned about their health and the health of their family, some were over-occupied with homeschooling. Therefore, their sexual problem was not considered urgent or a timely need. For others, the pandemic period didn’t stop the sexual problems from being a bothersome or important concern. Sex therapy for couples that were cohabiting was not a different process than before other than the fact that the sessions were online and that the role of mood, health and occupational concerns were now more prominent than in the pre-pandemic period. The most challenging sessions were for those patients that were single or in distance from their partner. For single patients, flirting, casual sexual encounters or paid sex may be integrated to the treatment approach. During the lockdown, these strategies were limited although some people had the opportunity to expand their flirting repertoire through the online apps. For those couples that were in distance, some sexual interaction could be maintained or explored through digital communication. For example, performance anxiety could be experienced even with digital sexual encounters, and therefore there was some space for developing management approaches. People with hypersexual like behavior (e.g. high frequency of pornography consumption and cybersex) were at risk of experiencing an exacerbation of their symptoms due to boredom and social isolation. Although the treatment-seeking rates for such conditions during the lockdown have not been reported, we assume that they were rather low in the first period, slowly increasing with the passing time.

Apart from these observations, what should we expect from people with sexual dysfunction in a lockdown situation? Probably, those who are single or self-quarantining are more likely to experience a decreased anxiety about their sexual life, while those partners quarantining together are more likely to feel more anxious because of the “forced” nearness.

Tip 6

HCPs should benefit from more time to listen/advice and, on the other hand, take advantage of free time and better collaboration of the patients.

Clinicians should encourage their patients in taking care of their sexual problems during the lockdown situation. This could be a special time to combine education, treatment and practice. Those who are in relational isolation can use the lockdown to recover their self-esteem and confidence in sexual performance. For example, men with premature ejaculation can try the effect of topical agents and/or medication (dapoxetine) by masturbating, finding the best ways, in terms of time and dose, to use them. They can practice with condoms (for some men a difficult issue when with a partner), and different modalities of stimulation (with lubricants, toys, or alternative strategies) to improve their control over the ejaculation. Women with generalized anorgasmia can discover their sexual pleasure and the best way to self-stimulate. They can expand their awareness with some exploration exercises, finding the most arousing stimuli, learn direct masturbation using vibrators or erotica, increase their knowledge on how to get an orgasm with intercourse reading specific books or website.

With couples, we can help partners in modifying rigid sexual repertoires and encourage them removing barriers to intimacy. Specifically, we can guide the partners in improving their sexual communication, sharing their sexual preferences, planning sexual encounters and focusing on pleasure, instead of performance. The authentic boost for intimacy, during the lockdown, could be the “outercourse” (everything but penetration), a series of techniques aiming to enhance the sexual experience with both partners having greater opportunity to orgasm (11,12).

Human needs in the era of uncertainty

Trauma is defined as deeply distressing or disturbing experience. With post-traumatic stress disorder, after suffering a trauma, a person experiences intrusive negative thoughts and psychological distress. During this pandemic, people saw on the news what was happening in China, South Korea and Italy and anticipated the same to happen in their local community. People felt the psychological consequences of the trauma well before the actual trauma was experienced. We could call this a ‘pre-traumatic’ stress disorder. Still today, it’s not clear if the trauma is over or yet to come. Within this environment of great uncertainty, people live their lives. In or out of lockdown, the need for connection, for love, for flirt and sexual expression remain. These human needs may be amplified or reduced, but they remain. The clinical significance of the dynamic interplay among sexual well-being, psychological individual-level factors and the societal environment during the pandemic remains to be understood.

For the predictable future, HCPs will need to incorporate new scientific advances regarding COVID-19 into how they think about sexual health and risk. Antibody tests may play a key role in how we evaluate sexual risk (4), but further research is needed to evaluate how reliable the antibody tests are, and to what extent these tests can inform about risk assessment. It will be important for HCPs to proactively discuss with patients what we learn from the emerging science, with the awareness that sexual health is a value and an important human right.

References

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4. Turban JL, Keuroghlian AS, Mayer KH. Sexual Health in the SARS-CoV-2 Era [published online ahead of print, 2020 May 8]. Ann Intern Med. 2020;M20-2004. doi:10.7326/M20-2004
5. https://www.unwomen.org/
6. https://www.nbcnews.com/think/opinion/health-sex-coronavirus-how-does-sexual-intimacy-change-during-pandemic-ncna1169811
7. Jacob L, Smith L, Butler L, et al. COVID-19 social distancing and sexual activity in a sample of the British Public [published online ahead of print, 2020 May 14]. J Sex Med. 2020;10.1016/j.jsxm.2020.05.001. doi:10.1016/j.jsxm.2020.05.001
8. Li W, Li G, Xin C, Wang Y, Yang S. Changes in Sexual Behaviors of Young Women and Men During the Coronavirus Disease 2019 Outbreak: A Convenience Sample From the Epidemic Area [published online ahead of print, 2020 Apr 29]. J Sex Med. 2020;S1743-6095(20)30597-X. doi:10.1016/j.jsxm.2020.04.380
9. Arafat SMY, Alradie-Mohamed A, Kar SK, Sharma P, Kabir R. Does COVID-19 pandemic affect sexual behaviour? A cross-sectional, cross-national online survey [published online ahead of print, 2020 Apr 30]. Psychiatry Res. 2020;289:113050. doi:10.1016/j.psychres.2020.113050
10. Yuksel B, Ozgor F. Effect of the COVID-19 pandemic on female sexual behavior. Int J Gynaecol Obstet. 2020;150(1):98-102. doi:10.1002/ijgo.13193
11. https://www.bustle.com/p/7-outercourse-techniques-to-help-you-orgasm-build-intimacy-according-to-sex-experts-80269
12. Michael Dawn, The ultimate intimacy guide for passionate people, Pillow Book Media, 2017.

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