ABSTRACTIntroduction

Recent studies have reported that the quarantine imposed in several countries around the world due to Covid-19 affected the sexual function and relationship quality. On the March 23, 2020 the Greek government imposed a national quarantine to contain the spread of the pandemic. The impact of such conditions on sexual function and relationship quality of couples is unknown.

Aim

To investigate sexual function and relationship quality of couples during the quarantine.

Methods

An online anonymous survey was conducted one month post-impose of the quarantine, between the April 21 and the May 3, 2020. Adult respondents in a relationship completed a questionnaire including sociodemographic characteristics, structured inquiries regarding sexual activity and quality of relationship, anxiety level, and mood during the quarantine, as well as the IIEF and FSFI indices.

Outcomes

Sexual function was assessed using the Greek versions of the FSFI and IIEF for females and males respectively. Sexual activity using 5 statements regarding frequency of sexual thoughts, masturbation, and intercourse, quality of intercourse and general estimation of the level of sexual function. Participants graded their level of agreement. Relationship quality was assessed using 5 questions regarding communication, company, understanding, tension and general estimation of companionship. Participants graded their level of agreement. Two additional statements were used in order to evaluate mood and the level of anxiety.

Results

A sum of 299 adult heterosexual participants in a relationship participated. Little or no negative impact on sexual function was reported. Increased anxiety and deficient mood were reported only for those with no access to their partner. Being in a steady relationship and living with their partner, but only for couples without children, resulted in satisfaction by sexual activity and enhanced emotional security.

Conclusion

Sexual function and relationship quality appeared as not affected by the quarantine and by the measures of social distancing. Sotiropoulou P, Ferenidou F, Owens D, et al. The Impact of Social Distancing Measures Due to COVID-19 Pandemic on Sexual Function and Relationship Quality of Couples in Greece. Sex Med 2021;9:100364.

INTRODUCTIONThe Covid-19 pandemic, caused by the SARS-CoV-2 is considered an unprecedented challenge for the global community. As of February 10, 2021, more than 107 million Covid-19 cases have been confirmed worldwide, with more than 2.3 million lives lost due to the virus.1

COVID-19 Map. Johns Hopkins: Coronavirus Research Center. Available at: https://coronavirus.jhu.edu/map.html. Accessed September 25, 2020.

The first case of Covid-19 in Greece was reported at the end of February 2020. On the March 23, 2020 quarantine was imposed by the Greek government in an effort to contain the spread of COVID-19 in the community. During the quarantine, circulation and gatherings in public spaces were banned, in cases possible employees worked from home, schools were shut down, and external activities were allowed only after granted permission. Similar containment measures and quarantines were implemented by several European and other countries worldwide as urgent health-protection strategies. The quarantine in Greece was terminated on the May 4 of, resulting in a total of 42 of days of social distancing and self-isolation. In contrast to other European countries such as Spain or Italy, the spread of the pandemic was successfully contained possibly because the measures of social distancing were applied on a timely manner. As a result, the number of people infected as well as the death toll were much lower compared to other European countries.2Fountoulakis KN Fountoulakis NK Koupidis S et al.Factors determining different death rates because of the COVID-19 outbreak among countries.Sexual activity is related to both physical3Sexual intercourse and risk of ischaemic stroke and coronary heart disease: the Caerphilly study., 4Lê MG Bacheloti A Hill C Characteristics of reproductive life and risk of breast cancer in a case-control study of young nulliparous women., 5Miner M Esposito K Guay A et al.Cardiometabolic risk and female sexual health: The Princeton III Summary (CME)., 6Cardiac disease, anxiety, and sexual functioning., 7Vaginal intercourse frequency and heart rate variability. and mental health,8Smith L Yang L Veronese N et al.Sexual activity is associated with greater enjoyment of life in older adults., 9Examining associations between sexual behaviours and quality of life in older adults., 10Jackson SE Yang L Koyanagi A et al.Declines in sexual activity and function predict incident health problems in older adults: Prospective findings from the English longitudinal study of ageing., 11Smith L Grabovac I Yang L et al.Sexual activity and cognitive decline in older age: a prospective cohort study., 12Sex on the brain! Associations between sexual activity and cognitive function in older age. while recent studies showed that Covid-19 negatively affected the mental health of subjects; preliminary evidence suggested that anxiety and depression, as well as self-reported stress are among the symptoms that demonstrated an upward trend since the outbreak of the virus.13Covid-19 and mental health: A review of the existing literature. Thereby, a scientific interest was raised with regards to the affect of the Covid-19 pandemic on the sexual health of populations. Studies conducted in Italy and the UK where the pandemic hit harder, revealed that sexual activity was reduced in both women and men. Schiavi et al. assessed the impact of the social distancing measures on the sexual function of reproductive-aged women in Italy; results reported a decrease in both mean sexual intercourse and FSFI scores.14Schiavi M Spina V Zullo M et al.Love in the time of COVID-19: Sexual function and quality of life analysis during the social distancing measures in a group of italian reproductive-age women. Jacob et al. investigated levels of sexual activity with relation to the Covid-19 social distancing measures in 868 male and female participants; an overall decrease of sexual activity was reported, but being a woman, unmarried and belonging in older age groups were predictive factors of sexual inactivity.15Jacob L Smith L Butler L et al.Challenges in the practice of sexual medicine in the time of COVID-19 in the United Kingdom. Suchlike were the results for both men and women in China; Li et al. investigated the impact of Covid-19 related measures on the sexual health of young individuals and found decreased sexual desire and intercourse frequency, as well as deterioration of intimate relationships.16Li G Dongdong T Song B et al.Impact of the COVID-19 pandemic on partner relationships and sexual and reproductive health: Cross-Sectional, online survey study. In Greece, online surveys regarding the impact of the Covid-19 pandemic on university students’ mental health, showed an increase in anxiety and depression levels, along with suicidality.17Patsali ME Mousa DP Papadopoulou EV et al.University students’ changes in mental health status and determinants of behavior during the COVID-19 lockdown in Greece.,18Kaparounaki CK Patsali ME Mousa DV et al.University students’ mental health amidst the COVID-19 quarantine in Greece. Among the examined components was the sample's sexual function, and results reported a deterioration in sexual life of university students.18Kaparounaki CK Patsali ME Mousa DV et al.University students’ mental health amidst the COVID-19 quarantine in Greece.

In recent history, this type of imposed isolation and social distancing measures has not been previously experienced in such a large scale. Thereby, primary aim of this study was to identify whether the quarantine influenced the quality of sexual function and relationship of adult couples in Greece. Secondary aim was to clarify whether anxiety was increased due to the pandemic and subsequently affected sexual function and relationship quality.

MATERIALS AND METHODS Participants

This was an online survey which consisted of a sample of 299 subjects. In order for a participation to be eligible, the individual had to be over 18 years of age and in a steady relationship during the quarantine, regardless of cohabitation with their partner. Participants’ sexual orientation did not constitute a reason of exclusion. The participants were asked to complete an online questionnaire on an online surveys’ platform. Recruitment of subjects was achieved via various social media networks; the first distribution was conducted among the researchers’ social and professional networks and they in turn further distributed the link of the survey on social media platforms. The duration of the study was 2 weeks (from the April 21 until the May 3, 2020, while implemented restrictions of the quarantine were still active.

 Outcome Measures

Sociodemographic characteristics: gender, age, family status (married/steady relationship and having children or not, educational level and occupational status before and during the quarantine, and exposure to information about Covid-19 were required in order to assess the correlation with the possible change in sexual function during the quarantine.

International Index of Erectile Function (IIEF): It is a 15-item self-report questionnaire, designed to assess erectile dysfunction. It evaluates five domains; erectile function, orgasmic function, sexual desire, intercourse satisfaction and overall satisfaction. The cut-off point of the scale is 25, and score below this margin indicates erectile function issues. It has been translated and validated in the Greek language.19Rosen RC Riley A Wagner G et al.The international index of erectile function (IIEF): a multidimensional scale for assessment of erectile dysfunction.Female Sexual Function Index (FSFI): It is a 19-item self-report questionnaire, designed to assess female sexual function. It evaluates six domains; desire, arousal, lubrication, orgasm, satisfaction, and pain. The cut-off point for the FSFI is 26.5 and scores lower than that indicate increased risk of sexual dysfunction. It has been translated and validated in the Greek language.20Zachariou A Filliponi M Kirana PS. Translation and validation of the Greek version of the female sexual function index questionnaire.

Sexual activity: Comparison of sexual activity before and during the quarantine was assessed with 5 statements structured by the researchers regarding frequency of sexual thoughts, masturbation, intercourse and quality of intercourse, and general evaluation of the level of sexual function (e.g. intercourse with my partner is more frequent). Participants stated their level of agreement on a 5-point Likert scale, ranging from “strongly disagree” to “strongly agree”.

Relationship quality: Quality of the relationship before and during the quarantine was assessed with 5 statements structured by the researchers regarding communication, company, understanding, tension and general evaluation of companionship (e.g. communication with my partner is better). Participants stated their level of agreement on a 5-point Likert scale, ranging from “strongly disagree” to “strongly agree”.

Mood and anxiety: These were assessed with 2 statements structured by the researchers regarding the respondents’ anxiety level and mood before and during the quarantine (e.g. my mood has worsened, I experience more anxiety than before). Participants stated their level of agreement on a 5-point Likert scale, ranging from “strongly disagree” to “strongly agree”.

 Ethical Considerations

Participants were informed of the survey's purpose with a brief description of the research protocol before proceeding to its completion and that submission of their response was considered as an automatic consent. The questionnaire administered was anonymous and no remuneration was provided. Safety of the collected data was maintained. The study's protocol was approved by the Ethics Committee of Eginition hospital, where the Outpatient Clinic for Sexual Health of the 1st Department of Psychiatry of the Medical School of Athens pertains to.

 Statistical AnalysisFor the continuous variables mean (standard deviation) or median (interquartile range) were calculated. Categorical variables were presented as absolute (n) and relative frequencies (%). To assess the relationship between categorical variables the Chi square test was applied. Given that FSFI and IIEF subscales were not normally distributed (Shapiro-Wilk test), only non-parametric tests were used to analyse the data. To test whether the total score of the FSFI or the IIEF erectile function of the sample differ from an estimated median based on previous research in Greek population (studies conducted before the outbreak), the one sample non-parametric sign rank test was applied. Τo assess the effects of demographic and other participants’ characteristics on sexual function (IIEF and FSFI scores), the non-parametric Kruskal-Wallis H test (for more than 2 groups) and the Mann-Whitney U test (for 2 groups) were used. Statistical significance was set to Pτ correlation coefficient was calculated. As multiple correlation tests were performed, the Holm -Bonferroni adjustment was applied to correct the p values.21A simple sequentially rejective multiple test procedure.,22Multiple correlations and Bonferroni's correction. Statistical analyses were performed using the SPSS for Windows (version 25) statistical software (SPSS Inc., Chicago, IL).DISCUSSION

This study aimed to investigate the possible impact of lockdown, social distancing and self-isolation on sexual function and relationship quality of couples in Greece. The majority of study's sample consisted of women (71.2%), had a tertiary education (82.6%) and was employed (79.3%). 62.2% were either married / cohabiting with their partner or in a steady relationship (37.8%). Most of them reported having access to their partner during the quarantine period (85.6%). Women of our sample were younger than men, were more likely to work from home during the lockdown, and spent less time in gathering information about covid-19 compared to men.

Most subjects of the sample reported that during the quarantine they enjoyed the qualitative elements of their relationship such as the company, understanding and support of their partner more than before. This comes in line with previous findings16Li G Dongdong T Song B et al.Impact of the COVID-19 pandemic on partner relationships and sexual and reproductive health: Cross-Sectional, online survey study.,26Challenges in the practice of sexual medicine in the time of COVID-19 in China. who reported that, among other factors, being in an exclusive relationship is an indicator of better relationship quality. A plausible explanation could be that people in a steady relationship during challenging periods are more interested in companionship rather than sexual contact. On the contrary, it was found that the quarantine did not positively impact their sexual activity in general, and that they masturbated less. It appeared that the reported level of anxiety did not correlate with IIEF, but was correlated with the FSFI. This applied for the Satisfaction and Pain subscales and the total score of the index. The fact that female sexual function was more affected by the pandemic when compared to males, could be explained by the findings of a previous study, suggesting that genital arousal and sexual satisfaction in females can be affected under stressful conditions.27Ter Kuile MM Vigeveno D Laan E. Preliminary evidence that acute and chronic daily psychological stress affect sexual arousal in sexually functional women.With regards to the participants’ age, the younger individuals had more sexual thoughts and fantasies compared to the older. Additionally, it was found that younger participants were masturbating with higher frequency, and that participants in the 29−36 agegroup reported an improvement of their sexual life in contrast to the older age groups, which reported the opposite. These results came to an agreement with Jacob et al,15Jacob L Smith L Butler L et al.Challenges in the practice of sexual medicine in the time of COVID-19 in the United Kingdom. who reported that being young, combined with other factors, enhanced sexual activity during the lockdown in the UK.Couples that had children and cohabited with them, reported having less sexual thoughts, fantasies and masturbation as well as lower understanding and support from their partner compared to those not living only with their partner. A plausible explanation for this finding can be given by an earlier study which suggested that maternal stress plays an important role in both partners’ sexual satisfaction.28Leavitt CE McDaniel BT Maas MK et al.Parenting stress and sexual satisfaction among first-time parents: A dyadic approach.Another study29Exploring the link between daily relationship quality, sexual desire, and sexual activity in couples. suggested that the presence of children has a negative effect on women's sexual desire and on the relationship's quality. In similar findings concluded the study by Cito et al (2020) who reported that having children was a restrictive factor as far as the number of sexual intercourse is concerned, and the higher the number of children the lower the number of intercourse was.30Cito G Micelli E Cocci A et al.The impact of the COVID-19 quarantine on sexual life in Italy. Considering that our sample consisted mostly of women, it is possible that women having their children at home during the under-study period made them more absorbed by their maternal role; possibly a burden of responsibility that cannot be positively affected by the presence of their partner.Those who spent the quarantine with their partner, reported better communication and sexual life, compared to those who didn't have access to their partner. The latter reported more frequent sexual thoughts, fantasies and masturbation but worse mood as well. Results showed that the participants in immediate contact with their partner were benefited by the quarantine as far as the emotional aspect of the relationship is concerned. This emotional advantage may explain the reported improved sexual life. Dewitte et al29Exploring the link between daily relationship quality, sexual desire, and sexual activity in couples. found that the better the relationship the more possible it was for their study's participants to have sexual intercourse, which subsequently amplified the satisfaction they got from their relationship.The score of the subjects’ FSFI was similar to that of the general population. This means that female sexual function in the study's sample was not affected by the quarantine. This came in contrast to other findings that reported a reduction of sexual activity for women in Italy regardless of their access to their partner during the quarantine.14Schiavi M Spina V Zullo M et al.Love in the time of COVID-19: Sexual function and quality of life analysis during the social distancing measures in a group of italian reproductive-age women. This could be explained by the fact that the course of the covid-19 pandemic took different directions for the two countries; during the time this study was conducted the clinical cases of covid-19 in Greece were profoundly fewer compared to Italy's and the death toll was one of the smallest in the world. Findings of this study were contradicting with the results of another research conducted solely on females, and showed that sexual function declined and this was associated with higher levels of anxiety.31Fuchs A Maton A Pilarska J et al.The impact of COVID − 19 on female sexual health. Surprisingly, some of the female participants of the study reported better sexual function and relationship quality during the quarantine. The youngest women of the sample reported increased desire and decreased pain, and those who worked from home during the lockdown reported better orgasmic function and less pain. These results are contradictory with a study conducted in Turkey; Yuksel et al. found that, though sexual desire and number of intercourse were increased, quality of sexual life was deteriorated.32Effect of the COVID-19 pandemic on female sexual behavior. It was previously suggested that women's income has a slight but positive impact on women's sexual satisfaction,33Satisfaction guaranteed? How individual, partner, and relationship factors impact sexual satisfaction within partnerships. thereby continuing being financially active during the quarantine might be the explanation for the positive results for these women. In addition, literature has shown that working women's sexual satisfaction might be affected by the sense of power and equality within the relationship that adding to the household's income provides.33Satisfaction guaranteed? How individual, partner, and relationship factors impact sexual satisfaction within partnerships.The score of the IIEF suggested better sexual health for the male portion of the sample compared to the general population. Results of this study showed that isolation measures did not affect the male sexual function. Given that all participants were in a romantic relationship or marriage, results came in line with Jacob's study; among the participants of that study, though they demonstrated an overall decreased sexual activity, married males had greater sexual activity.15Jacob L Smith L Butler L et al.Challenges in the practice of sexual medicine in the time of COVID-19 in the United Kingdom. In the study which was conducted by Arafat el at (2020) researchers reported improved sexual interactions with their partners but only for a small portion of their participants.34Arafat S Alradie-Mohamed A Kar SK et al.Does COVID-19 pandemic affect sexual behaviour? A cross-sectional, cross-national online survey. Their finding which comes in line with this study's results is the fact that the majority of the subjects for both studies reported increased satisfaction by the relationship with their partner.

This study bears certain limitations. Firstly, the results may have been biased by the methodology used with respect to study recruitment, yet the limited timeframe available to recruit subjects forbid a method of a more strict and accurate design. . Lastly, comparison of the FSFI and IIEF scores of the participants’ pro- and post-quarantine was not feasible.