The impact of mental health and stress concerns on relationship and sexuality amidst the COVID-19 lockdown

AbstractBackground

Since 23rd January 2020, the Chinese government has imposed restrictive measures including self-isolation, travel restrictions and lockdown of Wuhan city in order to prevent the incoming waves of COVID-19 outbreak in the country. However, the impact of mental health and stress concerns on relationship and sexuality amidst the COVID-19 lockdown was currently unclear.

Aim

The cross-sectional study was designed to determine the changes in health, relationship and sexuality among the Chinese couples who lived together amid the early stages of COVID-19 pandemic in China.

Methods

Participants of Chinese nationality aged ≥18 years were asked to complete a self-administered online questionnaire regarding sexuality behaviour and impact of event scale (IES) in March 2020. Non-random sampling was used for participant recruitment. Also assessed were sociodemographic data including sex, age, employment, region, sexual dysfunction, and whether participants tested positive for COVID-19.

Outcomes

IES score, frequency of sexual intercourse per week, quality of usual sex life, emotional bonding and duration of relationship were measured.

Results

A total of 1139 participants (i.e., 735 males and 404 females) were included in the study. Mean age and IES of participants was 33.6±9.5 years and 27.4±8.6, respectively. Being male was significantly associated with increased frequency of sexual intercourse amid the COVID-19 pandemic (P=0.012). Also, participants with an IES score <26 were more likely to report that they had increased frequency of sexual intercourse per week (P<0.001) and the COVID-19 pandemic had positively affected the quality of their usual sex lives (P<0.001). On the other hand, participants with IES score ≥26 were more likely to report that the COVID-19 pandemic had positively affected their emotional bonding (P<0.001).

Clinical implications

Frequency of sexual intercourse and quality of sex life in participants who experienced high stressful impact were more likely to be affected by the COVID-19 pandemic.

Strengths and limitations

This was one of the first studies to assess sexual behaviour during the COVID-19 pandemic in Chinese adults. Since participants were asked to self-report their sexual behaviour, this potentially introduced self-reporting and recall bias into our findings.

Conclusions

Our study reported that despite the moderate-to-severe stressful impact due to the COVID-19 pandemic, the majority reported no significant changes in the frequency of their sexual intercourse per week, quality of their usual sexual lives and emotional bonding.

IntroductionSevere Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV2) virus, which was first reported in December 2019 in Wuhan, China, has led to a global health emergency.A Review of Coronavirus Disease-2019 (COVID-19). As of August 2020, SARS-CoV-2 had infected more than 23 million people, resulting in more than 800,000 deaths (at https://www.who.int/emergencies/diseases/novel-coronavirus-2019/situation-reports/). SARS-CoV-2 causes an infectious disease called coronavirus disease 2019 (COVID-19).Lai C-C Shih T-P Ko W-C Tang H-J Hsueh P-R. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease-2019 (COVID-19): The epidemic and the challenges. Therefore, in order to contain the COVID-19 pandemic and stop COVID-19 from spreading rapidly to other parts of the world, many countries have enacted strict measures such as transportation restriction, border closures, and self-isolation.Cheng VCC Wong SC To KKW Ho PL Yuen KY. Preparedness and proactive infection control measures against the emerging novel coronavirus in China.In China, the majority of businesses were closed between February and March 2020. In addition, non-emergency elective surgeries and medical care were suspended in order to ease the healthcare system pressure due to the increasing cases of COVID. Following the self-isolation period due to the COVID-19 pandemic, some behaviours including sexual activity may be impacted. Although sexual inactivity might be not an important focus for public health attention except its adverse outcomes such as sexual dysfunction, regular sexual activity has been reported to be associated with greater quality of life and well-being.Blanchflower DG Oswald AJ. Money, sex and happiness: An empirical study., Several studies have reported the impact of mass disasters on sexual behaviours.Hannoun AB Nassar AH Usta IM Zreik TG Abu Musa AA. Effect of war on the menstrual cycle.Kissinger P Schmidt N Sanders C Liddon N. The effect of the hurricane Katrina disaster on sexual behavior and access to reproductive care for young women in New Orleans.Liu S Han J Xiao D Ma C Chen B A report on the reproductive health of women after the massive 2008 Wenchuan earthquake. For example, some individuals who experienced psychological pressure due to the temporary closure of businesses or loss of jobs amidst the COVID-19 pandemic might be more likely to be vulnerable to negative sexual health outcomes because of reduced access to healthcare service. In addition, individuals who were separated with their partner amidst the COVID-19 pandemic might also have increased risk of experiencing negative sexual health outcomes.Li G Tang D Song B et al.Impact of the COVID-19 pandemic on partner relationships and sexual and reproductive health: Cross-sectional, online survey study.To our knowledge, although the COVID-19 has caused huge impact to the public health and social life,Ma ZF Zhang Y Luo X et al.Increased stressful impact among general population in mainland China amid the COVID-19 pandemic: a nationwide cross-sectional study after Wuhan city's travel ban was lifted. there are still limited studies that assessed the impact of the COVID-19 pandemic on sexual behaviour in the general population, particularly in China. Therefore, the aim of the study was to assess the changes in the health, relationship and sexuality behaviours among the Chinese couples who lived together amid the COVID-19 pandemic in China. We hypothesised that the mental health and stress concerns would affect the relationship and sexuality in our study population amidst the COVID-19 pandemic.DiscussionTo our knowledge, our study was the one of the earliest studies to assess the impact of mental health and stress concerns on the relationship and sexuality, especially in mainland China during the early stages of the COVID-19 pandemic. The lockdown due to the COVID-19 pandemic has not only impacted the health and economy, but it has also caused deterioration of social life in the Chinese population.Impact of the COVID-19 pandemic on mental health and quality of life among local residents in Liaoning Province, China: a cross-sectional study.,Psychological responses and lifestyle changes among pregnant women with respect to the early stages of COVID-19 pandemic. However, it is unclear if to what extent, this would also affect the sexual behaviour of Chinese couples. Although the SARS-CoV-2 is rapidly evolving into a global pandemic at the time of the study, there is a paucity of literature regarding the impact of COVID-19 on sexual behaviour.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.Jacob L Smith L Butler L et al.COVID-19 social distancing and sexual activity in a sample of the British Public.Effect of the COVID-19 pandemic on female sexual behavior.Our study reported that although being male was associated with a higher stressful impact, being male was also significantly associated with increased frequency of sexual intercourse amid the COVID-19 pandemic. Our findings were in line with the results by Jacob et al. who reported that being male was significantly associated with greater sexual activity in UK adults amid the COVID-19 self-isolation period.Jacob L Smith L Butler L et al.COVID-19 social distancing and sexual activity in a sample of the British Public. On the other hand, a study by Hall et al. reported that young women with moderate/severe stress symptoms had significantly higher proportions of sexually active weeks than those without these stress symptoms (43% vs. 35%, respectively).Hall KS Kusunoki Y Gatny H Barber J. Stress symptoms and frequency of sexual intercourse among young women. Therefore, additional research is needed to understand whether and how the sexual behaviours shape the mental health outcomes in both sexes, especially in stressful environment. In addition, it is still unclear how male sexual behaviour may possibly affect female sexual attitude and vice versa, which is another possible future research area to be pursued and emphasised.In addition, our study also reported that duration of relationship and employment status were significantly associated with the changes in sexual behaviour amidst the COVID-19 pandemic. In our study, being in a full-time job was significantly associated with positive sexual health outcomes including quality of sexual life and emotional bonding. One possible reason might be that individuals being employed in a full-time job were less vulnerable to financial issues and negative psychological impacts due to the COVID-19 pandemic.Li G Tang D Song B et al.Impact of the COVID-19 pandemic on partner relationships and sexual and reproductive health: Cross-sectional, online survey study. Therefore, having a full-time job was more likely to lead to more economic stability and less stress, which could then impact sexuality. Also, participants who were in relationships less than one year were more likely to have positive sexual health outcomes including increased frequency of sexual intercourse per week and quality of sexual life amidst the COVID-19 pandemic. It is suggested that participants who were in relationships less than one year had high hopes for romance and were still in romantic relationships.Does a long-term relationship kill romantic love?.In our study, participants who reported experiencing mild psychological impact of the COVID-19 pandemic were more likely to have an increase frequency of sexual intercourse per week. In addition, participants who experienced mild psychological impact of the COVID-19 pandemic were more likely to report that the COVID-19 pandemic had positively affected the quality of their usual sex lives. Our findings were consistent with the findings from the published literature.Gómez-López M Viejo C Ortega-Ruiz R. Well-being and romantic relationships: A systematic review in adolescence and emerging adulthood. There are some factors that can help to facilitate the sexual intimacy, which subsequently may result in an increased frequency of sexual intercourse. These include: greater well-being and increased time spent together.Muise A Schimmack U Impett EA. Sexual frequency predicts greater well-being, but more is not always better. Therefore, it is suggested that having greater well-being and more time together would lead to more frequent sexual activities. During the COVID-19 lockdown period, the couples were self-isolating at home and consequently, they were more likely to have an increase in time spending together with their intimate partner.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. In a study of young Chinese adults by Li et al., 41%, 30% and 23% of young Chinese adults had decreased sexual frequency, increased masturbation frequency, and increased use of pornography amidst the COVID-19 pandemic.Li G Tang D Song B et al.Impact of the COVID-19 pandemic on partner relationships and sexual and reproductive health: Cross-sectional, online survey study. However, the authors did not further examine the gender dimensions and differences in these aspects, which should have been emphasised.Li G Tang D Song B et al.Impact of the COVID-19 pandemic on partner relationships and sexual and reproductive health: Cross-sectional, online survey study. A study by Jacob et al. reported that the number of days in self-isolation was significantly associated with sexual activity in UK adults during the COVID-19 self-isolation period.Jacob L Smith L Butler L et al.COVID-19 social distancing and sexual activity in a sample of the British Public. Similarly, another study by Yuksel et al. also reported that during the COVID-19 pandemic, there was a significantly higher frequency of sexual intercourse and sexual desire in Turkish adults.Effect of the COVID-19 pandemic on female sexual behavior. The authors suggested that sexual activity was used to overcome boredom, anxiety and stress, which were more likely to increase with increasing days of self-isolation during the COVID-19 self-isolation period.Jacob L Smith L Butler L et al.COVID-19 social distancing and sexual activity in a sample of the British Public. However, it was still unclear how this would differ by gender due to limited available studies.Jacob L Smith L Butler L et al.COVID-19 social distancing and sexual activity in a sample of the British Public.,Effect of the COVID-19 pandemic on female sexual behavior.In addition, stressful life has been reported to decrease the frequency of sexual intercourse.Chronic stress and sexual function in women. A study by Liu et al. also reported a decrease in the frequency of sexual intercourse in a group of Chinese adults after being exposed to traumatic events which were associated with chronic stressors.Liu Q Luo D Haase JE et al.The experiences of health-care providers during the COVID-19 crisis in China: a qualitative study. Therefore, future quantitative and qualitative studies should consider investigating if there are gender and age-related differences in terms of frequency of sexual intercourse in different population groups from different countries. Moreover, additional research is also needed to investigate if there is a significant association between sexual activity and number of days in self-isolation among different population groups amid the COVID-19 lockdown period.On the other hand, in our study, participants who experienced moderate-to-severe psychological impact of the COVID-19 pandemic were more likely to report that the COVID-19 pandemic had positively affected their emotional bonding. It is possible that during the COVID-19 lockdown period, they were getting more support from their intimate partner and spending more quality time together.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. Studies have reported that romantic experience and relationship when sustained over time are considered important sources of emotional bonding.Gómez-López M Viejo C Ortega-Ruiz R. Well-being and romantic relationships: A systematic review in adolescence and emerging adulthood. In addition, the couples were spending more time together at home and there were no loss of living space amid the COVID-19 pandemic.Effect of the COVID-19 pandemic on female sexual behavior. This is because due to the fast pace of life in modern times, they may have little discretionary time to spend with their intimate partner, especially during non-pandemic times.Jacob L Smith L Butler L et al.COVID-19 social distancing and sexual activity in a sample of the British Public. Therefore, although the COVID-19 pandemic have disrupted the time for performing daily work activities including commuting to work, this time can now be used to spend with their intimate partner to reconnect and emotionally engaged.Jacob L Smith L Butler L et al.COVID-19 social distancing and sexual activity in a sample of the British Public.

Our study had several strengths including a larger sample size. In addition, our study was one of the earliest studies to assess sexuality and health behaviours amidst the COVID-19 pandemic. Our study also assessed the IES of participants and correlated the IES with sexual behaviour among participants. This is particularly important because it offered a unique opportunity for understand how the stressful impact caused by the COVID-19 affected sexual behaviour, particularly in Asian context. In addition, pre-testing and pilot testing of the questionnaire used in our study had been performed to ensure the validity of the questionnaire used in our study was checked by pilot testing the questionnaire in our community. However, it is important to note that our study findings must be interpreted in light of its limitations. Since the questionnaire used in our study was self-administered and the participant responses were based on their declaration; therefore, this could potentially introduce self-reporting bias into our study findings. In addition, we did not obtain the information regarding the number of days in self-isolation during the COVID-19 lockdown period. Our study also did not assess if participants had children. This is another limitation because children in the home are an important variable impacting stress and sexual behaviour. The use of convenience sampling in our study also limited the generalisation of our study findings to the whole Chinese population. Other partnered conducts including petting, kissing, masturbation, oral and anal sex were not assessed in the study. Also, other limitations of sexual activity to marital coitus and the living in a couple dimension as a major driving force for sexual activity were not determined. Therefore, future studies should consider including these dimensions of sexual activity, and emphasising the gender differences and dimensions.

In conclusion, our study reported that despite the moderate-to-severe stressful impact due to the COVID-19 pandemic, majority of participants reported no significant changes in the frequency of their sexual intercourse per week, quality of their usual sexual lives and emotional bonding. In addition, we also identified some factors including being male were associated with higher stressful impact and increased frequency of sexual intercourse amid the COVID-19 pandemic. However, it is important to note that more is not always better and instead, quality of sex life should also be taken into consideration. Future studies should also consider investigating if the public health strategies designed to promote safe and consensual sexual activity may be used as a means to alleviate the detrimental health consequences in relation to self-isolation amid the COVID-19 pandemic.

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