key: cord-0907543-l3ghf84t
authors: Mollaioli, Daniele; Sansone, Andrea; Ciocca, Giacomo; Limoncin, Erika; Colonnello, Elena; Di Lorenzo, Giorgio; Jannini, Emmanuele A.
title: Benefits of sexual activity on psychological, relational and sexual health during the COVID-19 breakout
date: 2020-10-23
journal: J Sex Med
DOI: 10.1016/j.jsxm.2020.10.008
sha: a44262610cfbe0eeb993e65a8013909060d081f3
doc_id: 907543
cord_uid: l3ghf84t

BACKGROUND: The COVID-19 related lockdown has profoundly changed human behaviors and habits, impairing general and psychological well-being. Along with psychosocial consequences, it is possible that sexual behavior was also affected. AIMS: With the present study we evaluated the impact of the community-wide containment and consequent social distancing on the intrapsychic, relational, and sexual health through standardized psychometric tools. METHODS: A case-control study was performed through a web-based survey and comparing subjects of both genders with (Group A, N=2608) and without (Group B, N=4213) sexual activity during lockdown. The Welch and chi-square tests were used to assess differences between groups. Univariate analysis of covariance, logistic regression models and structural equation modeling (SEM) were performed to measure influence and mediation effects of sexual activity on psychological, relational, and sexual outcomes. OUTCOMES: Main outcome measures were General Anxiety Disorder-7 for anxiety, Patient Health Questionnaire-9 for depression, Dyadic Adjustment Scale for quality of relationship and a set of well-validated sexological inventories (International Index of Erectile Function, Female Sexual Function Index, and male-female versions of the Orgasmometer). RESULTS: Anxiety and depression scores were significantly lower in subjects sexually active during lockdown. Analysis of covariance identified gender, sexual activity and living without partner during lockdown as significantly affecting anxiety and depression scores (p<0.0001). Logistic regression models showed that lack of sexual activity during lockdown was associated with a significantly higher risk of developing anxiety and depression (OR: 1.32 [95% CI: 1.12 - 1.57, p<0.001] and 1.34 [95% CI: 1.15 - 1.57, p<0.0001], respectively). SEM evidenced the protective role of sexual activity towards psychological distress (β(males)=-0.18 and β(females)=-0.14), relational health (β(males)=0.26 and β(females)=0.29) and sexual health, both directly (β(males)=0.43 and β(females)=0.31), and indirectly (β(males)=0.13 and β(females)=0.13). CLINICAL TRANSLATION: The demonstrated mutual influence of sexual health on psychological and relational health could direct the clinical community towards a re-interpretation of the relationship among these factors. STRENGTHS AND LIMITATIONS: Based on a large number of subjects and well-validated psychometric tools, this study elucidated the protective role of sexual activity for psychological distress, as well for relational and sexual health. Main limitations were the web-based characteristics of the protocol and the retrospective nature of pre-lockdown data on psycho-relational and sexual health of subjects recruited. CONCLUSIONS: COVID-19 lockdown dramatically impacted on psychological, relational and sexual health of the population. In this scenario, sexual activity played a protective effect, in both genders, on the quarantine-related plague of anxiety and mood disorders.

INTRODUCTION 1 10 to 6. This test has an adequate explanation of sexological terms regarding the items 20, 21 . 2

The IIEF-5, or Sexual Health Inventory for Men (SHIM), an abridged, five-item version of the 3 IIEF, is often used in the clinical setting, as it provides a quicker, yet solid evaluation of the erectile 4 function of the patient; however, the SHIM does not investigate the remaining subdomains, therefore 5 missing on aspects of male sexuality not necessarily associated with erection, such as desire, ejaculation 6 and orgasm 22 . 7

Finally, the self-perceived orgasmic intensity was assessed by the male Orgasmometer, a single-8 item Likert scale, derived from Visual Analog Scale for Pain 23 , assessing how intense is the perception 9 of the orgasmic experience, ranging from 1 (lowest intensity) to 10 (maximum intensity) 24 . 10

Female sexual functioning was assessed via the Female Sexual Function Index (FSFI), a self-11 report test composed of 19 items with six possible responses investigating female sexuality according to 12 the following scales or domains: Desire, Arousal, Lubrication, Orgasm, Satisfaction and Pain. 13

Moreover, it is possible to calculate a total score with a cut-off corresponding to 26.5. Even this test has 14 an adequate explanation of sexological terms into the items. The FSFI investigates with each item the 15 four weeks prior to compilation, therefore depicting the current clinical scenario during lockdown 25, 26 . 16 In this case, differently from the male subset, the abridged form called FSFI-6 27 was not used being a 17 screener not useful for the present purpose. 18

Finally, the quality and intensity of orgasm response was assessed by the female Orgasmometer, 19 a single-item Likert scale, derived from Visual Analog Scale for Pain 23 , assessing how intense is the 20 perception of the orgasmic experience, ranging from 1 (lowest intensity) to 10 (maximum intensity) 28 . 21

One-way analysis of covariance was performed to assess differences between study groups, 1 based on gender, and sexual activity, work status and cohabitation with the partner during lockdown. 2

Logistic regression models (with Tukey post-hoc analysis) were used to evaluate protective and/or 3 potentially deleterious factors related with clinical categories among research variables of interest. 4

Effect size was measured with Cohen's f for both analysis of covariance and logistic regression models. 5

Analysis was performed by using the statistical software R (version 3. 6 .3), mainly using the tidyverse, 6

Rmisc car, effectsize and multcomp packages. 7

To investigate the impact of frequency of sexual activity on study variables, structural equation 8 modeling (SEM) was carried out with Analysis of Moment Structures (AMOS) package for IBM SPSS 9 (version 26.0) 29 , through which the path diagram was drawn. 10

Three latent factors were created: an anxiety/depression latent factor (named Psychological 11

Distress, PsyD) was derived from PHQ-9 and GAD-7 scores, a dyadic adjustment latent factor (named 12 Relational Health, RelH) was derived from the cohesion and satisfaction subscales of the DAS-32 and a 13 sexological latent factor (named Sexual Health, SexH) was derived from subscales of male and female 14 sexological inventories (IIEF-15 and Male Orgasmometer for males; FSFI and Female Orgasmometer 15 for females). Latent factors are preferable respect to manifest variables because are free from 16 measurement error, and, hence, yield more reliable findings. 17

The final path models (one for each gender) were appropriately conducted according to 18 modification indices. Standardized regression weights were used to represent path coefficients between 19 variables with P-values below 0.05. The overall fitting model was evaluated with the following indices: 20 ratio of χ 2 values and degrees of freedom values (CMIN/DF), goodness-of-fit index (GFI), normed fit 21 index (NFI), standardized root means square residuals (SRMR), and root mean square error of 22 approximation (RMSEA). For each index, the following cutoff values to measure goodness-to-fit are 23 considered acceptable: for NFI and GFI values equal or greater than 0.90, for SRMR values below 0.08 24 or 0.05, and for RMSEA values lower than or equal to 0.08. R 2 is equal to the variance explained for 25 sexual variables in the model.

Descriptive data from study population, grouped according to sexual activity during lockdown, 3 are reported in Table 1 . Not surprisingly, almost half of the study population came from Northern 4 Italy (47.32%), the part of the Country most affected by the epidemic. No significant difference was 5 observed concerning the self-referred prevalence of SARS-CoV-2 positivity between men and women 6 (χ = 1.071, p = 0.3). 2608 participants (38.2%) referred to be sexually active during lockdown (Group 7 A to be spending lockdown with their partners, whereas participants from Group B were mostly living 15 alone or with their relatives (χ = 3293.29, p < 0.0001). Very interestingly, 26,7% of sexually active 16 people did not spent lockdown with their partner, while 7,3% of sexually inactive ones lived with their 17 partners. Despite no significant difference was found among study groups, a consistent amount of the 18 sample (14,1%) reported the presence of psychological symptoms (such as stress, anxiety, and 19 depression) before the lockdown. 20

Clinical outcomes are presented in Table 2 . A statistically significant difference was observed 21 between the two study groups in regards to the raw scores for both the GAD-7 (Group A: 6.01±4.23; 22

Group B: 7.26±4.44; p <0.0001) and PHQ-9 (Group A: 6.73±4.75; Group B: 8.31±5.17; p <0.0001) 23 questionnaires. We initially performed a one-way analysis of covariance model to measure how gender, 24 sexual activity during lockdown, work status due to lockdown measures and living with the partner 25 influenced GAD-7 and PHQ-9 scores. These findings are summarized in Figure 2 and reported in 26 detail in Supplementary Table 1 . Higher GAD-7 scores were found for women (β = 2.33, SE = 0.20, p < 0.001), subjects reporting no sexual activity during lockdown (β = 0.89, SE = 0.39, p < 0.05), and 1 those separated from their partner (β = 1.00, SE = 0.30, p < 0.001); similarly, higher PHQ-9 scores 2 were found for women (β = 2.28, SE = 0.23, p < 0.001), subjects reporting no sexual activity during 3 lockdown (β = 0.94, SE = 0.45, p < 0.05), and those separated from their partner (β = 1.31, SE = 0.35, 4 p < 0.001). While both models were significant (p<0.0001), they explained a weak proportion of 5 variance (adjusted R 2 0.08 and 0.07 for GAD-7 and PHQ-9 scores, respectively) and no significant 6 interaction between gender, sexual activity during lockdown and living with the partner was found. 7

Based on these premises, we decided to perform logistic regression analysis to identify the 8 effects of different variables on the prevalence of anxiety and depression. As stated in the methods, 9

presence of anxiety and disorder in the study population was measured according to GAD-7 and PHQ-10 9 scores, using a cutoff score ≥10 for both. As depicted in Figure 3 , female gender, lack of sexual 11 activity exclusively during lockdown, living without partner during lockdown, age greater than 40 years, 12 self-referred psychological symptoms before the lockdown, being temporary lay-off and unemployed 13 were all significantly associated with an increased risk of developing anxiety and depression. When 14 addressing the effects of sexual activity on both anxiety and depression, no significant effect was found 15 comparing people who were sexually active during lockdown to those who never had any prior sexual 16 activity; on the other hand, when comparing sexually active subjects to those who did not have sexual 17 activity during lockdown, a significantly higher risk of developing anxiety and depression was found 18 In order to assess the risk of multicollinearity or sphericity, correlation analysis to assess the 3 relationship between variables was performed. Results of correlation analysis are represented in Figure  4 4. Since no correlation was deemed able to significantly affect the regression models, all variables were 5 included in all subsequent steps of analysis. 6

To assess the relationship between frequency of sexual activity during lockdown with 7 psychological symptoms, relational quality and sexual function, we performed maximum likelihood 8

SEMs, separately, for both genders (Figure 5 ) belonging to Group A. We used age, previous 9 psychological symptoms and living without the partner during lockdown as covariates, frequency of 10 sexual activity (FSA, ranging from 1= less than 1 time a week to 5 = more than 1 time a day) as 11 exogenous variable, with psychological distress (PsyD, composed by anxiety/depression score of GAD-12 7 and PHQ-9, respectively) and relational health (RelH, composed by dyadic cohesion and satisfaction 13 subscales of the DAS) as mediator variables, and female/male sexual health (SexH, resulting from 14 scores of each sexual domains of IIEF and FSFI and orgasmometer) as latent dependent (outcome) 15

variable. PsyD has a direct negative effect on SexH, irrespectively of gender (β=-0.23, p<0.0001 in 16 males; β=-0.21, p<0.0001 in females). Conversely, RelH has a direct positive effect on SexH (β=-0.33, 17 p<0.0001 in males; β=-0.34, p<0.0001 in females). FSA significantly mediates, in a protective way, 18 levels of PsyD (β=-0.18, p<0.0001 in males; β=-0.14, p<0.0001 in females;), RelH (β=0.26, p<0.0001 19 in males; β=0.29, p<0.0001 in females) and SexH (β=0.43, p<0.0001 in males; β=0.31, p<0.0001 in 20 females). The amounts of variance explained (R 2 ) in the models are 49% and 33% for males and female 21 sexual health, respectively. Goodness-to-fit indices of SEMs were acceptable (males: χ 2 Regarding indirect effects, FSA describes the 23% and 29% of total effect mediated in males 25 and females, respectively. Moreover, we observed that the "FSA=>PsyD=>SexH" and the mediated and β=0.089, p<0.001, 16% of total effect mediated, respectively) and females (β=0.030, 1 p<0.001, 7% of total effect mediated and β=0.097, p<0.001, 22% of total effect mediated, respectively). The COVID-19 pandemic and the consequent lockdown have had unprecedented, dramatic 5 repercussions at both macrosocial, such as the economy and policy, and microsocial level, such as on 6 the psychological and relational well-being of persons 3, 30 . This affects not only infected patients, or 7 suspected ones, but also caregivers, health care workers, and quarantined family members 31-33 . 8

Moreover, following social isolation, several aspects of daily life have dramatically changed. We found 9 in our naturalistic observation that sexual functioning acts as a predictor and marker of psychological 10 well-being. 11

If data have been produced on the repercussions of COVID-19 related social isolation norms 12 on the psychological health, and specifically on the prevalence and nature of psychopathological 13 symptoms 13, 34 , we trust that no studies have so far investigated the sexual health as a variable to 14 evaluate psychological distress due to the COVID-19 related confinement and social isolation. 15

We found that half of our study sample (50.3%) reported an interruption of sexual activity 16 during lockdown. This demonstrates that the lockdown itself dramatically affects sexual health, for two 17 possible reasons: distress due to quarantine and impossibility to reach the preferred sexual partner. 18

Moreover, another COVID-related study highlighted how social distancing due to lockdown negatively 19 impacts on sexual activity 35 . 20

We discovered that subjects who could maintain sexual activity during lockdown had lower 21 psychological distress, as proven by both GAD-7 and PHQ-9 scores, than those who had to give up on 22 sexual activity due to lockdown policies (e.g., couples separated during lockdown). Moreover, the same 23 scenario is present on a relational level, with subjects who continued to have sexual intercourses during 24

lockdown showing better scores on dyadic cohesion and satisfaction subscales of DAS-32, confirming 25 the evidence that a regular sexual activity leads to a better relational health 36 . 26 J o u r n a l P r e -p r o o f Not differently from other clinical sets, female gender is more likely to develop anxiety and 1 mood disorders 37, 38 . Our data agree with evidence regarding both the worsening of the psychological 2 well-being during COVID-19-related social isolation 39, 40 and the historical knowledge about the major 3 female susceptibility to the development of emotional diseases 39 and sexual dysfunctions 41, 42 . Moreover, 4 together with biological factors 43-45 the exposition to a major stressor (pregnancy complications, lack of 5 partner or of social support, history of sexual abuse, presence of life adverse events) increases in 6 women the risk to develop a psychopathology 46 . The higher ability of females in reading their own 7 emotional status and that of the others 47 may potentially expose them to a peculiar perception of their 8 own positive/negative emotions, and hence to a higher risk to develop psychopathological symptoms. 9

Vice versa, also during the COVID-19 breakdown, males resulted less at risk for the development of 10 symptoms of anxiety and depression 11 . Unsurprisingly, we also found that work status, like being 11 temporary lay-off from work or being unemployed increased the chance to develop anxiety and 12 depressive symptoms. Lockdown measures had certainly lead a great amount of companies (e.g. 13 restaurants, event planners, home-builders ecc.) to stop their activities, with a forced downsizing of 14 their staffs and having recourse to social safety net or also stopping any possible hiring campaigns. This 15 scenario could have a negative impact on psychological status, as confirmed by literature. 36 , 48-50 16

We found that general sexual functioning of females and males during quarantine was mediated 17 by different variables. If the social isolation, together with the activity restriction and the reduction of 18 rewarding events, may represent a risk factor for the development of a psychopathology and 19 consequent psycho-relational difficulties, our data have revealed a novelty in the relationship between 20 sexuality and psychological distress, i.e., the role of the frequency of sexual activities on anxiety, 21 depression, couple relationship and sexual function itself. In other words, we found both more 22

anxious-depressive symptomatology both more sexual dysfunctions in people with lower frequency of 23 sexual activities. At the same time, subjects with higher frequency of intercourse had better sexual 24 functioning, as well as a better dyadic adjustment. Adequate dyadic cohesion and satisfaction represent 25 another protective and positive factor to the safeguard of sexual functioning, according to our findings.

Further proofs of the protective effects of sexual health on anxiety and depression come from 1 our structural equation models, where both anxiety and depression did not negatively mediate the effect 2 of the frequency of sexual activity on sexual health, as shown by the analysis of indirect effects on 3 female and male sexuality. This further strengthens our study evidence that a regular-to-high sexual 4 activity could decrease the negative effects of anxiety and depressive symptoms towards sexual 5 function, in both genders. 6

While the role of anxiety in dramatically affecting sexual performance is clearly recognized 51, 52 , 7 the anxiolytic effect of successful sexual activity is less studied. Neurobiology of anxiety has found to 8 be complex, involving both centrally and peripherally the GABAergic/opiatergic circuitries and the 9 adrenergic activation, accounting, respectively, for the reduction in the sexual desire and the 10 impairment in arousal and even orgasm 53 . More efforts should be paid in the future in exploring how 11 sexual activity, most probably throughout the dopaminergic circuits 54 , may directly or indirectly reduce 12 the levels of anxiety. 13

The positive and healthy effects of an adequate sexual activity on psychological wellness, and on 14 relational and sexual health have been documented 55, 56 . Sexual activity itself is able to trigger not only 15 the activation of the hypothalamus-pituitary-gonadal axis, but also other psycho-neuro-endocrinological 16 factors regulating psycho-sexological fitness 55, 57-59 . Such a possible mechanism, based on the well-17 known ability of sexual intercourse to boost testosterone levels, or to maintain optimal androgenic 18 tone 60, 61 , may explain the negative correlation between sexuality and affective disorders, at least for 19

depression. This has been hypothesized as a bona fide hypothalamic action on GnRH pulsatility, 20 peripherally measured by the LH bioassay as a surrogate marker of LH glycosylation, affecting the 21 ability of the testicular Leydig cell producing testosterone 56, 62 . As occurring for the physiological 22 reduction of metabolism during forced starvation, the impossibility of regular sexual activity because of 23 the lockdown, or other internal factors, may reset the hypothalamic pulse generator to a lower activity 63 . 24

The decreased intercourse frequency has been, in fact, bidirectionally coupled to poor relational health, 25 being its deterioration associated with impairment in sexual activities, and, as here hypothesized, to an 26 evident reduction in testosterone levels 64 . Since low levels of testosterone have been related to mood disorders, while reaching eugonadism to a restoration of them 55 , the lower presence of depression in 1 male and in both sexes when indulging with the sexual rewards during the COVID-19 quarantine could 2 be hypothesized, at least partially, to be androgen-dependent 63 . 3

Interestingly, we found in our study sample that sexual dysfunctions were not age-dependent: 4 this constitutes a unique and peculiar finding. Robust, epidemiological studies unanimously evidence 5 that presence and severity of the very large majority of sexual dysfunctions is directly correlated to age 6 in both sexes 65-67 . For example, across epidemiological studies, increasing age appears to be a strong risk 7 factor for ED 68, 69 , with a prevalence overtly age-dependent, with a steep increase beyond the 5 th decade 8 9 . Similarly, epidemiological studies for female sexual disorders reveal that the prevalence, which ranges 9 from 19% to 45% 27 , is also highly dependent on biologic, as well as contextual and relationship 10 variables, but ultimately increases with age 70 . The evidence that during the COVID-19 lockdown age 11 loses its weight as a statistically significant predictor for sexual dysfunctions might shed a light on the 12 pattern through which psychological suffering impacted on psychological health and, consequently, on 13 sexual health. Indeed, being the COVID-19 pandemic and the lockdown per se conditions that, 14 irrespectively of age, brought about new and significant changes in everyone's daily life habits 15 (including romantic and sexual intimacy), it is tenable to sustain that the prevalence of the sexual 16 dysfunctions in our study sample may reflect this unprecedented scenario. 17

Differently from sexual dysfunctions, psychological distress -measured in terms of anxiety and 18 depression -resulted significantly poorer in young persons with respect to the older ages. While these 19 results again do not completely follow the common age distribution, they mirror recent findings related 20 to COVID-19 quarantine in different Italian and Chinese populations 40, 71, 72 . Indeed, it is recognized 21 that in the general population, younger people are more at risk for psychological disorders. This is true 22 especially for anxiety but not for depression. Moreover, psychological status is strictly related to sexual 23 health and depression, and anxiety is a well-known determining factor of overall sexual functioning 73, 74 . 24

Based on our findings, loneliness during lockdown and the absence of the partner seem to be 25 additional risk factors for the development of symptoms of anxiety and depression, especially in 26 easily explained by the separation from the partner, the increased risk to be prone to anxiety and/or 1 depression due to the solitude is less understandable, especially in younger people, such as those 2 enrolled in this study. In agreement with our findings, literature data suggest a higher vulnerability in a 3 sizeable part of the population to develop psychopathology, if exposed to loneliness 75-78 . Hence, we may 4 conclude that the COVID-19-related quarantine has induced a general vulnerability, not only from a 5 general health point of view, but also from a psychological and psychosexological ones. 6

The COVID-19 pandemic and the consequent lockdown has made possible the measurement 7 of the psycho-relational and sexological modifications of the persons in a unique and peculiar social 8 environment. We believe that the present study represents a first, large-scale attempt to explain the 9 modifications of the psychological, relational and sexological functioning of the individuals exposed to 10 a major social and personal distress. Considering the ability of relational and sexual health in improving 11

intrapsychic health, the former should be carefully considered when establishing the norms of 12 quarantine and when analyzing their efficacy based on the personal adhesion. If sexuality has a major 13 reward role 79, 80 , it may also have a major motivational role in challenging and difficult tasks. Our 14 findings support the idea to consider relational-sexual health as a fundamental tool to improve adhesion 15 and as a unique predictor of intrapsychic health. 16

The real-life nature of our study produced some limitations, such as the impossibility to have 19 quantitative data about the psycho-relational and sexological functioning before the COVID-19 20 lockdown. Among descriptive data, we found that almost a half of the sample came from northern 21

Italy. This may represent a relative bias of selection, being the population most severely reached by the 22 COVID-19, probably, more interested in participating. Another limitation is related to the use of online 23 investigation for the information collection. If it is true that online surveys have been considered an 24 equal good methodology of the sex surveys for the subjects' recruitment and the study of specific 25 topics 81 , it is even more true that in this specific historical period, characterized by social isolation, 26 online experimental protocols represent the unique possibility to study human behavior.

Behavioral sciences play a crucial role in fighting general crises such as the pandemics 82, 83 . We 3 demonstrated by well validated tools that the COVID-19 lockdown dramatically impacted on the sexual 4 health of the population. We also found sexual activity as protective, in both genders, to the quarantine-5 related plague of anxiety, depression and relational issues. Addressing sexual health of the population is 6

proposed, finally, as a pivotal strategy to improve the adhesion to the difficult social norms 7 characterizing the breakdown. of Covariance was computed to evaluate differences in anxiety (F(7, 6813) 

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