key: cord-0927428-6weeip78
authors: Pennanen-Iire, Corina; Prereira-Lourenço, Mário; Padoa, Anna; Ribeirinho, André; Samico, Ana; Gressler, Marina; Jatoi, Noor-Ahmed; Mehrad, Mehri; Girard, Abby
title: Sexual Health Implications of COVID-19 Pandemic
date: 2020-11-05
journal: Sex Med Rev
DOI: 10.1016/j.sxmr.2020.10.004
sha: b6b8889586b5ee600ce99a5183fd687f312fcca9
doc_id: 927428
cord_uid: 6weeip78

INTRODUCTION A novel coronavirus (COVID-19) reached pandemic levels by March 11th, 2020, with a destructive impact across socioeconomic domains and all facets of global health, but little is known of its impact on sexual health. OBJECTIVE To review current knowledge on sexual health-related containment measures during pandemics, specifically COVID-19, and focus on 2 main areas: intimacy and relational dynamics and clinical effects on sexual health. METHODS We carried out a literature search encompassing sexual health and pandemic issues using Entrez-PubMed and Google Scholar. We reviewed the implications of the COVID-19 pandemic on sexual health regarding transmission and safe sex practices, pregnancy, dating and intimacy amid the pandemic, benefits of sex, and impact on sexual dysfunctions. RESULTS Coronavirus transmission occurs via inhalation and touching infected surfaces. Currently, there is no evidence it is sexually transmitted, but there are sexual behaviors that pose a higher risk of infectivity due to asymptomatic carriers. Nonmonogamy plays a key role in transmission hubs. New dating possibilities and intimacy issues are highlighted. Sexual activity has a positive impact on the immune response, psychological health, and cognitive function and could mitigate psychosocial stressors. COVID-19 pandemic affects indirectly the sexual function with implications on overall health. CONCLUSION Increased awareness of health-care providers on sexual health implications related to the COVID-19 pandemic is needed. Telemedicine has an imperative role in allowing continued support at times of lockdown and preventing worsening of the sexual, mental, and physical health after the pandemic. This is a broad overview addressing sexual issues related to the COVID-19 pandemic. As this is an unprecedented global situation, little is known on sexuality related to pandemics. Original research is needed on the topic to increase the understanding of the impact the current pandemic may have on sexual health and function. Pennanen-Iire C, Prereira-Lourenço M, Padoa A, et al. Sexual Health Implications of COVID-19 Pandemic. Sex Med Rev 2020;XX:XXX-XXX.

In December 2019, a novel coronavirus, the severe respiratory syndrome coronavirus-2 (SARS-CoV-2), was first found in Wuhan, China [1, 2] , and was officially named by the WHO on 11 th February 2020, as COVID-19 [3] . One month later, COVID-19 spread to pandemic levels creating global socioeconomic instability. A disease pandemic can impact sexual and reproductive health and rights in various ways, at individual and societal levels [4] . Guidelines for a safe sexual activity amid the COVID-19 pandemic have already been suggested by public institutions and professional societies [5, 6, 7] . From the clinical experience of previous pandemics, little emerges on sexual dysfunctions. Human coronaviruses, including SARS-CoV-2, can persist on inanimate surfaces like metal, glass or plastic for up to 9 days, but the infectivity can be efficiently reduced by surface disinfection procedures [8, 9] . A recent study showed that SARS-CoV-2 is more stable on plastic and stainless steel than on copper and cardboard, and that a viable virus is detected up to 72 hours after contact with these surfaces [10] . Therefore, viral transmission occurs by touching infected surfaces and passing to the mouth, nose, or eyes. Although COVID-19 is known to spread through the respiratory tract and by direct contact [11] , it may be possible for it to shed through additional routes, as SARS-CoV-2 has been found in fecal swabs and blood [12] . The mean incubation time has been estimated to be 5.2 days, varying in between 4 and 7.5 days [11] supporting the need to quarantine the exposed individuals for 14 days.

Person-to-person transmission of SARS-CoV-2 occurs rapidly, mainly between individuals in close contact with patients, but also from asymptomatic carriers of all ages [13] . Importantly, the severity of COVID-19 and disease mortality are largely determined by the immune response of the infected person [14] . Human transmission has been shown to be high enough to cause 2,944,728 tested cases, with 203,948 deaths reported as of 26 th of April 2020

(https://www.worldometers.info/coronavirus/). Rates of hospitalization and death have varied widely, along with varying methods of social distancing and quarantine in different countries.

However, when intervention strategies such as travel restrictions, isolation, academic center closures, and social distancing are implemented, a 90% compliance rate has shown controlled spread within 14 weeks, while 70% compliance of measures is unlikely to control spread for any duration [15] .

Despite the rigorous, unprecedented prevention measures, COVID-19 escalated to pandemic levels, causing increasing global frustration, exhaustion, and possible long-term negative implications on mental and sexual health.

This article reviews the existing data concerning the novel coronavirus with respect to containment measures during times of pandemic. Based on the existing knowledge of viral infectivity, we intend to revise safety recommendations for sexual activity, including the impact of the COVID-19 pandemic on intimacy and relationships. Furthermore, we aim to discuss the potential clinical impact of the current pandemic on the sexual health, including both, benefits of sex during the lockdown, and implications for sexual behaviors and dysfunctions.

We carried out a literature search encompassing sexual health issues during pandemics. Relevant

English literature was reviewed through Entrez-PubMed and Google Scholar. In addition Besides, we collected opinion papers issued by professional sexual medicine societies and institutions. We reviewed the implications of the COVID-19 pandemic on sexual health and behavior concerning two main categories: effects on intimacy and relational dynamics, and clinical effects. Within the first category, we focused on the infectivity and sexual activities, pregnancy, and relational patterns.

Within the latter one, we revised analyzed two specific areas: benefits of sex and sexual dysfunctions.

Sexual transmission and safe sex practices during the pandemic. When considering safe sex practices and COVID-19, several scenarios must be addressed. Based on the knowledge of previous coronaviruses, there is no evidence that COVID-19 is a sexually transmitted disease and such a likelihood is very low [14, 16] . Nevertheless, we know that COVID-19 transmission occurs via inhalation of respiratory droplets and touching infected surfaces [11, 17] (skin-to-skin, touching infected inanimate objects), so kissing should be avoided with anyone symptomatic or with people outside one's household and proper hygiene should be the rule [10, 17] . Sex with a cohabiting partner is allowed unless one is symptomatic. In a scenario where the sexual partner is quarantined following infection or known exposure, sex should be avoided. The same applies if someone has typical symptoms of COVID-19. As there is evidence of oral-fecal transmission of the SARS-CoV-J o u r n a l P r e -p r o o f 2, [12, 17] , analingus should be avoided with anyone symptomatic or people outside one's household.

Social distancing has proven effective in controlling disease spreading [13, 15, 18] .

Accordingly, close contact between sexual partners may increase the risk of contagion, because of possible asymptomatic carriers [19, 20] . Sexual behavior and network connectivity studies show that people with many partners play a key role either in global connectivity or as transmission hubs [21] ; therefore sex with anyone outside one's household should be avoided. This applies both for non-monogamous relationships and for monogamous ones where partners are not sharing the same home.

Pregnancy and infectivity. During novel pandemic times, the need for contraception should be considered. MERS and SARS can cause adverse pregnancy outcomes including miscarriage, prematurity, fetal growth restriction, and maternal death [22] . So far, COVID-19 has been reported in relation to fetal distress and preterm delivery [4] . Intrauterine maternal-fetal transmission before delivery is a risk, although the fetus is unlikely to be exposed during pregnancy while the postpartum transmission is more likely [4, 23] . Small case series did not identify laboratory evidence of vertical transmission and there are no reported cases of breastfeeding transmission (Chen 2020, Zhu 2020, Rasmussen 2020, Qiancheng 2020, Yan 2020). A possible explanation might be the absence of the ACE receptor at the fetal-maternal interface, as the virus has not been found in the amniotic fluid, or maternal milk (Schwartz 2020, Liang H 2020).

Although the outcomes of mothers and newborns are globally favorable, there is a trend toward spontaneous prematurity and the high rate of cesarean deliveries is worrying (Della Gatta 2020).

There is no evidence to support pregnant women are more susceptible to COVID-19 than the general population, but pregnancy is a known risk factor for severe disease following other respiratory viruses [24] . Recent data shows that pregnant women have a clinical presentation similar J o u r n a l P r e -p r o o f to other non-pregnant adults (Chen 2020, Zhu 2020, Rasmussen 2020). Clinicians and women wishing to conceive should consider the potential effects of COVID-19 in early pregnancy and potential teratogenicity, until clear evidence becomes available on the topic.

Relational impacts of COVID-19. Despite widespread interventions meant to manage the spread of COVID-19, people across the world continue to find ways to adapt and connect. It is natural that Naturally, increased levels of stress can reduce this urge, but social distancing and stressful circumstances can also increase the need for emotional bonding. Online dating apps can facilitate connection while experiencing a stressful event that can encourage prosocial behavior and strengthen people's bonds [25] . Regardless of whether one is uncoupled, dating, or in a long-term relationship, expressing intimacy through virtual and/or physically distant means is vital to sustaining positive coping and psychological well-being.

It is important to note that while the focus of this review has explored sexual health implications, there are also indications that during times of pandemic, there is the potential for several other relational impacts. For instance, across the globe, online pornography use has increased dramatically, with a recently documented 24% rise in viewing (https://www.pornhub.com/insights/corona-virus). This may be due to increased home confinement and social distancing measures, but could also be that individuals are using pornography to cope with stress, anxiety, and uncertainty, or as a way to cope with fears related to death [26] . Increased pornography use may be one of many relationship stressors, especially in couples who have conflict around pornography use, or when one partner already struggles with compulsive sexual behavior (CSB). What's more, those who struggle with CSB may find themselves increasingly vulnerable due to a decreased access to coping strategies and increased stress or anxiety at home.

Accordingly, the heightened stress and the diminished quantity or quality of social networks may negatively influence relationships during and after the pandemic, exacerbating already existing J o u r n a l P r e -p r o o f conflictual relationships [27] and reducing the capacity and motivation of interpersonal interactions [28] . Additional considerations ought to be made related to the role of home confinement on couple conflict, divorce, and intimate partner violence, but these are beyond the scope of this paper.

Benefits of sex during the pandemic. In pandemic times, management interventions including 

The benefit of sexual activity on cardiovascular health has been investigated in a study

showing that women who endorsed emotionally satisfying sexual activity had less fewer cardiovascular events in 5 years. In a similar study on men, the frequency of sexual activity, and cardiovascular events were inversely related [30] . In addition Besides, sexual activity is a form of mild to moderate exercise, equivalent to 3-5 metabolic equivalents (METS; climbing 2 sets of stairs or walking briskly). During sexual activity, the rise in blood pressure rarely exceeds 170 mmHg, and heart rate almost never goes over 130 bpm, peaking for about 15 seconds during orgasm [31] .

Physical intimacy and sexual activity, as well as leisure and mental activities, protect against mild cognitive impairment (MCI) [32, 33] , whereas poor social network and divorce status increases the risk for MCI [34] . Regarding aging, researchers found that sexually active adults aged 50 to 90 years old had better memory and were less likely to feel depressed and lonely [35] . MCI is a pre-clinical stage for Alzheimer's disease (AD), during which memory complaints exist with minimal impact on daily life, yet neuroimaging-proven atrophic changes in brain structures are already present [36, 37] .

Furthermore, sexually active individuals may have a more efficient immune system. Studies have explored the role of Salivary Immunoglobulin A (SIgA), a major mucosal defense which that acts by directly attacking microorganisms and by first barrier macrophage recruitment, thus diminishing infections. In a study on 112 college students, those that had sex more than once or twice per week had significantly higher levels of SIgA than less sexually active ones [38] .

Interestingly, the presence of maintained sexual activity with a partner, but not by masturbation, can also influence immunity, reflected by SIgA levels, during a high score depressive episode [39] . 

Psychological benefits of sex. The WHO defines health as "a state of complete physical, mental and social well-being" and not merely "the absence of disease or infirmity." During pandemic periods, mental health is an essential issue to pay attention to [40, 41, 42] . According to the literature, the most prevalent symptoms of those who have been quarantined are depressed mood, irritability, fear, nervousness, and guilt [43, 44] . Studies have also demonstrated a positive association between duration of quarantine and worse mental health, specifically more specific symptoms of post-traumatic stress (PTS) [45, 46] , avoidance behaviors, and anger [44] .

The mechanism through which sexual activity impacts mental health remains speculative. It could be through the social interaction, physical activity, or through other unique pathways. In older adults, frequent dopamine release during intercourse has been shown to improve cognition, especially in the memory and task executing domains [47] . Assumptions that combine biological and behavioral factors have been suggested to underlie this effect [35, 47] . Within biological factors, studies have suggested deregulation of neurotransmitter levels and/or of the hypothalamicpituitary-adrenal axis, changes in endogenous levels of sex hormones, and an important role of endorphins, oxytocin, and prolactin [48] . The behavioral model claims that those who suffer from depression have a negative vision of themselves and the world, presenting multiple cognitive distortions, low self-esteem, and lack of self-confidence [48] . The latter emotional states significantly affect sexual function.

Sexual health is essential for the global health and well-being of individuals, couples, and families [49] . In pandemic times, sexual activity with a partner or through masturbation can provide psychological and emotional benefits. Studies correlate sex with increased satisfaction with one's mental health, increased levels of trust, intimacy, and love in relationships, improved ability to perceive, identify, and express emotions, and lessened use of immature psychological defense mechanisms [50] .

Impact of the pandemic on sexual dysfunction. Amid the pandemic, safety measures such as social distancing, home confinement, and quarantine are necessary to prevent spread. Despite this, there are invariable relationship and sexual health challenges to navigate during these times.

Recognizing these challenges is vital to address possible preventative measures as well as to pay attention to implications for treatment. Individuals already experiencing sexual dysfunction may experience changes in treatment, symptoms, and distress related to their sexual problems. For some, the increased stress and anxiety caused by the global pandemic may be the precipitating factor that leads to the advent of sexual problems. In the current section, we analyze the potential impact of the current COVID-19 pandemic on specific sexual dysfunctions: sexual desire and desire discrepancies, erectile dysfunction, orgasmic and ejaculatory disorders, genito-pelvic pain penetration disorders.

Sexual desire and desire discrepancies. Concerns around low sexual desire are highly prevalent across populations, ranging from 10-40% [51, 52] and are one of the most widespread sexual problems adults face. Sexual desire discrepancy (when partners report significantly different desires for sexual intimacy) remains one of the most common reasons for couples to seek therapy services due to the negative impact on a relationship and sexual satisfaction: distress related to sexual desire discrepancies has been shown to cause more conflict in relationships [53, 54, 55] . What we know about sexual desire, in general, is that it is multi-faceted and quite individualized. Due to the impact, connection. For some people, increased anxiety around death and mortality has been shown to be linked to an increase of desire and sexual interest, but not for all. The difference has been attributed to individual comfort with physical intimacy, body image, and self-esteem, suggesting that some people use sexual intimacy to cope during times of stress [56] . According to the "Dual Control

Model of Sexual Response", individual differences in sexual excitation and sexual inhibition may account for such different reactions. From this lens, people who tend to be sexually inhibited would have a more difficult time becoming aroused in stressful situations; whereas times of anxiety and stress may amplify sexual arousal in people who are usually easily excitable [57] .

Erectile Dysfunction. Erectile dysfunction (ED) is the most common male sexual health concern, effecting between 13-28% of men aged 40-80 years [58, 59] , with prevalence increasing with age [51] . While there is no data that no data explores the relationship between COVID-19 and the additional risk of developing ED, men at greatest risk for having serious complications secondary to COVID-19 are also those traditionally at risk for ED: older adult, diabetic, men with cardiovascular disease, overweight/obesity, and with multiple comorbidities [60, 61, 62] . Therefore, it is important to consider the role of added stress, anxiety, and physical health implications for men with ED amid the COVID-19 pandemic.

There is the potential that COVID-19 may add to the collective risk of developing ED or Conditions derived from the coronavirus pandemic, such as pressure related to economic and job instability, loss of external social interaction, and potential distance from one's sexual partner(s), are all factors that contribute to increasing levels of anxiety and depression [42] and may J o u r n a l P r e -p r o o f influence erectile function. These psychosocial changes can both cause and exacerbate ED, even in younger men [69] , through a mechanism of psychogenic ED, mediated by hyperstimulation of the sympathetic nervous system [60] . Depressive symptoms are commonly associated with the incidence and severity of ED [70] , with a bidirectional relationship, wherein ED causes or worsens depression as well [71] . Anxiety is usually involved in the etiology of ED in the early stages of sexual life, while positive sexual experiences are protective [71] . Anxiety can lead to some failures in initial attempts at sexual intercourse, leading to greater anxiety in later attempts and perpetuating this vicious cycle [72] . Due to the relational impact of ED, its multifaceted nature should be kept in mind, regardless of the pandemic implications.

When addressing treatment of ED, it is important to note that regardless of the ED nature, physiologic or psychogenic, the treatment methods are largely shifting to telemedicine to adjust to ongoing needs amid the pandemic. As with many other diseases that are less "critical" in nature,

there is a chance that ED may be prioritized less or seen as non-essential from the perspective of men with ED, as well as their primary healthcare providers. Ongoing global economic instability may lead men to have difficulties obtaining their medications. In addition to the direct effects of interrupting their ED medication, it must be kept in mind that the decompensation of cardiovascular and mental illnesses can aggravate ED [73] .

Orgasmic and ejaculatory disorders. The etiology of orgasmic and ejaculatory dysfunction often includes stress, anxiety, and preoccupation [74, 75] . In both men and women, significant time spent in quarantine can increase psychological distress, including low mood, anxiety, depression, irritability, and fear [42] , which can complicate sexual dysfunction presentation in general and orgasmic disorders in particular, like orgasm dysfunctions, premature ejaculation (PE), or anorgasmia. Decreased motivation to seek treatment for sexual problems may further exacerbate potential relational distress and conflict. Important considerations include access to ongoing sexual J o u r n a l P r e -p r o o f therapy treatment, comorbid sexual health problems, and potential side effects of medications prescribed to treat the aforementioned psychiatric symptoms [74, 76, 77] .

Pain/Penetration Disorders (GPPPD) merges the previous DSM-IV-TR diagnoses of Dyspareunia and Vaginismus [78] . GPPPD have has been shown to be very common: prevalence studies of vulvodynia, a common cause for dyspareunia, have indicated lifetime estimates ranging from 10%

to 28% in reproductive-aged women [79] . The prevalence of vaginismus in sexual clinical settings ranges from 5% to 17% [80] .

Home confinement and quarantine may have a significant impact on women with GPPPD, both on a psychological and on a practical level. Studies on the psychological effects of quarantine in the general population have shown a high prevalence of depression [46] , low mood [43] , acute stress disorder [81] , and PTS symptoms [44] , during and following a quarantine. Pre-existing psychiatric conditions [41] , younger age (16-24 years) , and female gender [82] have been shown to be are associated with worse psychological impact [42] . This information may imply that women suffering from GPPPD, a condition typically presenting in young adulthood, and associated with clinical and sub-clinical depression and anxiety, may be at significant risk for worsening or exacerbation of their mood disorder [83, 79] . In women with GPPPD, anxiety and depression have been also associated with greater pain intensity and sexual dysfunction [79, 84, 85] , so that a highly stressful situation such as home confinement may potentially result in worsening of sexual function.

A recent study has shown women who experienced more severe and frequent pain during intercourse reported increased loneliness and depressive symptoms [86] . Social isolation measures required to control the pandemic may potentiate such feelings of loneliness and further increase the distress of GPPPD patients. Couple dynamics play a central role in the adaptive coping of women with GPPPD and their partners [87] . The attachment style of partners, dyadic sexual J o u r n a l P r e -p r o o f communication, partner responses to pain, affection, and ambivalence over emotional expression have all been shown to impact pain and dysfunction [87] .

Post-traumatic stress disorder (PTSD), especially following sexual abuse, has been documented as a common antecedent to GPPPD [88, 89] and may cause increased vulnerability of GPPPD patients to acute stressful events. The effect of the pandemic, social isolation, and quarantine on pre-existing PTSD has not been studied yet. Nevertheless, the literature has shown that conditions involving fear of infirmity or death, loss of control over one's life, and disruption of one's sense of safety, may potentially provoke PTSD symptom reactivation [90, 91] . Based on these findings, we may assume that the risk of post-traumatic symptoms worsening during the pandemic and home confinement is significant.

As GPPPD has long been conceptualized as a biopsychosocial phenomenon, its treatment should ideally be based on an individualized, multidisciplinary approach, involving medical doctors, physiotherapists, sex therapists, and/or psychologists. [92, 93, 94, 95] . CBT therapy for GPPPD involves home exercises, such as the use of vaginal accommodators (dilators) [96] : women usually carry out the exercises in their own privacy and sometimes, often at later stages, with the aid of their partner. During home confinement, when both partners and sometimes additional family members are at home all of the time, negotiating personal privacy can become a challenge, and interruption of the exercises may be inevitable. Physiotherapy (PT) modalities may be an alternative to solitary exercises using accommodators [97] . However, the accessibility of medical and PT treatment for non-emergencies becomes scarce at the pandemic time. The lack of client-medical caregiver interaction may have physical effects in some cases, but deleterious psychological effects may occur as well: the client-caregiver relationship is an integral part of the social context of someone suffering from a chronic illness, and halting this relationship can negatively affect treatment compliance and health outcomes [98, 79] . A last important factor to consider during J o u r n a l P r e -p r o o f quarantine is financial loss, with people unable to work and having to interrupt their professional activities with no advanced planning [42] . In this situation, it can be impossible for some women and couples to pay for weekly psychological and sexual treatment sessions, as in many countries the public healthcare systems do not include these therapies in their health packages.

Based on current published and revised studies referring to sexual health and behaviors in correlation to coronavirus pandemics, we wish to call for key questions about sexual behavior during the COVID-19 pandemic, with respect to the effects of quarantine, social distancing and home confinement on sexual health. Table 1 summarizes our main results-based discussions and conclusions.

Intimacy and relational dynamics effects. When revising the knowledge of COVID-19 and infectivity, sexual activities, dating, and relational dynamics, our summary and recommendations are in line with the statements issued by the public institutions and professional societies on the safety of sexual activity and disease transmission prevention (Table 1) . [5, 6, 7] Since the onset of COVID-19 new dating possibilities must be adapted and intimacy issues highlighted. While sexual activity should be encouraged between cohabiting partners during the pandemic, sex with multiple partners and casual sex is firmly discouraged, so is sex with a quarantined partner. Very recent studies found the presence of SARS-CoV-2 in the semen fluid [99] , but not in the vaginal secretions Considering the immunity aspects within such a provocative infection, individuals with medical conditions which can lead to more severe COVID-19 (lung disease, heart disease, diabetes, cancer or a weakened immune system), should avoid sexual contact as a preventive measure. Additionally, early pregnancy should be considered for possible risk and even potential teratogenicity when infected with SARS-CoV-2, until clear evidence becomes available on the topic.

Clinical effects. Sexual activity has a positive impact on the immunity, mental state, and cognitive outcome, and therefore it should be encouraged between cohabiting partners during the pandemic.

We discuss pandemic impact on sexuality with an emphasis on benefits of sex, sexual desire, erectile dysfunction, genito-pelvic pain penetration disorders, and couple dynamics.

Benefits of sex. The psychosocial and economic implications of the current pandemic and the profound impact they have on collective, dyadic, and individual adjustment, are expected to have deleterious collateral effects on general health. Changes in level of physical activity and diet, social isolation, exacerbation, or re-activation of pre-existing depression and anxiety, the impact of stress on the immune system, should all be considered significant secondary health hazards. Based on the information outlined above, which summarizes the facilitative effect of healthy sexual activity on physical and mental health, we suggest maintenance of sexual activity should not be discouraged, but rather globally recommended by professional healthcare societies at this time, as it may emerge in psychological and emotional benefits.

In addition to changes in psychological health, measures of social distancing, isolation, and quarantine also present unique challenges in navigating sexual desire discrepancies (Table 1) . For some, these differences may manifest for the first time where one partner is looking to have more sex and the other is distracted, preoccupied, or otherwise disengaged. For others, stress and extended proximity to one's partner exacerbate differences in desire.

Home confinement, combined with the psychological stress of living in a pandemic, may amplify the already existing sexual dysfunction, like sexual desire discrepancies, ED, premature ejaculation (PE), or GPPPD (Table 1) . When faced with sexual dysfunction, being confined at home with one's romantic/sexual partner may heighten sexual anxieties and fear of performance failure, affecting sexual satisfaction and overarching relationship conflict (Table 1) . Accordingly, quarantine situations may exacerbate the already complex interpersonal responses that maintain and worsen sexual issues (Table 1) .

However, in the context of a healthy relationship, it also holds opportunity for couples to engage in sexual intimacy at their own pace, to better comply with home exercises, such as sensate focus or other behavioral techniques, as the daily schedule is flexible and lack of time is less of an issue. Free from many of life's external pressures, couples may feel more able to confront and better cope with ED, PE, anorgasmia or GPPPD (Table 1) . Additional consideration ought to be made for individuals who are not cohabitating with their sexual partner(s) or are not in committed sexual relationships. While home confinement and social distancing further complicates physical and sexual engagement in practical ways, it also creates an opportunity for these partners to engage in creative ways of increasing intimacy and eroticism, such as through virtual sex.

In conclusion, the current COVID-19 pandemic and its effect on everyday life has significant implications regarding the ability of women and men with sexual dysfunction to successfully cope with their condition. Increased emotional distress, mood disorder, PTSD exacerbations, and worsening couple dynamics may be expected. Despite the accessibility of telemedicine and online psychotherapy options, treatment plan interruption and possibly regression of symptoms may be observed, as postponement of most elective, non-urgent medical treatments and putting "on hold" topics that are not a direct, immediate threat to one's health and safety are expected. In some cases, the schedule flexibility which is a side product of lockdown and J o u r n a l P r e -p r o o f confinement, may provide an occasion to devote time to increased intimacy and communication, leading to better comply compliance with couple therapy and sex therapy behavioral exercises.

Access to materials with recommendations and knowledge for self-therapeutic exercises to engage in safe sexual activities should be available to the public (Table 1) . 

Kissing is allowed between healthy, unexposed cohabiting partners. [6] Kissing should be avoided with anyone symptomatic or with people outside one's household. [6] 

Vaginal intercourse is allowed, as there is no evidence that COVID-19 is transmitted through vaginal secretions and ejaculate. [6] 

Anal intercourse is allowed, provided fecal-oral transmission is carefully avoided. [12] [17] Analingus, or "rimming", should be avoided as fecal-oral transmission of the virus has been documented. [7] [6] Virtual sexual activity Video dates, sexting, chat rooms, erotic phone conversations are safe alternative to sexual contact. [6] Sexual Dysfunction General considerations:

Call for increased awareness that stress, anxiety, and depressed mood resulting from direct and collateral effects of the pandemic may negatively impact all types of sexual dysfunction.

Treatment of sexual dysfunction should be higher prioritized than other non-urgent medical issues.

Counselling sessions and medical consultations should shift even more to different online platforms and telemedicine.

Guidelines & recommendations should be available for free, because the financial loss can make it difficult to pay for weekly psychological and sexual treatment sessions. [42] Call for awareness that only motivated couples may find home confinement an occasion to comply with sexual therapy exercises, as the daily schedule is flexible Sexual desire and desire discrepancies Anxiety around infirmity and mortality may be linked to either increased or decreased sexual interest in different individuals. [57] [56] Stress and extended proximity to one's partner may exacerbate differences in desire.

Men at greatest risk for having serious complications secondary to COVID-19 are also those traditionally at risk for ED (older age/ comorbidities). [60] [61] [62] Psychosocial changes such as economic pressure or job instability can both cause and exacerbate ED [69] Economic instability may lead men to have difficulties obtaining their medications [73] Orgasmic and ejaculatory disorders Low mood, anxiety, depression, irritability, and fear may worsen orgasmic disorders [74] [75] Genito-pelvic pain penetration disorders (GPPPD) PTSD, a common antecedent to GPPPD, may undergo symptom reactivation following fear of infirmity and confinement during the pandemic [88] [89] Home confinement may amplify and exacerbate the interpersonal responses that maintain GPPPD. Lack of privacy can prevent compliance with home exercises. [98] 

A novel coronavirus from patients with pneumonia in China

A pneumonia outbreak associated with a new coronavirus of probable bat origin

Situation report 22. World Health Organization

COVID-19: What implications for sexual and reproductive health and rights globally?. Sex Reprod Health Matters

International Society for the Study of Womens Sexual Health. Position Statement on Sexual Activity and COVID-19

Is it safe to have sex during the coronavirus (COVID-19) pandemic? ISSM

COVID-19). NYC Health

Efficacy of various disinfectants against SARS coronavirus

Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents

Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1

Molecular and serological investigation of 2019-nCoV infected patients: implication of multiple shedding routes

Interventions to mitigate early spread of SARS-CoV-2 in Singapore: a modelling study

The origin, transmission and clinical therapies on coronavirus disease 2019 (COVID-19) outbreak -an update on the status

Modelling transmission and control of the COVID-19 pandemic in Australia

Identification of new respiratory viruses in the new millennium

An Imperative Need for Research on the Role of Environmental Factors in Transmission of Novel Coronavirus (COVID-19)

COVID-19 containment: China provides important lessons for global response

A Familial Cluster of Infection Associated With the 2019 Novel Coronavirus Indicating Possible Person-to-Person Transmission During the Incubation Period

Epidemic potential by sexual activity distributions

Guidelines for pregnant women with suspected SARS-CoV-2 infection

Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records

Pandemic influenza and pregnant women

The Social Dimension of Stress Reactivity: Acute Stress Increases Prosocial Behavior in Humans

The body as a source of self-esteem: The effect of mortality salience on identification with one's body, interest in sex, and appearance monitoring

Can mental health interventions change social networks? A systematic review

Interpersonal concomitants and antecedents of depression among college students

Sexual Satisfaction and the Importance of Sexual Health to Quality of Life Throughout the Life Course of U.S. Adults

Is Sex Good for Your Health? A National Study on Partnered Sexuality and Cardiovascular Risk among Older Men and Women

Sexual activity and cardiovascular disease: A scientific statement from the American Heart Association

Cognitive Impairment, Sexual Activity and Physical Tenderness in Community-Dwelling Older Adults: A Cross-Sectional Exploration

Late life leisure activities and risk of cognitive decline

A 3-year follow-up study of social, lifestyle and health predictors of cognitive impairment in a Chinese older cohort

Sex on the brain! Associations between sexual activity and cognitive function in older age

Hippocampus and entorhinal cortex in mild cognitive impairment and early AD

A voxel based morphometry study on mild cognitive impairment

Sexual frequency and salivary immunoglobulin A (IgA)

Interactions of sexual activity, gender, and depression with immunity

The world health report 2001 -Mental health: new understanding, new hope

Mental health status of people isolated due to Middle East Respiratory Syndrome

The psychological impact of quarantine and how to reduce it: rapid review of the evidence

The experience of SARS-related stigma at Amoy Gardens

Is quarantine related to immediate negative psychological consequences during the 2009 H1N1 epidemic

SARS control and psychological effects of quarantine

Frequent sexual activity predicts specific cognitive abilities in older adults

Erectile dysfunction and depression: a systematic review and meta-analysis

Defining Sexual Health. The world health report 2006: working together for health. World Health Organization

The relative health benefits of different sexual activities

Sexual dysfunction in the United States: prevalence and predictors

Sexual problems and distress in United States women: prevalence and correlates

The relative impact of individual sexual desire and couple desire discrepancy on satisfaction in heterosexual couples

Sexual desire discrepancy: The effect of individual differences in desired and actual sexual frequency on dating couples

Exploring the effects of sexual desire discrepancy among married couples

Intimacy and risky sexual behavior-What does it have to do with death? Death Stud

The Dual Control Model: Current Status and Future Directions

The sexual habits of British men and women over 40 years old

The incidence, prevalence, and natural history of erectile dysfunction

Comorbidity and its impact on 1590 patients with Covid-19 in China: A Nationwide Analysis

Severe outcomes among patients with coronavirus disease 2019 (COVID-19)-United States

When COVID-19 encounters interstitial lung disease: challenges and management. Zhonghua jie he he hu xi za zhi

Evolution of pulmonary pathology in severe acute respiratory syndrome

The role of infection in the pathogenesis of idiopathic pulmonary fibrosis

Correlates of erectile dysfunction in moderate to severe chronic obstructive pulmonary disease patients

Thorax Computed Tomography Findings in Patients with Erectile Dysfunction

Optimizing quality of life in patients with idiopathic pulmonary fibrosis

Changes in the prevalence and risk factors of erectile dysfunction during a decade: the Korean Internet Sexuality Survey (KISS), a 10-year-interval web-based survey

Erectile dysfunction in fit and healthy young men: psychological or pathological?

A systematic review of the psychosocial outcomes associated with erectile dysfunction: Does the impact of erectile dysfunction extend beyond a man's inability to have sex?

Genital Image, Sexual Anxiety, and Erectile Dysfunction Among Young Male Military Personnel

Economic crises and mortality: A review of the literature

Diagnosis and management of female Orgasmic disorder

Management of Sexual Dysfunction in Men and Women: An Interdisciplinary Approach

Early maladaptive schemas and sexual dysfunction in men

Sexual dysfunction in selective serotonin reuptake inhibitors (SSRIs) and potential solutions: A narrative literature review

The Comorbidity Between Premature Ejaculation and Erectile Dysfunction-A Cross-Sectional Internet Survey

Diagnostic Classification. in Diagnostic and Statistical Manual of Mental Disorders (DSM-5)

Definition, Prevalence, Impact, and Pathophysiological Factors

Psychobiological Correlates of Vaginismus: An Exploratory Analysis

Factors influencing compliance with quarantine in Toronto during the 2003 SARS outbreak

Factors influencing psychological distress during a disease epidemic: Data from Australia's first outbreak of J o u r n a l P r e -p r o o f equine influenza

Factors associated with vulvodynia incidence

Do psychosexual factors play a role in the etiology of provoked vestibulodynia? A critical review

Provoked vestibulodynia: Psychological predictors of topical and cognitive-behavioral treatment outcome

Loneliness mediates the relationship between pain during intercourse and depressive symptoms among young women

Genito-Pelvic pain through a dyadic lens: Moving toward an interpersonal emotion regulation model of women's sexual dysfunction

Adult-onset vulvodynia in relation to childhood violence victimization

Is chronic stress during childhood associated with adult-onset vulvodynia?

The effects of September 11 on traumatized refugees: Reactivation of posttraumatic stress disorder

Beware of multiple traumas in PTSD assessment: The role of reactivation mechanism in intrusive and hyper-arousal symptoms

Effectiveness of cognitive-behavioral therapy and physical therapy for provoked vestibulodynia: A randomized pilot study

Feasibility and preliminary effectiveness of a novel cognitive-behavioral couple therapy for provoked vestibulodynia: A pilot study

A comparison of mindfulness-based cognitive therapy vs cognitive behavioral therapy for the treatment of provoked vestibulodynia in a hospital clinic Setting

Impact of educational seminars on women with provoked vestibulodynia

The use of amielle vaginal trainers as adjuvant in the treatment of vestibulodynia: An observational multicentric study

Influence of context effects on health outcomes: A systematic review

Clinical Characteristics and Results of Semen Tests Among Men With Coronavirus Disease

Severe acute respiratory syndrome coronavirus 2 detection in the female lower genital tract