Locked- Down of Intimacy, Sexuality and Relationship during Covid Pandemic: Short Review

Financial Support: None declared Conflict of Interest: None declared Date of Submission: 23-12-2021 Date of Acceptance: 10-02-2022 Date of Publication: 28-02-2022 Correspondence: Mahendra Kumar (Email: Kumarmahen9@gmail.com) Copy Right: The Journal retains the copyrights of this article. However, reproduction is permissible with due acknowledgement of the source. National Journal of Community Medicine│Volume 13│Issue 02│February 2022 Page 126 How to cite this article: Kumar M, Rohilla K, Singh A, Kumari A, Sharma R. LockedDown of Intimacy, Sexuality and Relationship during Covid Pandemic: Short Review. Natl J Community Med 2022;13(2):126-132. DOI: 10.55489/njcm13220225 REVIEW ARTICLE pISSN 0976 3325│eISSN 2229 6816 Open Access Article (CC BY-SA) www.njcmindia.org DOI: 10.55489/njcm13220225 LockedDown of Intimacy, Sexuality and Relationship during Covid Pandemic: Short Review Mahendra Kumar1, Kusum R Rohilla2, Ankita Singh3, Anita Kumari4, Raman Sharma5  1Stroke Team Coordinator, Department of Neurology, PGIMER, Chandigarh 2PhD Scholar, Nursing Department, AIIMS Rishikesh 3Nursing Officer, Nursing Department, AIIMS, New Delhi 4MNS Officer, Nursing Department, Base Hospital, Lucknow 5Associate Professor, Department of Hospital Administration, PGIMER, Chandigarh


INTRODUCTION
For the first time after the Second World War, the current pandemic is re-scripting the history of crisis and panic across the globe. Since November 2019, the world is facing the Covid-19 pandemic caused by severe acute respiratory syndrome (SARS-COV-2) which is the reason behind the death of millions of people. 1 WHO announce the Covid-19 as an International Public Health Emergency on 30 th January 2020 and on 11 th March 2020, declared it the pandemic that turned to be the deadliest pandemic of the century. 2 The arbitrary and uncertainty of the worst health emergency of the century comes as a nightmare for the world as two-thirds population of more than 90 countries was inside their home for months. 3 Researchers across the world highly expect the nega-tive impact of the Covid-19 pandemic on sexuality and relationship among inmates. 2,4 Researchers also indicate that sexually active generations are facing excessive challenges during the vicious circle of Covid-19 pandemic and several aspects of the reproductive and sexual health affected by the pandemic. 4,5 Unfortunately, very little information and attention focused on the negative impact of the pandemic on sexual health and this area is largely unmeasured despite its powerful impact. 6

Need to discuss on sexual health and relationship during Covid pandemic
The risk of Covid-19 transmission by sexual relationship is still unanswered even after 2 years of the pandemic. Although Covid is not a sexually transmitted disease but can get a transfer into others by close contact with suspected or confirmed positive partners. Moreover, the impact of the Pandemic on sexual relationships and intimacy among couples is not reported as we have studies on both sides that decrease and increase the frequency of sexual intercourse during the pandemic. The WHO summarizes the definition of sexual health as the physical, emotional, mental, and social well-being of an individual. Whereas sexual dysfunction can be described as any of the conditions preventing the individuals from being satisfied by the sexual activity at any stage of the sexual relationship. This review is aimed to bring some glimpse of recent studies targeted to cover the impact of Covid-19 on the sexual health of individuals and how their life is being affected by pandemic restrictions on the cost of their relationships and affection.

METHODS
An open-access literature search was conducted from December 2019 to December 2021 using multiple databases/search engines including Google Scholar, Medline, PubMed. These few keywords were searched: Covid, pandemic, sexual health, intimacy, stress, anxiety, sexual behavior, and divorce was searched. The initial attempt searched section involved the impact of the Covid-19 pandemic created lockdown, impact of pandemic restriction over sexual health and intimacy of inmates. Anxiety, fear, and stress of getting an infection from sexual contact were searched. Secondary search type includes the impact of the Covid-19 pandemic over reproductive health of women, preferring of getting pregnant, and relationship crisis during home confinements and condition of women during a critical time of the pandemic. Additionally, a gray literature search was also reviewed to find evidence of the impact of pandemic over sexual frequency and sexual practices of individuals.
Inclusion criteria: Research papers including studies exploring impact of Covid-19 pandemic on sexuality and intimacy of individuals published in the English language only. Mainly studies focusing on sexual health and relationship during pandemic only.
Exclusion criteria: Studies that do not mention data collection and analysis or source of data. Non-peerreviewed journal articles, letters.

Impact of pandemic restriction (lockdown) on sexuality and intimacy of individuals
Keeping six feet of distance was also getting excessive popularity as social distancing during the initial days of the Covid pandemic that later replaced by the world health organization with physical distancing 5 Initiatives to slow the spread of disease civic authorities announced countrywide restrictions and physical distancing guidelines at one point in time. 7 Spending too much time together contributed to the notable decline in partnered people's sex lives. 5 Sexual health is essential for couples to maintain trust, intimacy, and love in their relationships. 8 For others, sex can be a source of managing stress and couples feel bonding with each other and strengthen their intimacy. 9 There is diverse evidence on the effect of the Covid-19 pandemic on human sexuality and intimacy in the previous literature. 5,6,10 A study from Australia reported sexual activities declined significantly during pandemic restrictions find half of the study population reported having less frequent sexual activities than in the year 2019 before the pandemic. 11 In an Indian family setting it's not unusual to find inlaws and parents living near their adult children. The Indian culture of the joint family provides a context for affection, companionship, and solidarity among old-age family members and children. Continuing presence of elders at home and compromised privacy were behind declined sexual intercourse even couples was living close for months under the same roof. Increased family supervision of family members, the continued presence of children, inmates at home make it difficult to find a moment of intimacy during the pandemic. 12

Fear of sexual transmission of Covid infection impacting over intimacy
Good mental health impact positively over sexuality and intimacy of partners. 13 Although with available research, no study so far claims to find the direct impact of the Covid pandemic on an individual's sexuality. Although across the world, several researchers reported a lower frequency of partnered sex during the pandemic. 3,14 The high risk of getting the infection through contacts, excessive panic around about the disease which has no specific treatment available people feared to get involved in sexuality. 7,15 The primary route of Covid-19 transmission is through respiratory droplets, aerosols, and person-to-person contact. 13 Furthermore many recent studies claim to transfer Covid-19 infection into the male reproductive tract, and semen of recovering patients who had Covid-19 infection. 9,12 The Covid pandemic was also blamed to impact on sexual practices. 16 A decline was reported in common practices of partnered sexual activity like physical touch, kissing, and hugging is taken as crucial parts of sexual intimacy and determinant of emotional connection between couples. 18 Although little evidence has revealed that, a substantial amount of Covid-19 virus is present in saliva and evidence is available of fecal-oral transmission of the Covid-19. 15,16 Interestingly, another study conducted by Maya Luetke from the USA describes that Covid-19 impacts negatively on the frequency of intimacy practices such as cuddling, lip to lip kissing, and re-ported less frequency of sexual intercourse during the pandemic. 17 Availability of limited verified information about the possible risk of sexual transmission of Covid-19 infections, the couple reported avoiding foreplay and sexual practices like kissing and physical touching in partnered sexual activities. 18 Continuing physical relationships with partners who live share household and do not go out is considered to be safe until none of them shows Covid-19 related symptoms. 19 The sexual practices of couples changed accordingly to avoid any possible risk of transfer of deadly Covid infection. Reports from various resources indicate the decreased frequency of sexual intercourse and fantasy intimacy practices such as kissing, oral sex. 3 Many studies reported covid-19 pandemic anxiety; stress was negatively impacting the frequency of sexual frequency and sexual practices. 20,21

Impact of Pandemic on women's Sexual Health
Whether we agree or not but the male dominating society has a common belief that sex should always be outstanding and with a "perfect "act. If it is not as perfect as supposed then considered improper and the sign of "lack of love or affection" or a dent in the intimacy and couple bounding. 22 For centuries women are facing compounding burdens of high expectations to work more and speak less about their rights and needs. Somewhere we all agreed to witness women is sharing challenges by shouldering much of the burden at home and workplace during pandemic crisis times.
Moreover, excessive representation of women in the health care system makes them more venerable to get exhausted during serving in pandemic either at the home or workplace. 23 Almost two-thirds (70%) of the health workforce world widely is women. A number that goes up to 90% if including social care workers. United Nations reports revealed that over 70% of Covid-19infections in healthcare workers in the USA, Italy, and Spain are reported among women. 24 However, as Covid-19 continues to spreads across the world, the impact of the pandemic on women is becoming increasingly severe. Women are more at risk of feeling insecure and alone due to social isolation from friends and relatives during the pandemic and prefer avoiding sexual encounters with their partners. 22,23 While shreds of evidence reporting men are getting more affected by Covid than women as fatality rates for men who have contracted Covid-19 are 60-80% higher than for women. 25

The black clouds of pandemic over sexuality and intimacy
During the initial days of the pandemic in India, leading newspapers reported a sudden surge in the sale of condoms and contraceptives hence there was a prediction of a rise in pregnancies. 26 In the time of lockdown closer markets disrupted the supply chain of contraceptives resulting in stock-outs supplies. In another study from China said there was no change in condom uses among their participants due to Covid-19. However, they experienced a sudden shortage of contraceptives. 27 A similar study from South Africa's shared their experience of covid-19 and reported that there was difficulty to access the supply of condoms during the Covid-19 pandemic especially during the initial days of the pandemic due to lockdown restrictions. 28 The pandemic guidelines of restriction and closer of markets made it difficult to easily availability of contraceptives supply. Reference Reproductive health consultation of couple's, want for family planning was not met properly. 29 However, the lack of access to comprehensive health care services leaves serious numbers of women and couples risked for increasing negative sexual health outcomes. 30 The contrasting outcome was revealed in an Italian study, which reveals that couples preferably avoid conceiving during the pandemic due to possible human-to-human transmission, the impact of Covid -19 on children as fear of vertical transmission in newborns. 31 An Iranian cross-sectional study disclosed in their findings that because of covid-19 pandemic stress and anxiety, pregnant women desired to discontinue their pregnancies prematurely. 32 In another study, a massive drop was reported in the frequency of sexual intercourse during the Covid-19 pandemic. Another important observation was a significant increase observed in contraceptive use including condoms during the Covid-19 .33 Pandemic created difficult access to reproductive and maternal health care facilities due to guidelines to lessen pressure on the already over bourdon health care system by suspending non-Covid medical care. 33,34

Impact of Covid-19 pandemic on the relationship among partners
Marriage has remained one of the most intense relationships which human civilization has witnessed and sustained over centuries. 35 In India marriage to be believed as a sacred union between the couple is considered indissoluble and irrevocable. Studies show married individuals enjoy better mental health than never-married individuals likely due to the support of their partner. 36 A survey study conducted by A. Ahmad et al during a pandemic to examine the association between anxiety and socio-demographic factors during the Covid-19 lockdown among the Indian population reported that their married partici-pant population had a lower level of anxiety during Covid-19 lockdown than compared to unmarried participants. 37 Fuchs et al. reported a decline in the frequency of sexual intercourse since the pandemic. The author found two main reasons linked with these findings. First was lockdown and restriction guideline with the closer of all activities increase risk of conflict among couples who were inside houses since long. Previously also researchers indicated that forced proximity is a risk factor for domestic violence. Furthermore, stress about a possible risk of sexual transfer of Covid infection. 38 Lockdown and quarantine created family dependencies due to a long home stay, closer of social activities, and further increase in domestic abuse cases and a situation of unwanted confinement and disputes widely. 39 Marital distress could add to decreased libido and further affect sexual intimacy. 40 The limitation of space in the home increased in physical abuse and some cases exacerbated the quarrels turning to physical violence within the cohabiting couple; it further lead to differences of opinion, thus affecting and weakening the couple's bond and their intimacy. 41,42 A study from Western and Southern European countries also reported an increase in relationship conflicts and intimate partner violence during the covid-19 pandemic. 43 The supporting evidence comes from another study conducted in 57 countries subsequently in 3593 population. Authors indicate Covid-19 related stressors, such as isolation due to lockdown and social distancing, the financial constraint of losing the job and financial survival were found associated with greater conflict in inmates relationships and conflicts. 44 Many marriages are in difficulty and some couples are more vulnerable than others who already going through relationship issues the Covid pandemic situation may advance this process. A study from China, where the pandemic was initiated and millions of people faced isolation, restrictions, reported a surge in cases of broken marriages, soar in recent months. 45 Researchers also reported stress, including financial instability, disagreements between spouses, can be a leading factor to predict divorce. The Covid pandemic came with the invisible stressor of unemployment, cost-cutting leading to terminating services of their employees. 46 The Covid pandemic social restrictions norms led to, a circumstance that is likely to unfavorable impact on intimate relationships and sexuality of couples due to an increase in spousal interference. 47 A German study observes that families have been suffered badly from the Covid-19 pandemic and its associated lockdown. About half of the study population couples reported declines in marital satisfaction during the pandemic. 48 Contrary to other researchers a well-powered large sample size national study gave another side of Covid pandemic impact over couple intimacy and relationship where they reported that people even became more tolerant and less blaming of their daily small issues of their partner. Another important benefit of staying together for long as people were sharing meaningful time like eating, cooking, performing religious practices, and watching movies on TV is also called marriage enhancer 34 Another study aimed to assess sexuality during Covid pandemic observe that reported that the pandemic-related lockdown resulted in an increased sexual desire and higher frequency of partnered sexual activities. 47 Another study on a similar track conducted in Turkey discusses that the partners spent more time together due to lockdown found it worth repairing their conflicts and reported an increase in sexual satisfaction. 49 Pandemic offered a much-needed respite to couples who previously longed for spending time together for intimate moments. Secondly, couples and families' lockdown and closer of working may come as great opportunity to correct their relationship and give focus on each other's and spend extended amounts of time together. 50 But the overall majority of researchers indicate pandemic turn couples relationship in hard testing time. More incidences of verbal spats due to sharing responsibilities of household works like cooking, cleaning, and managing home were being shared by husband also as house help was not coming since the announcement of lockdown. Although it is believed that the way to a man's heart is through his stomach, most of the conflicts were reported over the cooking.

Health Care workers and Covid Pandemic
A study from the tertiary care center of northern India reported the impact of working in the Covid care area on sexual health negatively. The participant health care worker found higher sexual dysfunction as compared to those who were not working in a Covid care setting. 3 This may have an impact on their emotional well-being. 51 Even the spouse of Health care workers were in dilemma to welcome back them home after working in the high infective area of Covid-19. 52,53 Some healthcare workers have quarantined themselves from their families, while others practice good hand hygiene and have a separate set of clothing dedicated to working. 54

CONCLUSION
Despite the overwhelmed development of human civilization sexuality is remains a matter of closed doors and especially it's difficult to address in Indian society. For most, pandemic-induced lockdowns created an atmosphere of uncertainty and fear. In ways, the Covid-19 has proven toxic for sexuality. The pandemic thoroughly, changing sexual relationships, sexual practices and intimacy among couples. Over 200 countries worldwide are affected by the novel corona virus and we are witnessing a century's crisis where the whole world is under threat of rapidly spreading the new infection COVID -19 and the overall global impact of this new pandemic is yet uncertain.