The World Health Organization (WHO) defines mental health as “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.” Maintaining a positive state of mental health can be difficult to achieve, especially during a time of prolonged crisis such as the COVID-19 pandemic due to fears and anxieties related to the highly contagious and evolving SARS-CoV-2 virus. Although having an active sex life can help to promote overall well-being, concerns about viral transmission due to close personal contact can alter and hinder normal sexual practices and function, leading to dissatisfaction. In this article, we review the impact of COVID-19 with respect to sexuality and mental health.

With the rise of the COVID-19 pandemic, many studies have been undertaken to determine its effects on different populations ranging from changes in sexual behavior to adverse outcomes with mental health, substance use and suicidal ideation.¹ Although it is difficult to separate correlation from causation, it is reasonable to assume that changes in sexual behavior and adverse effects on mental health are intertwined, with 62% of men rating sexual health as highly important to quality of life.² Overall sexual behavior has changed during the COVID-19 pandemic, as evidenced by many surveys taken at the beginning of the pandemic in 2020. Among heterosexual male respondents in China, the number of sexual partners decreased for 53% and sexual frequency decreased for 40% of those surveyed and 41% of heterosexual couples reported decreased sexual intercourse during this time period. Autoeroticism such as masturbation increased in 30% of respondents, and 23% reported an increase in viewing pornography.³ For men who have sex with men (MSM) in the U.S., 51% of respondents also experienced a decreased number of sexual partners and 68% reported reduced opportunities for sexual encounters.⁴ Similar changes in sexual behavior were also reported by Israeli MSM engaging in casual sex with reduction of kissing, oral sex, and anal sex and increased use of condoms, engaging in phone sex/webcam, and consumption of pornography.⁵

While changes in sexual behavior may be attributed to fear of transmission of the SARS-CoV-2 virus, there has been no evidence to suggest viral transmission via vaginal or anal intercourse since transmission of SARS-CoV-2 is primarily through respiratory droplets. However, anilingus may represent a risk for infection as live virus has been detected in feces.⁶ Subsequently, different governmental agencies have taken a proactive stance in providing guidelines for safer sex practices during the pandemic. Health departments from New York City, Washington, D.C., San Francisco and Toronto have urged harm reduction strategies such as: getting vaccinated; talking about COVID-19 risk factors prior to hooking up; encouraging face coverings during close contact; maintaining distance when possible, mutual masturbation, cybersex, handwashing, and use of condoms and/or dental dams; and avoiding sex parties, kissing and multiple partners as ways to make informed and consensual decisions about sex while also reducing the spread of the SARS-CoV-2 virus.⁷

Even with guidelines in place to minimize risk of viral transmission during sexual activity, other factors such as isolation and quarantine have been shown to have a negative impact on overall well-being and sexuality. In a survey of 1,576 Italian adults without COVID-19 during the country’s lockdown period, there was a significant decline in well-being associated with a correlating decrease in frequency of intercourse mainly due to poor household privacy and lack of psychological stimuli.⁸ In a cross-sectional online survey of 1,010 U.S. adults in April 2020 during the early stages of the COVID-19 pandemic, 34% of adults in relationships reported conflict with their romantic partners due to the initial spread of COVID-19 and its related stay-at-home restrictions, with escalations in conflict corresponding to a greater likelihood of decreased frequency of sexual intimacy.⁹ Among 1,954 Taiwanese respondents also surveyed in April 2020, decreased frequency of sexual activity was significantly associated with having a higher risk perception of COVID-19 and having greater general anxiety even though this was a period of COVID-19 mitigation in Taiwan.¹⁰ With tensions created by staying at home for prolonged periods of time coupled with increased general anxiety and fear of contracting the virus, it is easy to see how negative psychological reactions such as adjustment disorder and depression can develop and lead to declining sexual activity.

As the world continues to combat the SARS-CoV-2 virus and its variants, the pandemic will continue to have profound effects on mental health with subsequent changes in sexual behavior as people learn to live and adapt to threats of surges and outbreaks related to the virus. Physicians and mental health practitioners should be informed about the relationships between mental health, sexual behaviors and overall well-being of our patients, and should continue to work together to address the wide-ranging effects of the pandemic on the patients we serve.