Sexual Activity in Adolescents and Young Adults through COVID-19 Pandemic

During the COVID-19 pandemic, it has been postulated that the sexual life of adolescent and young adults has been impacted in various aspects, potentially affecting their well-being. Our aim is to investigate the potential changes in the sexual activity and relationships of adolescents and young adults during the COVID-19 pandemic. In general, a decrease in sexual desire was reported during the COVID-19 pandemic, in both genders. Fewer sexual intercourses and bonding behaviors between partners were associated with loneliness and depressive symptoms. On the contrary, an increase in sexual desire was expressed in a few people, with masturbation to be the most preferable means of satisfaction. The present paper highlights the multifaceted impact of COVID-19 upon the sexual life of adolescents and young adults during the ongoing pandemic. The changes observed in their sexual activity and relationships, could provide the basis of future preventive and educational programs.


Introduction
In December 2019, the first cases of COVID-19 were reported in Wuhan, China, raising concerns due to rapid spreading. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the underlying cause of the coronavirus disease (COVID- 19), which has spread worldwide, forcing the World Health Organization (WHO) to declare it as a pandemic on 11 March 2020 [1,2]. Many countries imposed restrictive measures, such as lockdowns, social distancing, wearing masks, and frequent washing of hands through the day [3].
The fear of contacting the virus, as well as the public health measures, led people to diminish their visits to crowded places and thus many have faced difficulties in personal relationships, especially adolescents and young adults [4][5][6]. The lack of peer-to-peer contacts, due to home confinement and school closures, changed many aspects of life for youths. As a result, sexual activity, intimate relationships, access to contraception, protection from HIV, or other sexually transmitted infections (STIs) and physical, mental, or emotional well-being were adversely affected [7,8]. The social distancing that was imposed consequently led to the restriction of contacts between individuals, and therefore has affected the frequency of sexual activity, number of sexual partners, sexual desire and satisfaction, and the use of pornographic content [9]. According to the available literature, all these consequences seem to concern mainly younger individuals, such as adolescents and young adults [4][5][6][7][8][9].
The sexual life and activity of the above-mentioned age groups plays an important role in forming healthy sexual relationships and expressing their sexuality [8,9]. Sexuality constitutes a meaningful aspect of human development. The impact of COVID-19 in the sexual life of adolescents and young adults may significantly affect their sexuality. Thorough study of those effects will highlight the needs of youths during the pandemic and will provide substantial information in order to maintain their well-being. Thus, the purpose of this paper was to investigate the potential impacts and changes in the sexual activity and relationships of adolescents and young adults caused by the measures imposed due to the ongoing COVID-19 pandemic and the potential consequences to their sexuality in general.

Methods
A research of the literature was conducted in the following databases: Google Scholar, PsycInfo, PubMed, SCOPUS, and ERIC up to 14 June 2021. The algorithm used included: (sexual OR sex OR sexuality OR intimate) AND (health OR wellness OR life OR wellbeing OR well-being) AND (teens OR teenagers OR youngster OR youngsters OR adolescence OR adolescent OR adolescents OR "young adults" OR "younger adults" OR "Generation Z" OR juvenile OR juveniles OR youthful) AND (COVID-19 OR SARS-CoV-19 OR SARS-CoV-2 OR "2019-nCoV" OR "novel coronavirus"). The references of the eligible studies were searched through a snowballing technique, along with the relevant reviews.
The inclusion criteria were the following: Studies that examined changes in the sexual activity and relationships of adolescents and young adults (11-24 years old) during the ongoing COVID-19 pandemic were considered eligible. Studies that incorporated adolescents and young adults in a significant percentage were also included. Sexual activity must refer to sexual desire, frequency of intercourses, number of sexual partners, sexual satisfaction or dissatisfaction, and sexual preferences among adolescents and young adults. Concerning the type of study, case reports, cohort studies, cross-sectional studies, case series, and case-control studies, were included, while no language restrictions were imposed. The selection of studies was conducted by two authors (C.S. and A.S.) who worked independently. The following variables were used to extract data for each study: Title of the article, name of first author and year of publication, region/country where the survey was conducted, language, study period, study design, sample, sample size, age range and selection of sample, ascertainment and/or association with COVID-19 pandemic, outcomes, statistical analysis, and main findings. Quality assessment was performed in order to present accurate results. For this purpose the Newcastle-Ottawa Scale for cross-sectional studies [10] and cohort studies [11] were used.

Selection of Studies
The research in the database retrieved 20,246 publications, while 1050 of them were duplicates; 16 studies (49,078 individuals) were finally considered eligible following the inclusion criteria imposed as mentioned above [12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27]. The eligible studies included data from various countries, three of them from China [12][13][14], four from the USA [15][16][17]25], while two presented data from UK [18,19], three from Italy [20,21,26], the remaining three from various countries, namely, France [22], Poland [23], and Turkey [24], while one included data from various countries [27]. The majority of them were cross-sectional studies (n = 10) and the remaining five were cohort studies, and only one study included mixed methods. Eleven studies referred to the COVID-19 pandemic or outbreak in general, whereas five studies referred to lockdowns (Table 1). A reduction in sexual desire was experienced (25%) while 44% reported a decrease in the number of sexual partners, with men reporting more (53% vs. 30%). Lower frequency in sexual intercourse was reported by 37%, including 26% married men and 28% married women. From married men (49%) and married women (29%) a decrease in the number of sexual partners was reported. A total of 32% of men and 39% of women experienced a reduction in sexual satisfaction and in risky sexual behaviors. Only 18% of men and 8% of women experienced increased sexual desire.

Multinomial logistic regression
In the past month of sexual behavior, half of all adults reported change, mostly a decrease. The younger the age of their children (under the age of five), the greater the likelihood of stability and/or increased partnered behaviors, whereas having elementary-aged children was often associated with a decrease in these behaviors.
Past month of depressive symptoms and loneliness were associated with both reduced partnered bonding behaviors and partnered sexual behaviors. The greater the perceived risk of COVID-19, the lesser the reported solo and partnered sexual behaviors. Stability in partnered sexual behaviors was reported in people with greater COVID-19 knowledge.  and lower PSSS and SCS compared to rural participants, while only COVID-19-related stress (p < 0.001) and SCS (p < 0.05) differences were significant. Therefore, these results showed that differences in COVID-19 stress, PSSS, and SCS were significant for gender, years, and urban/rural status. Most couples responded that they did not perceive any differences in their sexuality, despite the pandemic's consequences. Some female participants reported a decrease in pleasure, satisfaction, desire, and arousal.
The main reasons for this seemed to be worry, lack of privacy, and stress. Even though participants seemed to show high levels of resilience, the negative aspects of lockdown could affect their quality of sexual life. There was statistically significant association between the workplace and the change of FSFI scores before and during the COVID-19 pandemic (p < 0.01). The largest decrease in FSFI score was noticed in the group of women who did not work at all (5.2 ± 9.9). A total of 39.9% of the sample reported engaging in sexual activity at least once per week on average, was classified as sexually active during lockdown. The mean number of sexual activities was 1.75 in the overall population, and was significantly higher in men than women. The prevalence of sexual activity significantly increased from 33.5% in people who were self-isolated for 0-5 days to 47.0% in those who were self-isolated for 11 days.
Adults with sexual activity were mostly male and of a younger age; married/in a domestic relationship, employed, having high annual household income, and consuming alcohol, while the number of chronic physical conditions was significantly lower in the sexually active than in the non-sexually active group.

Sexual Activity and Behavior
According to the studies, a general decrease in sexual desire during the COVID-19 pandemic was reported from individuals [12,13,15,16,[19][20][21][22][23][24]. More specifically, in a Chinese study conducted on youth (age range: 15-35 years old), 41% reported fewer intercourses, while 20% also reported a decrease in alcohol consumption before or during sex [12]. Men expressed more often a decrease in sexual partners (53%) compared to women (30%), while sexual satisfaction was reduced in both genders (32% of men and 39% of women), according to another Chinese study, in which the majority of the sample was 15-30 years old [13]. Gender and age differences could predict sexual dissatisfaction, along with COVID-19 potential infection during contact and occurrence of depressive symptoms, as stated by an Italian study by Cocci A et al. (mean age 21 years old) [20]. Following the above, another study in Italy (age range 18-40 years old (33.4% were 18-30 years)) presented a decrease in sexual intercourse by individuals during quarantine, mainly due to a lack of privacy and psychological stimuli [26].
According to Luetke et al., in the US, during home isolation and social distancing, conflicts were inevitable, leading to lower levels of sexual satisfaction mostly in men (a significant percentage (36.7%) in ages 18-39) [16]. Loneliness and depressive symptoms were associated with fewer sexual intercourses and bonding behaviors between partners in the US study by Hensel et al. (38.3% participants of ages 18-39) [15]. According to the Chinese study by Jianjun et al., women reported higher scores in the Sexual Compulsivity Scale (SCS) than men, while older counterparts also presented higher scores in SCS from younger ones (age range between 17 and 24 years), and individuals who live in urban areas reported lower scores in SCS than those living in rural areas [14]. The study by Fuchs et al. in Polish women (mean age: 25.1 years) reported a decrease in Female Sexual Function Index (FSFI) scores that was associated with the lack of work before and during the COVID-19 pandemic [23].
On the other hand, a small increase in sexual desire was expressed from men and women in China, Turkey, and France [13,22,24]. Masturbation was a preferable mean of satisfaction, through pornographic content during quarantine [12,20,22,25]. People who self-isolated from 0-5 days increased their sexual activity (33.5%) more than people who self-isolated for 11 days or more (47%) (32.4% were 18-34 years) according to a UK study. [19]. Higher knowledge of COVID-19 consequences was associated with more stable sexual behaviors among partners (a significant percentage (38.3%) in ages 18-39) [15]. According to the above, a significant number of individuals in an Italian study did not report a reduction in their sexual desire (71.3%, a large proportion of the sample being 18-30 years) [26].
Concerning couples, a decrease in sexual desire was reported in 10.4% of females and 9% of males in a French study (the majority of the sample were 15-30 years old) [22] while a Chinese study reported fewer instances of sexual intercourse by both genders (which also had a majority of the sample in the 15-30-year age group) [13]. Having children under five led to greater instances of sexual release, while having older children (elementary aged) lead to a decrease in those behaviors, as evidenced by Hensel et al. in the USA [15]. Although, many couples reported no difference in their sexual activities in general, in an Italian cross-sectional study (61.5% were under 34 years old), 12.1% of men and 18.7% of women stated that there was an increase in their sexual desire [21].
The use of technology, including dating or hooking-up apps, decreased, as evidenced in a study on 15-40+-year-old US men having sex with men [17]. Those apps were used by young people, in order to stay in touch, but not in face-to-face interactions. Thus, the opportunities for sexual intercourse were limited. The reduction of sexual activity among young people (under 17 and over 18 years old), could be reflected in the reduction in demand for sexual health services (SHS) as stated by Thomson-Glover et al. in the UK [18]. Findings support the above data were also presented in a study including Adolescents Sexual Minority Men (ASMM) (14-17 years old), who used social media and virtual means of communications to stay in touch with their sexual partners [25]. In addition, in the same context, in a study including Gay, Bisexual, and Other Men Who Have Sex With Men (GBMSM) (age range 18-35 years old), the use of social media for communication was reported, while an impact on sexual life during the ongoing COVID-19 pandemic was expressed [27].

Risk of Bias
The majority of studies were cross-sectional (n = 10) and six of them scored high (either 9 or 8) in the Newcastle-Ottawa scale. In some cases, the selection of the sample was detailed, but in six of them, the non-responder rate was not justified. The ascertainment of the exposure was implemented through online questionnaires, due to COVID-19 restrictions, and thus were not always validated. Although the control of confounders was performed through appropriate statistical analysis, the outcome was mainly assessed through self-report questionnaires and could not be totally reliable. Furthermore, the five cohort studies provided good (n = 2) and fair quality (n = 3).

Discussion
The ongoing COVID-19 pandemic seems to have multiple effects in the sexual life of youth. Adolescents and young adults are the age groups who might be less vulnerable to the virus, but seem to suffer greatly from psychosocial consequences [28]. Social distancing, school closure, and restriction of activities lead to a reduction of any kind of social contact. Additionally, as they were obliged to stay most of the time inside, adolescents and young adults were subjected to increased parental monitoring, which reduced independence, physical interaction with peers, and privacy [29]. Subsequently, according to available reports, a decrease was observed in age groups concerning partnered sex, sexual behaviors, and relationships [4,29]. On the other hand, an increase was recorded in online social connections, as 65% of teenagers used texting or interaction via social media more often than usual [29].
Additionally, according to our findings, the knowledge of COVID-19 consequences was associated with more stable sexual behaviors among partners in ages 18-39 [15]. Our study also detected that the use of dating or hooking-up apps decreased during COVID-19 restrictions, according to a study on men having sex with men (age range 15-40 years old) [17]. Nevertheless, online connections seem to be rather important, as they offer options to connect despite the social distancing and stay-at-home orders [29]. Another finding was the reduction in demand for sexual health services, mainly due to fear of infection, among young people [18], possibly associated with problems in accessing condoms, HIV and STI testing, and treatment services, leading to increased rates of sexually transmitted infections and unintended pregnancy among youth [4]. For adolescents and young adults considered to be vulnerable, especially those who are part of the LGBTQ community, who had to face discrimination, violence, and lack of access to health, the COVID-19 pandemic created a more hostile environment for them. Thus, deterioration in their mental health and well-being was noted, including their sex life [30,31].
On the other hand, during COVID-19 and due to the circumstances, methods such as telehealth, home-based sexually transmitted infections screening, and contraceptive delivery were developed [4]. According to the literature, these methods were considered safe and effective and acceptable to youth. Thus, some of them could be adopted afterwards in order to provide better health care concerning the sexual health of these age groups [4]. Inaccessibility of sexual and reproductive healthcare services seems to be one of the main causes of increased rates of sexually transmitted infections among adolescents and young adults, a fact that was also highlighted during the pandemic [4,18].
Furthermore, it seems that the COVID-19 pandemic has exposed adolescents and mostly girls to multiplied risks concerning their sexual health, such as sexually transmitted infections including HIV and Human Papilloma Virus, as well as unintended pregnancies [30]. According to reports, an increase was also observed in sexual and gender-based violence, a fact that is probably the result of the difficulty in accessing relevant services such as intervention programs [30]. Thus, the pandemic seems to have additionally highlighted the need for better organization and the development of youth-friendly and easy-to-access sexual and reproductive healthcare services. Concerning the limitations of this study, the COVID-19 pandemic is an ongoing phenomenon, and thus, the impact in the sexual activities of adolescents and young adults need to be further tested. In order to provide a global understanding of relevant effects, an examination of diverse groups should be a priority. Confinement measures and social distancing created a more complex reality, affecting all aspects of social life; the interplay with sexual life should be monitored in a more systematic way. Furthermore, the majority of the studies were cross-sectional, providing no long-term results, while self-reported assessments limited the validity of studies.

Conclusions
In conclusion, the present paper highlights that sexual activity, an important aspect of adolescents' and young adults' life, was reported to be considerably affected during the ongoing COVID-19 pandemic. The changes observed in sexual activity and relationships could play an important role in forming preventive and educational programs in collaboration with parents, caregivers, teachers, and medical staff, aimed towards good sexual health and well-being.