COVID-19, quarantine and sexual life: a cross-sectional online survey of Brazilian individuals

Introduction: The COVID-19 outbreak was responsible for a high number of deaths worldwide. Not only the physical health was affected by COVID-19. Thus, to avoid the infection spreading, social distancing and quarantine have been adopted, bringing rupture to previous habits, economic losses, and isolation. Objective: To study the sexual life during the COVID-19 pandemic in Brazilian individuals. Methods: This cross-sectional study using an internet survey was conducted from June 10th to July 30th, 2020 with epidemiological questions, questions on fatigue and depression, and the sexual quotient scale (SQS). Results: The survey was answered by 2,131 individuals: 325 males, median age 25 years (IQR=22.0-33.5 years), range between 18 to 69 years and 1,806 females with median age 25 years (IQR=22-31 years), range between 18 to 67 years. In 49% of males and 29% of females (29%), there were no changes in sexual life. In 43.7% of females and 32.1% of males, some deterioration was observed while in 26.3% of females and 18.1% some improvement was noted. Despite this, 90.8% of males and 85% of females scored as having good sexual performance according to SQS. Sexual performance was negatively influenced by fatigue, state of mind in males and females; having a fixed partner and staying at home impaired male performance. Conclusion: Despite the pandemic, the studied sample showed good sexual performance in the studied period.


INTRODUCTION
The COVID-19 outbreak was recognized by the World Health Organization (WHO) as a pandemic in March 2020 1 . The coronavirus or SARS-CoV-2 is an RNA virus that affects primarily the respiratory system and causes a wide range of symptoms that go from a common cold to severe acute respiratory syndromes 2 . It has been responsible for a high number of deaths worldwide 2 .
Not only the physical health was affected by COVID-19. So far, no drug can be considered effective against it. Thus, to avoid the infection spreading, social distancing and quarantine have been adopted, bringing rupture to previous habits, economic losses, and isolation. Fear of contamination and of the loss of one's own life or that of loved ones bring additional stress and contribute to anxiety and depression.
In Brazil, contradictory orientations by government agencies contributed to poor control of the disease spreading, and Brazil became one of the countries severely affected by the pandemic. Until June 2021, more than 500,000 deaths were reported with a mortality rate of 241.3/100,000 3 with huge financial, social, and psychological losses.
The literature observes that confinement may have serious psychological effects in cases of incarceration, long periods in submarines, and during some expeditions causing tedium, sleep deprivation, and stress. Depression, anxiety, suicidal behavior, post-traumatic stress disorder, and domestic violence have also been observed in such context 4

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Nevertheless, the real impact of isolation procedures implemented during the COVID-19 pandemic is not known. An analysis of 500 individuals from Hong Kong done during the pandemic showed that depression was present in 19% and anxiety in 14%, numbers considered much higher than those from previous studies (13.5% for depression and 4.6% for anxiety). In this same work, 25.4% stated that their mental status had declined with the pandemic 5 . Another, in a sample of 976 adults from Spain, observed that there was an increase in the levels of stress, anxiety, and depression in this population and that these findings were worse in the young people 6 .
The individual's sexual life may be affected throughout the pandemic as psychiatric disorders are some of the most important risk factors for sexual dysfunction. Depression has been linked to low sexual desire; anxiety was associated with the lack of subjective arousal and pleasure, to orgasmic difficulties, and sexual pain 7 . Also, preventing measures such as closing public spaces and reinforcing the need for social distancing bring difficulties in meeting a partner or dating and further impair the sexual life.
To recognize and treat sexual dysfunction is important not only to improve an individual's sexual life but also their overall satisfaction with life. It is also known that sexual dysfunction may also affect the wellbeing of the partners 8 .
Herein we aimed to evaluate the modification of sexual habits in a sample of Brazilian individuals during the COVID-19 pandemic period hypothesizing that this situation may have hurt sexual life. In this context, we also studied the influence of fatigue, perception of mental status alterations, and having or not a fixed partner.   Table 1.

Participants and design
The male questionnaire has ten questions on trust, preliminaries, satisfaction with the partnership; quality of the erection; ejaculatory control; ability to achieve orgasm, and satisfaction with sexual intercourse. The English translation for the questions of the SQSmale version are shown in Table 2.
Each item of both male and female SQS is answered on a scale graded from 0-5 based on frequency and level of satisfaction, with 0 indicating "never" and 5 indicating "always;" thus, higher scores indicate greater sexual satisfaction. For the composition of the scores, the sum of all points attributed to each question is calculated, multiplying the total result by 2, resulting in a final score based on a 100-point scale. In the female SQS, question number seven must be transformed before this calculation, as it goes in the reverse direction, according to the following form: Q7 reverse=5 -Q7, as indicated by Abdo 9,10 in her study.
Incomplete questionnaires were excluded.
Values from 82-100 points are considered as excellent sexual performance, from 62-80 points a very good performance, 42 -60 pointsgood performance, from 22-40 points fair performance, and from 0-20 points poor performance.

Data analysis
Data was collected in frequency and contingency tables. Data distribution was studied by the Shapiro Wilk test and the central tendency of numerical variables (SQS of males and females) was expressed in median and interquartile range (IQR). Comparison of nominal data (having a fixed sexual partner, feeling tired or depressed during a pandemic, perception about changes in sexual behavior during a pandemic) and categorical data (monetary income, level of education, degree of isolation) was done by chi-squared tests. The comparison of QS of males and females according to perceptions of feeling tired, depressed, and having a fixed sexual partner were done by the Mann-Whitney test.
Comparison of QS of males and females according to categories of education, monetary income, and educational level were done by the Kruskal Wallis test with Dunn's multiple comparison tests when needed. Bonferroni correction was used to calculate p significance.
The software Graph Pad Prism, version 6.00 for Windows (GraphPad Software, La Jolla, California, USA) was used for statistical analysis.

RESULTS
The survey was answered by 2,131 individuals: 325 males, median age 25 years (IQR=22.0-33.5 years, range between 18 to 69) and 1,806 females with median age 25 years (IQR=22-31 years, range between 18-67 years). The description and comparison of epidemiological data of these two groups are in Table 3. There it is possible to note that most of the responders were females, students, that homosexuality was more common in males, and that the studied sample had a good educational level. Table 4 shows individuals' behavior and mental health perception during the pandemic in the studied sample as well as a comparison between males and females. This table shows that females more than males were affected by fatigue and notice that mental health and sexual behavior have changed. Women stayed more at home. The number of males who have virtual sex was significantly higher than females; however, there was no significant increase during the pandemic in both genders. Most males and females stated having no fear of having an intimate relationship after the pandemic. showing that most of the sample (90.8% of males and 85% of females) had a moderate to good and good to excellent performance according to SQS. Table 3 shows the median values of the SQS in males and females according to the studied variables (having a fixed sexual partner, the influence of perception of altered mood and mental status, tiredness). It demonstrates the importance of mental status and the presence of fatigue in sexual performance in the whole sample; having a fixed sexual partner was important for males but not females.
The influence of monetary income and educational levels on sexual performance during the pandemic is in Table 5; no influence of these variables on sexual performance could be detected. The degree of isolation influenced male but not female sexual life.

DISCUSSION
Our results have shown that most of our responders adopted isolation during the pandemic, not leaving home or doing it minimally. They also showed that this population showed that 90.8% of males and 85% of females had a moderate to good and good to excellent performance according to the SQS scores. Unluckily we do not have data before the pandemic for comparison. Likewise, we could not find results from other studies to establish a comparison as most of them, using the present scale (SQS), were not done in the general population but limited to a special situation or a specific disease. It is important to use the same instrument to evaluate sexual performance to establish a correct comparison as it is known that they may affect the results 11 .
In this sample, a variable that affected sexual life in both sexes was" feeling depressed", showing that this is one of the points to be addressed to improve ones' sexual life. Salary and educational level did not have any impact. Risk factors for depression comprise a mixture of genetic and environmental components, such as family history and stressful environment 12 . Females seem to be more vulnerable than males in this context.
Depression and tiredness were more common in females than males; females more than males perceived changes in their sexual life. In addition, antidepressant drugs used as treatment could play a role in diminishing the libido for some people 12 .
Association between sexual performance and mental health has been stressed by others 12 . Chronic stress is associated with rising levels of endogenous cortisol, which can promote a decrease in gonadal steroids and adrenal androgens that have facilitating effects on sexual desire and genital arousal 13,14 . Kissinger et al. 15 studying females after the hurricane Katrina disaster observed that the frequency of intercourse decreased. Hamilton et al. 16 studying females with chronic stress showed that stress was associated with lower levels of genital sexual arousal response due to both psychological and hormonal factors. A study done during the COVID-19 pandemic, in 89 Italian females, showed that quarantine negatively influenced the sexual function in women who live with their sexual partners 17 .
On the other hand, another study in 58 females from Turkey found that sexual desire and frequency of intercourse increased during the COVID-19 pandemic, but that the quality of sexual life decreased 18 . Staying at home could improve desire but worrying about the pandemic and related aspects may imply alterations of the mood that may lead to a decrease in the quality of sexual life. In our findings, the degree of isolation was important only in males: those not leaving home performed worse than those going out regularly. We could not find any explanation for the differences, but we can hypothesize that in a patriarchal society like ours, staying at home could interfere with males' sense of independence, harming the self-image and self-confidence and impairing sexual performance. It is also interesting to note that males without a fixed sexual partner performed better than those with a fixed partner.
In the present study, it was also found that fatigue impaired sexual function in both men and women and this complaint was more common in women (69.7%) than men (58.5%). In the general population, fatigue has been considered the most common reason for the loss of sexual desire 19 . Physical and psychological fatigue appearance during pandemic has been considered to be related to preventive limitations of movement and exercise as well as fear and anxiety 20 . We can also believe that this symptom was more common in women due to workload that increased during this period because of the need for children's education at home and housework that increased with pandemic restrictions.
The studied sample did not represent the Brazilian population in general as we have a highly educated sample with good economic resources. This may have had a role in the decision to adopt isolation and in not having economic concerns. Nevertheless, for this population range, this survey shows that sexual life has deteriorated during the pandemic and that depression was the main associated variable. In Brazil, the internet is not available for the lower-income classes, so this may explain the present selection bias. In addition, people with low schooling may have had difficulties answering the questions, and the failure to complete the internet presented form did not allow such individuals to submit the answers to the program. Another limitation of this study is its transversal design that does not allow to compare the present results with those before the pandemic.
Concluding, in this study during the COVID-19 pandemic, the studied sample showed moderate to good sexual performance according to the sexual quotient scale. In