The current global focus remains on Covid-19. For most Americans, the new normal consists of social distancing measures, which introduces challenges to sexual intimacy. Although many individuals report a negative impact on their sex lives since the onset of the pandemic, others describe creative measures they have taken to maintain enjoyable sexual activity. In addition to the frequency and quality of sexual activity during this time, questions exist regarding Covid-19 and safe sex, including potential sexual transmission of the virus.

The concepts of sex and social distancing contradict one another. In March 2020, a majority of the United States went into lockdown to slow and prevent the transmission of Covid-19. Although many states have lessened stay-at-home restrictions, social distancing measures remain in effect across much of the country, posing an ongoing challenge to sexual intimacy.

Stay-at-home restrictions actually foster increased potential for sexual intimacy among cohabitating individuals, although factors such as adult children returning to live at home, constant exposure to partner(s), and financial stress may negatively impact sexual activity. Single individuals and those involved in long-distance relationships experience additional challenges related to dating and sex. Common dating locales such as bars and restaurants are closed or have limited hours and availability. Many outdoor events and gatherings are canceled or postponed, and travel restrictions limit the capability to visit out-of-town loved ones.

Despite all, evidence supports a rise in female sexual desire and frequency of sexual encounters during the initial quarantine phase, as well as increased creativity in the type and expression of sexual activities.^1,2 In a large online survey, however, half of respondents reported a decline in frequency of sexual activity.² One answer to this problem for many has been the use of technology to safely interact with individuals outside the home, including through online dating and virtual sexual activity.^2,3

Covid-19 facts

A common question for women’s healthcare providers relates to the potential for transmission of Covid-19 through sexual contact. The short answer is yes, Covid-19 can be passed through sexual contact, but this topic is complicated and multifactorial. Close contact of any type with an infected individual puts a person at risk for the virus.^4,5 Researchers have detected the virus in some bodily fluids, although the relevance of this to infectivity and the potential for transference through sexual contact has not yet been established. Here is what we do know about Covid-19 and sexual activity:

• It has been detected in respiratory droplets, semen, and human feces.^4,6–8

• High levels of viral shedding occur in the upper respiratory tract, including the nasal cavity and oropharynx, even in asymptomatic individuals infected with Covid-19.^4,6

• Transmission can occur via inhalation of the respiratory droplets of individuals infected with Covid-19 and/or direct contact of these droplets to mucosal tissues such as the eyes, nose, and mouth.^4–6

• No evidence yet supports the transmission of Covid-19 through contact with semen or vaginal secretions.⁸

• Direct contact with feces during sexual activity may transmit the virus to an uninfected partner.^7,9

• Covid-19 was detected in the urine of one infected patient, and urinary frequency and cystitis may be an overlooked symptom of infection.^10,11 Transmission through contact with an infected individual’s urine is unknown.

• It is unclear if cunnilingus or analingus performed by an individual infected with Covid-19 can transmit the virus to an uninfected recipient.^7,12

• Transmission of Covid-19 may occur from use of shared sex toys if an uninfected individual touches viral droplets on the toy(s) and then touches their eyes, mouth, or nose.^13,14

• Men have a disproportionately higher rate of severe disease from Covid-19 than women.¹⁵

Sexual partners and Covid-19

Until more is known about potential transmission during sexual activity, sexual interactions with individuals known or suspected to be infected with the virus should be avoided. High-risk partners should maintain at least 6 feet of distance from one another, wear masks, and quarantine when possible. Symptoms of Covid-19 include fever, dry cough, fatigue, myalgia, shortness of breath, headache, loss of taste and smell, nausea, vomiting, and/or diarrhea, and urinary frequency.^10,15–17 As with other potential sexually shared infections, individuals should consider potential risks associated with sexual activity with new or high-risk partners and take precautions to avoid transmission.

Although transmission of Covid-19 via semen and vaginal secretions remains unreported, barrier protection should be considered with new or high-risk partners, including male and female condoms and dental dams. It should be noted that barrier protection is not proven to protect against the transmission of this virus. Sexual activities that involve saliva should be avoided with sexual partners with known or suspected exposure to Covid-19.^13,14 This includes kissing, cunnilingus, analingus, and use of saliva for lubrication.

Covid-19 and masturbation

The safest form of sexual activity during a pandemic is certainly masturbation. Sexual aids and toys should be properly cleaned as per normal protocol, especially when shared between sexual partners. Special consideration should be given to sexual toys used in anal play such as anal beads, wands, and plugs that are shared with partners, as direct contact with feces may transmit Covid-19.^7,9

Covid-19 and technology

Use of technology has increased significantly during the pandemic to meet the needs of individuals and businesses. Although dating apps and social websites were well established prior to 2020, the use of such platforms for meeting and “dating” new individuals has increased exponentially during the pandemic.³ The use of technology to communicate virtually is also a method for maintaining sexual activity while concurrently practicing social distancing. This includes the sharing of erotic fantasies over the phone, secured video and text messaging for sharing live masturbatory activities, and erotic photos.

Many people now utilize technology to remain sexually active during the ongoing  pandemic, and individuals who have made such creative changes are more likely to report improvement in their sex life.² There are some important considerations to remember when sharing intimate content, however, especially with unsecure virtual platforms and with partners not well known by the individual. Any content shared virtually has the potential to be shared beyond the intended recipient. In general, shared photos and videos should not contain identifying characteristics such as the individual’s face, unique piercings, tattoos, and jewelry. To prevent sharing unwanted personal data, such as a home address, location services should be disabled when taking photos and videos. Although not entirely secure, many smart phones, tablets, and computers offer secure folders with additional password protection in which to place sensitive content like erotic photos and videos.

Covid-19 and pregnancy

Based on the fact that Covid-19 acts similarly to SARS [severe acute respiratory syndrome] and MERS [Middle East respiratory syndrome], pregnant women with Covid-19 may be at risk for increased morbidity related to the virus compared to nonpregnant women.¹⁸ Nevertheless, more recent data show that pregnant women in late gestation who test positive for Covid-19 may experience less severe symptoms compared to nonpregnant women.^19,20

Another concern is that of possible vertical transmission from mother to neonate.²¹ There is no evidence to support the transmission of Covid-19 through vaginal secretions, however, or that delivery by Cesarean section prevents transmission to the newborn.²² No evidence exists to support the transmission of Covid-19 via breastmilk, although an infected nursing mother can transmit the virus to the neonate through exposure to respiratory droplets.^19,23

Conclusion

Human social interactions change drastically in the midst of a global pandemic. Sex is one of the most intimate forms of human interaction and warrants special consideration related to Covid-19. At this time, there remains limited knowledge about the potential sexual transmission of Covid-19 through semen, vaginal secretions, feces, and urine, but the transmission of this virus through respiratory droplets is well documented. Healthcare providers should counsel patients to take precautions against the transmission of respiratory droplets through close contact with high-risk individuals including social distancing, mask wearing, and hand washing. In addition, all bodily fluids should be considered potentially contaminated with Covid-19, and barrier protection should be considered, especially with high-risk partners.

Brooke M. Faught is a women’s health nurse practitioner and the Director of the Women’s Institute for Sexual Health, a division of Urology Associates, in Nashville, Tennessee. She is a Fellow of the International Society for the Study of Women’s Sexual Health (ISSWSH) and the American Association of Nurse Practitioners. She is also a North American Menopause Society (NAMS) certified menopause practitioner. The author states that she serves as a speaker and/or advisory board member for AMAG, Lupin, Therapeutics MD, JDS Therapeutics, and Trophikos, and she receives research monies from IPSEN Innovations and AbbVie. Lisa Larkin is a women’s health internist and Founder and CEO of Ms.Medicine, a national organization working to advance women’s healthcare. She is a Fellow of ISSWSH and a NAMS certified menopause practitioner. The author states that she serves as a consultant and/or advisory board member for Proctor and Gamble, Therapeutics MD, AMAG, Lupin, Amgen, and Allergan. 

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