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From March 11 to April 26, 2020, the Italian government imposed a nationwide COVID-19 lockdown, a quarantine that resulted in significant restrictions on the movement and social contacts of the population, with a view to limiting the pandemic outbreak. The quarantine forced people to experience distorted social distance in two contrasting ways. For some people, it resulted in social distancing and isolation, for example by separating noncohabiting couples into different dwellings. For others, however, quarantine increased and imposed social closeness, forcing couples and families into constant, daily, and prolonged cohabitation. The aim of this study was to investigate the sexual health and behaviors of Italian adults during the lockdown period using a multimethod research. An open- and a closed-ended e-questionnaire were administered immediately after the end of the lockdown. A total of 465 Italian adults completed the digital questionnaire (female = 78.7%). Participants recognized their lived sexual experience with generally positive characteristics (related to openness, unproblematic relationship with the body, and awareness and self-reflection about one’s sexuality), while negative thoughts such as worry and pain were quite scarce. Participants with a disability (5.6%) showed a marked inversion compared to the mean of respondents, recognizing themselves mainly in negative thoughts related to low self-esteem, inadequacy, and feelings of suffering, yet reporting a higher than mean level of arousal. In the qualitative analysis, the Frequency-Inverse Document Frequency (TF-IDF) index was computed to measure the salience of the word used by participants to respond to the open-ended five questions. It revealed a generally depressed emotional experience associated with the experience of lockdown, both in terms of desire, which seemed to be shifted more to the level of imagination and fantasies, and the actual possibility of experiencing sexual activity as usual. Nevertheless, the participants emphasized an opening to new possibilities in terms of expressing sexuality, accompanied by a rediscovery of the value of tenderness and affectivity as well as a clearer awareness of their sexual life, needs, and desires.
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RESEARCH ARTICLE
The sexual experience of Italian adults during
the COVID-19 lockdown
Stefano FedericiID
1,2
*, Alessandro Lepri
1
, Alessandra Castellani MencarelliID
1,2
,
Evel Zingone
3
, Rosella De Leonibus
3
, Anna Maria Acocella
3
, Adriana GiammariaID
4
1Department of Philosophy, Social & Human Sciences and Education, University of Perugia, Perugia, Italy,
2Myèsis, Research and Development Company, Rome, Italy, 3Expressive Gestalt Psychotherapy Institute
of Perugia, Perugia, Italy, 4Independent Researcher, Udine, Italy
*stefano.federici@unipg.it
Abstract
From March 11 to April 26, 2020, the Italian government imposed a nationwide COVID-19
lockdown, a quarantine that resulted in significant restrictions on the movement and social
contacts of the population, with a view to limiting the pandemic outbreak. The quarantine
forced people to experience distorted social distance in two contrasting ways. For some
people, it resulted in social distancing and isolation, for example by separating noncohabit-
ing couples into different dwellings. For others, however, quarantine increased and imposed
social closeness, forcing couples and families into constant, daily, and prolonged cohabita-
tion. The aim of this study was to investigate the sexual health and behaviors of Italian adults
during the lockdown period using a multimethod research. An open- and a closed-ended e-
questionnaire were administered immediately after the end of the lockdown. A total of 465
Italian adults completed the digital questionnaire (female = 78.7%). Participants recognized
their lived sexual experience with generally positive characteristics (related to openness,
unproblematic relationship with the body, and awareness and self-reflection about one’s
sexuality), while negative thoughts such as worry and pain were quite scarce. Participants
with a disability (5.6%) showed a marked inversion compared to the mean of respondents,
recognizing themselves mainly in negative thoughts related to low self-esteem, inadequacy,
and feelings of suffering, yet reporting a higher than mean level of arousal. In the qualitative
analysis, the Frequency-Inverse Document Frequency (TF-IDF) index was computed to
measure the salience of the word used by participants to respond to the open-ended five
questions. It revealed a generally depressed emotional experience associated with the
experience of lockdown, both in terms of desire, which seemed to be shifted more to the
level of imagination and fantasies, and the actual possibility of experiencing sexual activity
as usual. Nevertheless, the participants emphasized an opening to new possibilities in
terms of expressing sexuality, accompanied by a rediscovery of the value of tenderness and
affectivity as well as a clearer awareness of their sexual life, needs, and desires.
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OPEN ACCESS
Citation: Federici S, Lepri A, Castellani Mencarelli
A, Zingone E, De Leonibus R, Acocella AM, et al.
(2022) The sexual experience of Italian adults
during the COVID-19 lockdown. PLoS ONE 17(5):
e0268079. https://doi.org/10.1371/journal.
pone.0268079
Editor: Peter Karl Jonason, University of Padova,
ITALY
Received: May 27, 2021
Accepted: April 21, 2022
Published: May 5, 2022
Peer Review History: PLOS recognizes the
benefits of transparency in the peer review
process; therefore, we enable the publication of
all of the content of peer review and author
responses alongside final, published articles. The
editorial history of this article is available here:
https://doi.org/10.1371/journal.pone.0268079
Copyright: ©2022 Federici et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: All raw data are
available from the following database: Federici, S.,
Lepri, A., Castellani Mencarelli, A., Zingone, E., De
Leonibus, R., Acocella, A. M., & Giammaria, A.
Introduction
COVID-19 (coronavirus disease 2019; the pathogen called SARS-CoV-2; previously
2019-nCoV) is an acute and highly contagious viral disease [1] that affects the respiratory sys-
tem. It was first detected in Wuhan, China, at the end of December 2019 [2]. Italy was the first
European country to announce an outbreak of the infection on February 21, 2020; the virus
rapidly affected the north of Italy and then spread to all other regions [3]. The epidemic caused
by COVID-19 has made it necessary to implement strategies to contain the contagion, ranging
from the so-called “quarantine,” which consists in the restriction of activities or separation of
subjects who may have been exposed to the pathogen, to isolation, i.e. the separation of sub-
jects who have contracted the disease from healthy subjects, in order to avoid contagion and
further spread of the virus [4, WHO, 5]. From March 11 to April 26, 2020, the Italian govern-
ment imposed a nationwide “lockdown”—a quarantine that resulted in significant restrictions
on the movement and social contacts of the population. These measures, as well as other inter-
ventions of a medical-healthcare nature, although necessary, have involved neither a few nor
negligible “side effects.”
In a scientific article published online in the prestigious British medical journal The Lancet
on February 26, 2020—when Italy had already exceeded 400 infected and counted the first
deaths from COVID-19 and the first cases were appearing in other European countries—a
team of researchers in medical psychology led by the psychologist G. James Rubin [4], from
King’s College London, reviewed 24 studies that had investigated the psychological impact of
quarantine following contagious diseases in recent years (Ebola, SARS, equine influenza). The
main negative effects reported by those studies were anger, irritability, sense of confusion, and
symptoms of post-traumatic stress disorder. In addition, a literature review by Chew et al. [6]
evidenced fears, anxieties, and depression as common psychological symptoms reported across
outbreaks; frustration and boredom over the uncertainty of the situation were also found to be
present [7]. The various stressors included fear of contagion and loved ones’ well-being, the
scarce or insufficient availability of products considered essential for a good daily life (for
example, a working cell phone and an Internet connection that allows communication on
social networks), disruptions in daily routine and work life, the treatment process, and infor-
mation pertaining to the disease [4,6]. Moreover, feelings of isolation, abandonment, and stig-
matization may have been experienced by survivors of the disease and by those who had been
quarantined; however, these resulted in being common reactions to discrimination during the
outbreak due to ethnicity, country of origin, and health status prior to the pandemic [6].
A later literature review [8] and studies about the impact of the current COVID-19 out-
break and related restrictions [3,912] found that psychological responses were similar to
those to previous outbreaks: Anxiety and depression were the main indicated and detected
ones, followed by stress, distress, insomnia, and post-traumatic stress symptoms [8]. These
studies found that being women, nurses, of a younger age, or at high risk of contracting
COVID-19, as well as having lower socioeconomic status, social isolation, and spending more
time watching or reading news about the pandemic, were major risk factors for adverse out-
come [7,8,1012]. Other factors reported as causing risk were being single and having a high
sexual drive and riskier sexual behavior before the pandemic [13].
Maintaining contact with friends and family and receiving social support were found to be
essential in reducing feelings of loneliness and frustration [4,6]. Other effective coping
responses acted upon before and during the pandemic were taking control of one’s health sta-
tus by applying behaviors to protect oneself and others, taking a positive attitude toward the
overall situation, and seeking distractions in daily activities [6,8,1012]. For instance, the use
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Sexual experience during the COVID-19
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(2022). Raw data about the sexual experience of
Italian adults during the COVID-19 lockdown.
Researchgate.net. https://doi.org/10.13140/RG.2.2.
13355.36640.
Funding: The authors received no specific funding
for this work.
Competing interests: The authors have declared
that no competing interests exist.
of pornography, phone sex, and webcam sex would help people to reduce stress due to the
state of uncertainty and insecurity [13].
The lockdown period may certainly have induced important changes in social relations
because of the paradox of the imbalance of spatial distances related to interpersonal communi-
cative interaction (proxemics), distorted both by physical distance—since social contact was
possible only to the extent that a certain physical/social distancing was guaranteed—and by
too much proximity, i.e. living together forced by the restriction of movement. Of course,
social distancing slows down the spread of the virus, but it also leads people to reformulate
their social and sexual life [2].
Last April (2021), the famous international journal The Archives of Sexual Behavior
launched a call for a special issue on COVID-19 in which space could be given to interventions
on the impact of the pandemic on sexual health and behavior, sexuality and sexual relation-
ships, access to healthcare and treatment, and the sexual and reproductive rights of all individ-
uals. The same call was also made by other journals such as Sexuality and Disability and
Sexually Transmitted Infections on topics such as prevention, sexuality and disability, access
sexual healthcare centers, and sexual behavior [14,15].
A review conducted by Do¨ring [16] on recent global media narratives (print, radio, and
television, Facebook, YouTube, Instagram, and Twitter) and scientific observations and pre-
dictions about sexuality-related effects of COVID-19 highlighted at least two aspects of sexual
behavior and sexual and reproductive health that may have been affected by the pandemic.
And not necessarily negative ones. Do¨ring [16] stated that it is gratifying that issues of sexual
and reproductive health and rights have entered mainstream media content so fast. It is note-
worthy that technology-mediated sexual intercourse and masturbation with pornography and
sex toys have been so easily normalized, to the point where they are officially recommended by
the media and health authorities as preventive health behaviors [16, NYCHD, 17]. These
behaviors are likely to involve young adults more because of their greater familiarity with the
use of electronic devices and social media [1820].
Other positive effects were found by a group of Southeast Asian researchers [21] on the fre-
quency of sexual intercourse and the improvement in emotional bonding in married couples
during lockdown compared to the period immediately before. It was also found that the happi-
ness of married individuals could be slightly increased by isolation [2]. For similar reasons,
given the increased “marital fidelity” and the difficulty of having casual sex, reductions in risky
sexual behaviors could affect the incidence of sexually transmitted infections [22]. In addition,
even if some people violated social-distancing restrictions to see their partners, they tried to
minimize physical contact with them in order to reduce possible exposure to the virus [13].
Not all researchers seem to observe only positive effects on sexual health. In fact, the Chi-
nese research group led by Li and colleagues [22] found a reduction in sexual satisfaction and
desire during the quarantine period in almost a third of the young Chinese people surveyed.
Ferrucci et al. [3] showed similar results for the Italian general population: Decreased sexual
activity emerged as one of the daily activities most affected by the psychological impact of
COVID-19. However, Panzeri et al. [23], Schiavi et al. [7], and Yuksel and Ozgor [24] found
that most of the couples who participated in their studies reported few differences in their sex-
ual life compared to the period prior to the outbreak of the pandemic. In all these studies,
female participants were the ones who reported major changes. These were described as a
decrease in the quality of pleasure, satisfaction, desire, and arousal/excitation; the reasons they
gave were related to the psychological impact of the pandemic and restrictions, such as worry,
lack of privacy, and stress [23]. Negative effects of stress are evident in female quality of life,
especially regarding sexual functions. It is proven that during the COVID-19 epidemic, Italian
women living with their partners suffered from negative influences from the external
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environment and that the emergency status impacted emotionally on women’s psychology [7].
An effect of this emotional condition was found in a sample of Turkish women by Yuksel and
Ozgor [24]. Despite an increase in the frequency of intercourse and an increase in sexual
desire, the number of women participating in the study (N = 58) who intended to become
pregnant decreased from 32.7% to 5.1% in the face of a significantly decreased rate of contra-
ception use by women; moreover, menstrual disorders were more common than before [24].
The present study reported quantitative and qualitative data on the sexual health and behav-
iors (activity, desire, arousal, fantasies, masturbation, use of sexual aids, emotional awareness)
of Italian adults collected at the end of the lockdown period in May 2020. To the best of our
knowledge, no other research has been conducted on sexual health and life during the
pandemic using multimethod research, by comparing data from self-administered closed-
ended questionnaires and short text messages (250 characters) in response to open-ended
questions.
We next present our expectations about the association between the lockdown condition
and sexual health and behaviors of Italian adults.
Expectations
Our expectations assume that the lockdown situation experienced in the first months of the
pandemic may have altered various aspects of Italians’ sexuality, due to the changes in daily
life imposed by the current COVID-19 outbreak.
Since people could have more time to reflect on the role of sexuality in their own experi-
ences—due to restrictions on social participation and limitations in work activities, as well as
the increased time they had to spend in their homes, isolated or in forced cohabitation—we
predicted that participants would show a growing consciousness about meanings, implica-
tions, and expectations regarding sexuality. In addition, negative feelings affected by anxiety
and depression, due to the terrible outbreak of the pandemic that particularly burdened Italy
before any other Western country, could affect sexual interest and arousal.
Our expectations match with both Arafat et al.’s study [21]—which reported an increase in
the occurrence of sexual intercourse and an improvement in affective attachment in couples
married during the lockdown compared to the period immediately before—and that of Pan-
zeri et al. [23], which reported a negative impact on sexual habits because of the lack of privacy
and the constant closeness. Moreover, we expected that the constant and demanding presence
of children at home would have reduced sexual desire and arousal [7]. At the same time, we
expected that having to cope with a period of separation or the inability to meet new partners
would have prompted participants to resort to the use of sexual aids and to adopt alternative
and creative ways to have sex.
As Li, Li [22], Li et al. [22], and Schiavi et al. [7] found in regard to the decrease in sexual
satisfaction and desire during the lockdown period in nearly a third of young Chinese and Ital-
ian women, respectively, as well as the increase in sexual arousal and desire as reported by
Cocci et al. [25], we predicted that we would also find a nonunique sexual behavioral response
among our participants. We felt that personal beliefs and feelings about the pandemic and sex-
uality might have different impacts on sexual arousal and desire.
In summary, we hypothesize positive relationships between the following factors:
1. Negative feelings related to anxiety and depression might affect sexual interest and satisfac-
tion, leading to a more conscious way of experiencing sexual life and habits;
2. Restrictions on participation and limitations on activities might affect the frequency and
perceived quality of sexual relations;
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3. Changes in sexual intercourse and masturbatory activities may have occurred with the
implementation of sexual tools and toys;
4. The lockdown period could lead to modifications in sexual desire and arousal.
Materials & methods
Study design
We adopted a cross-sectional survey design conducted with a mixed qualitative-quantitative
method. In the sample, variables within dependent type were analyzed. The rationale of this
study was descriptive. Data were collected through a mixed-method study with open- and
closed-ended questions.
Materials and apparatus
Open-ended e-questionnaire on sexual experience. Participants were invited to respond
with a maximum of 280 characters (“tweets”) to five open-ended questions formulated in Ital-
ian on the following five topics:
1. sexual activity (“Have you experienced a change, for the better or worse, in your sexual
activity during the lockdown period? Define it with three adjectives, and, for each one, add
or specify something more.”);
2. desire, arousal, and fantasies (“How did you do with your sexual desire and arousal? Have
you noticed a change in your erotic fantasies?”);
3. masturbation (“How did you experience your masturbation during the lockdown
period? How did the mode and amount of autoeroticism change, if at all, during
quarantine?”);
4. use of sexual aids (“What experience have you had during this lockdown period with sex
toys or other sexual aids, such as sexually explicit materials and websites? Have you used
technological aids to engage in online sex individually or with your partner (e.g.,
sexting)?”);
5. awareness about sexuality (“With respect to your sexuality and your experience of it in the
period just past, what do you feel you have understood that is important to you? Have you
discovered new sensations with respect to your body and your sexuality? What would you
keep and what would you leave behind?”).
Sexual Modes Questionnaire (SMQ)–Nonbinary form. This is a closed-ended self-report
questionnaire assessing the interactions between cognitions, emotions, and sexual response. In
its original English version [26], the questionnaire is composed of three independent subscales,
available in a female and male version: (i) “Automatic Thought” (AT), (ii) “Emotional
Response” (ER), and (iii) “Sexual Response” (SR). The three subscales are composed of 30
items (male) or 33 items (female). For each item, the respondents first have to indicate for the
AT subscale through a five-point Likert-type scale the frequency with which a thought or an
image occurs (from 1 = “never” to 5 = “always”). Then, for the same item answered in the AT
subscale, which has been assigned a value 2 (i.e., other than “never”), the respondents assess
emotions that they experience during sexual activity in the ER subscale. Respondents are given
a list of 10 emotions, of which eight are negative (worry, sadness, disillusion, fear, guilt, shame,
anger, hurt) and two positive (pleasure and satisfaction), to select from in evaluating their
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responses to the AT items. Finally, in the SR subscale, respondents assess subjective sexual
responses pertaining to the items of the AT subscale (which has been assigned a value of 2)
through an additional five-point Likert-type scale (from 1 = “very low” to 5 = “very high”).
The validity and reliability of the Italian version of the test have recently been demonstrated by
a psychometric study conducted by Nimbi, Tripodi [27]. In our questionnaire, a modified ver-
sion of the 56-item unique nonbinary (male/female) form of the SMQ was used, obtained
from merging the Italian version of the 30-item male and 33-item female forms after eliminat-
ing duplicate items. The Likert-type scales were anchored as the original: the higher the score,
the higher the frequency of AT and arousal of SR.
Sociodemographic and behavioral e-Questionnaire during quarantine. Two types of
information about participants were collected anonymously: sociodemographic data and
information about daily living during the first lockdown period. The sociodemographic sec-
tion inquired about: (i) sex as assigned at birth, (ii) age, (iii) gender identity (“I see myself/
define myself as a man”; “I see myself/define myself as a woman”, plus the 56 gender options
drawn from Facebook for respondents who did not simply identify as a “man” or “woman”),
(iv) sexual orientation based on the Kinsey Scale [28,29], (v) partner, (vi) marital status, (vii)
education level, (viii) employment, (ix) political orientation, (x) religious affiliation, (xi) dis-
ability/nondisability of the respondent, and (xii) disability/nondisability of child(ren). The sec-
tion on daily life experience during the lockdown period surveyed explored: (i) with whom the
lockdown period was experienced, (ii) activity and work pattern during the lockdown period,
(iii) province in which one lived during the lockdown, (iv) maintenance of a romantic rela-
tionship during the lockdown, (v) change in sex life during the lockdown, and (vi) exposure to
the COVID-19 virus.
The survey could only be accessed through the Qualtrics.xm (Provo, UT, USA) Internet
platform. Each time a questionnaire was completed, the data were sent directly to the online
database. Microsoft Excel software was then used for entering the data obtained and IBM-SPSS
version 25 software for their statistical processing. Qualitative processing and coding were
assisted by ATLAS.ti version 8.4.24 software.
Procedures
The administration of the questionnaire “Sexuality in Quarantine” took place from May 5 to
14, 2020—i.e., immediately after the lockdown ended and business reopened [30]. Adults
(18 years old) residing in Italy during the lockdown, understanding the Italian language,
and owning a device with Internet access, by clicking on a link available on the main social
media (Facebook, Instagram, Twitter), could gain access to the digital questionnaire called
“Sexuality in quarantine.” After accessing the e-questionnaire, the software showed the follow-
ing pages: (i) information sheet and brief introduction to the study, (ii) informed consent, and
(iii) privacy policy and processing of personal data. The participants could continue filling out
the e-questionnaire by indicating that they had read the consent information. Respondents
could decide to withdraw at any time without any penalty.
The survey was structured with the three questionnaires in the following succession: open-
ended questionnaire; Sexual Modes Questionnaire (SMQ) in nonbinary form; sociodemo-
graphic and behavioral questions that were required to be completed, otherwise the test would
be canceled.
Responses to the questionnaires were collected anonymously: participants were assigned an
anonymous alphanumeric protocol code, automatically generated by the Qualtrics.xm plat-
form, and used by researchers for data processing. The questionnaire could be completed in
an estimated time of 20 minutes.
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Statistical analyses
Data were analyzed using a mixed methodology including both a quantitative and a qualitative
approach. All research data are available in a public repository [31].
Quantitative analyses. These were conducted on participants’ responses covering the
SMQ questionnaire. Descriptive analyses (mean, mode, median, standard deviation, frequen-
cies, minima and maxima) and parametric inferential analysis (t-test, chi-square, Cronbach’s
alpha, and one-way ANOVA) were performed.
Qualitative analyses. ATLAS.ti 8 software was used to process all respondents’ open-
ended tweets. Using this qualitative text analysis tool, it was possible to extract only those
words (N = 1,313) that were relevant to the questions asked and had semantic relevance to the
study. Specifically, entering all tweets (2,315) into ATLAS.ti yielded a set of 4,535 words. From
this raw list, we proceeded to extract a “stoplist,” i.e. a set of empty words (articles, pronouns,
conjunctions, etc.). Then, to facilitate the analysis, the stemming procedure (manually con-
ducted and not supported by software) was used to reduce inflected (or derived) words to their
word stem (i.e., the main part of a word that stays the same when endings are added to it).
Whole words (i.e., not the stem) were maintained when present only once in the list. The
1,313 words not belonging to the stoplist were associated with each other based on the stem of
each word, obtaining a final list of 607 stems (S1 Table). The Term Frequency-Inverse Docu-
ment Frequency [TF-IDF; 32] weight function was applied to the list of stems. TF-IDF allowed
us to measure the relevance that a word takes in its context of use. There are five contexts of
use in this study, each of which collects all tweets in response to each of the five questions (sex-
ual activity; desire, arousal, and fantasies; masturbation; use of sexual aids; awareness of sexual-
ity). This measure of relevance is from the computation of inverse correlation between the
frequency of a word stem among the tweets provided in response to each question and the fre-
quency of the same stem among all 2,315 tweets gathered. Given a collection Cof documents
d, the TF-IDF value for each term tin a document d2Cis calculated as:
TFIDFðt;d;CÞ ¼ TFðd;tÞ  IDFðt;CÞ;
where TF (d,t) indicates the number of times a target term tappears in document d, and IDF
is equal to log(N/n), where Nindicates the number of documents in Cand nthe number of
documents where tis used. In this study case, the TF part of the formula, the collection Cis the
total number of documents (C = 5), the term tcorresponds to each of the roots (e.g.,
“abbracci”), and the document dis equal to each one of the five questions belonging to the
collection C. To avoid favoring longer documents, the TF has been divided by the length of the
document itself, where the latter is considered as the total number of stems for each open-
ended question. Concerning the IDF formula instead, Nis equal to the number of open-ended
questions (N= 5) and nis equal to the number of questions where the stem appears. The
salience of a stem (relative weight or TF-IDF) was considered higher the more its frequency in
a specific context of use was inversely proportional to its frequency within the total number of
607 stems (i.e., the final list computed; S1 Table).
Stems above the first (positive) standard deviation of the TF-IDF scores of each group of
stems were selected for each of the five open-ended questions. (As none of the stems belonging
to the fourth open-ended question exceeded the cut-off [SD 1], these were excluded from
further analyses). Subsequently, the stems were hierarchically clustered based on Euclidean
distances with respect to TF-IDF scores for each remaining context of use. Subsequently, the
stems were hierarchically clustered based on Euclidean distances with respect to TF-IDF scores
for each context of use (S2S5 Tables). For the choice of cluster solution (i.e., number of final
clusters), the variation in the agglomeration coefficient was observed (S6S9 Tables). This
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represents the degree of inhomogeneity within the cluster each time a new item (or cluster of
items) was merged: The higher the coefficient, the more dissimilar the grouped items were,
and the more the inhomogeneity increased. Therefore, the solution preceding the maximum
variation of the agglomeration coefficient was chosen as the best explanation for the final num-
ber of clusters.
Ethical issues
The project was approved by the Committee of Bioethics of the University of Perugia, protocol
no. 51854/2020. The observational study was carried out with full respect for the dignity of the
human being and his/her fundamental rights, as dictated by the Declaration of Helsinki and
the rules of Good Clinical Practice issued by the European Council. Informed consent was
obtained from all individual participants included in the study. Written informed consent was
obtained from all participants 18 years and older.
Results
Participants
A total of 465 people responded to the survey (sex as assigned at birth: female = 78.7%). The
mean age was 29 ±10.37 years (range = 18–34). Most participants reported having at least a
bachelor’s degree (71.2%). In regard to political orientation, the majority stated that they were
“left” (27.1%). “Center” affiliation was stated by 9.5%, “right” by 7.1%, while 41.7% reported
“no” affiliation or “I don’t know.” The top two, and nearly exclusive, groups in which partici-
pants placed themselves with respect to religious affiliation were Catholicism (44.3%) and no
religion (46%). Some 97.2% of the participants identified themselves as having a binary male/
female gender identity. As regards sexual orientation (Kinsey Scale), 71.6% of the respondents
affirmed they were exclusively heterosexual, 2.4% exclusively homosexual, and 3.4% bisexual.
In terms of functioning and disability, 5.6% of the respondents reported that they had a dis-
ability, with the majority (5.1%) having an invisible or sensory disability. Most respondents
(41.9%) lived in the municipality of Perugia during the quarantine period. A total of 396 par-
ticipants (85.1%) reported that they had not been exposed to COVID-19. All data collected by
the sociodemographic and behavioral e-questionnaire are reported in S10 Table.
Quantitative analysis on SMQ
All responses to the first and third scales of the SMQ were split quintiles. To discriminate
between major and minor values assigned to each item, only items belonging to the first quin-
tile (items with lower scores) and fifth quintile (items with higher scores) were extracted.
Respondents to the first scale (AT) had access to the second (ER) and third scales (SR) only if
the item on the first scale was assigned a score 2 (i.e., other than “never”). Cronbach’s alpha
was computed to test the reliability of the two Likert-type scales, obtaining excellent internal
consistency: AT scale on 56 items, α= .915; SR scale on 56 items, α= .917.
t-tests and one-way ANOVAs were conducted to compare the effect of the variables col-
lected through the sociodemographic questionnaire (independent variable) on the response
values that participants attributed to the SMQ questionnaire scales (dependent variable).
Effects were found with regard to the t-test from sex as assigned at birth (male/female) and
with the ANOVA from disability/nondisability on the SMQ questionnaire. Only the results of
these two analyses are reported below. Where appropriate, Bonferroni’s corrections have been
applied.
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Automatic Thought (AT), Emotional Response (ER), and Sexual Response (SR). The
first scale of the SMQ concerns AT. These are the thoughts about one’s beliefs, judgments, and
moods, both positive and negative, that arise when one is exposed to sexual stimuli. These
thoughts are often good predictors of sexual desires. Out of the total number of participants
(N = 465), the automatic thoughts that received the highest mean value on the response scale,
where 1 indicated “never” and 5 indicated “always” (max = 4.23, min = 3.35, i.e. between
“sometimes” and “always”), were Items 5, 6, 10, 12, 20, 21, 23, 27, 31, 38, 39, 41, 46, and 50.
Items 12, 39, and 50 result in a higher mean value in the responses of females only, and not
in males. In males, but not in females, two items had higher mean values, Item 6, “I am the
happiest person in the world” (mean = 2.86), and Item 31, “I need to show my manhood/femi-
ninity” (mean = 2.61). Also, compared to the total sample, the 10 automatic thoughts that
received the lowest mean scores on the response scale (min = 1.24, max = 1.58, i.e. between
“never” and “rarely”) were Items 42, 9, 3, 36, 53, 17, 19, 40, 48, and 54.
Among the 10 emotions of the second scale (ER)—of which eight were negative (worry,
sadness, disillusion, fear, guilt, shame, anger, hurt) and two positive (pleasure and satisfaction)
—associate at each item of the AT scale, positive emotions were found to be more frequent
than negative emotions. Out of the eight negative emotions, “worry” (9.30%) emerged signifi-
cantly as the most frequent and “hurt” (1.96%) as the least frequent, both in males and females.
Out of the two positive emotions, “pleasure” (11.50%) was the most frequently selected, turn-
ing out to be the most frequently chosen among all other emotions selected, both in males and
females.
In the last scale (SR), the mean intensity of sexual arousal that each thought elicited in
respondents was 1.42 (DS = .56), i.e. between “very low” and “low.” The items belonging to the
fifth quintile were 5, 12, 20, 21, 23, 27, 31, 39, 41, and 50, with Item 12 (“Making love is won-
derful”) obtaining the highest mean score (4.04). Males reported a higher level of arousal
(1.47) than females (1.40). The items belonging to the first quintile were 3, 9, 17, 19, 25, 32, 33,
34, 35, 36, 37, 40, 42, 45, 48, 52, 53, 54, 55, and 56, with Item 45 (“I am not penetrating my part-
ner”) obtaining the lowest mean score (.40).
Sex differences on SMQ scales. A t-test was computed to investigate the effect of the inde-
pendent variable sex (male or female based on the answers to “sex as assigned at birth”) on the
occurrence of automatic thoughts (AT scale, dependent variable), indicated by respondents
through a five-point Likert-type scale anchored by 1 (never) to 5 (always). As displayed in
Table 1, significant differences in values were found among 13 items of the first scale AT.
Disability effect on SMQ scales. One-way ANOVAs were conducted to compare the
effect of the variables collected via the sociodemographic questionnaire (independent variable)
on the occurrence of automatic thoughts (AT scale, dependent variable), indicated by respon-
dents through a five-point Likert-type scale anchored by 1 (never) to 5 (always). Only the vari-
able “xi. disability/nondisability” generated a statistically significant difference, F(1, 5.944, p <
.05). A univariate ANOVA with marginal mean estimation was computed on the 56-item AT
scale. As shown in Table 2, significant differences in values among 17 items were found.
The same ANOVA statical method was also computed on the SR scale. As shown in
Table 3, significant differences in values among seven items were found.
A chi-square test was computed on the ER scale. As displayed in Table 4, significant differ-
ences in values among 12 items were found.
Qualitative analysis of the five open questions
Before proceeding with the qualitative analysis, the authors (ACM and EZ) evaluated the perti-
nence of responses to the five questions. In agreement with all authors, the evaluators adopted
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a broad criterion of inclusivity to consider an answer pertinent to the question. Only those
tweets that were clearly intended to criticize the study or its authors, to insult or threaten peo-
ple, or that are meaningless (e.g., where only meaningless filler characters have been included
in the response field such as “wbkjwiudjeoq”) would have been excluded. A total of 2,311 out
of 2,325 expected tweets were evaluated as being pertinent to the question posed and uploaded
in ATLAS.ti. As detailed above in the subsection “Statistical Analyses,” out of 4,535 words col-
lected from tweets, a final list of 607 stems was extracted S1 Table. After applying the TF-IDF
[32] weight function, the most salient stems were considered those above the first (positive)
standard deviation to the relative TF-IDF mean value. From the final list of 607 (S1 Table), 76
salient stems were extracted as displayed in Table 5.
First question: An overview of sexual activity during the lockdown. For the first ques-
tion (“Did you experience a change, for the better or worse, in your sexual activity during the
lockdown period? Define it with three adjectives and for each one, add or specify something
more”), 31 salient stems (Table 5) were clustered in three groups (Fig 1).
Based on the common meaning emerging from the stems belonging to the group, the three
clusters were named as follows: Cluster 1 “suffering,” Cluster 2 “emotional-sexual flattening,”
and Cluster 3 “feelings about sexual activity.”
Table 1. t-test computed to compare the effect of sex (male/female) on the values of the AT scale at p <.05 level.
95% Confidence Interval for
Difference
SMQ–Automatic Thought Item Sex Mean Differences Std. Error Sig. Lower Bound Upper Bound
1. I can’t hear anything Male 1.9192 1.46138 .036 -.60460 -.02166
Female 2.2323
5. My body excites him/her Male 3.3434 1.53808 .010 -.71081 -.09728
Female 3.7475
9. He/she is abusing me Male 1.4545 1.00278 .038 .01212 .41212
Female 1.2424
12. Making love is wonderful Male 4.3838 1.31950 .009 .09037 .61671
Female 4.0303
14. If I don’t reach orgasm now, I won’t be able to later Male 1.5657 1.43684 .001 -.85223 -.27908
Female 2.1313
28. When does it end? Male 1.8081 1.55070 .0041 -.63251 -.01395
Female 2.1313
32. If I let myself go he/she will think I am easy Male 1.4141 1.43081 .016 -.63890 -.06817
Female 1.7677
33. I have to be able to have a relationship Male 2.2525 1.86351 .022 .06267 .80601
Female 1.8182
38. I don’t want to be hurt emotionally Male 2.4545 2.44486 .001 -1.37651 -.40127
Female 3.3434
41. What must he/she be thinking about me? Male 2.6970 1.93829 .032 -.81083 -.03766
Female 3.1212
43. I should wait for him to make the first move Male 2.0101 1.90016 .002 -.97494 -.21698
Female 2.6061
44. I am not getting excited Male 1.7475 1.34288 .001 -.75268 -.21701
Female 2.2323
46. I am getting fat/ugly Male 1.9798 1.82082 .001 -.99952 9.34670
Female 2.6162
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The first cluster, “suffering,” consisting of only one item, highlights a general experience of
suffering due to the limitations that the lockdown brought with it. For instance, a cisgender
woman aged 25 wrote about her stress condition:
“Physically and mentally I suffer from a lack of intimacy and bodily interaction.”
Items in the second cluster refer to a climate of “emotional-sexual flattening,” evidencing
how the restriction to mobility experienced by participants and the uncertainty of the future
negatively affected sexual experiences and mood. For instance, a 24-year-old man wrote about
his depression:
Table 2. Significant univariate effects for presence and absence of disability on the values of AT scale at p <.05 level.
95% Confidence Interval for
Difference
SMQ–Automatic Thought Item Presence/Absence of Disability Mean Differences Std. Error Sig. Lower Bound Upper Bound
3. It would be better to die than to be like this Disability 1.769 .178 .031 .034 .734
Nondisability 1.385
9. He/she is abusing me Disability 1.769 .14 .002 .167 .715
Nondisability 1.328
11. He/she doesn’t find my body attractive anymore Disability 2.307 .211 .047 .005 .834
Nondisability 1.888
13. I’m condemned to failure Disability 2.269 .213 .022 .069 .907
Nondisability 1.781
16. I am only doing this because he/she asked me to Disability 2.230 .197 .026 .054 .827
Nondisability 1.790
17. He/she is not respecting me Disability 2.153 .165 .001 .386 1.033
Nondisability 1.443
19. He only loves me if I’m good in bed Disability 2.115 .189 .001 .282 1.024
Nondisability 1.545
25. He/she only wants to satisfy himself Disability 2.307 .212 .007 .153 .986
Nondisability 1.464
33. I must be able to have intercourse Disability 2.692 .261 .001 .33 1.355
Nondisability 1.849
35. How can I get out of this situation? Disability 2.384 .255 .036 .036 1.038
Nondisability 1.847
36. This is disgusting Disability 1.769 .151 .016 .07 .662
Nondisability 1.403
37. Sex is all he/she thinks about Disability 2.269 .219 .013 .115 .975
Nondisability 1.724
38. I don’t want to get hurt emotionally Disability 3.576 .323 .033 .056 1.326
Nondisability 2.885
48. If I refuse to have sex, he/she will cheat on me Disability 2.153 .194 .001 .259 1.023
Nondisability 1.512
51. He/she will replace me with another guy Disability 2.153 .238 .013 .128 1.062
Nondisability 1.981
52. I’m getting old Disability 2.500 .228 .001 .282 1.178
Nondisability 1.770
55. This is not going anywhere Disability 2.384 .246 .033 .042 1.01
Nondisability 1.858
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“Often practicing autoerotism, I stopped, blocked, and dwelt on thinking about anything
else, as if it was an obligation.”
The third cluster, “feelings about sexual activity,” includes terms about how participants felt
and acted out sexuality under restricted social conditions.
“[I experienced] a change for the worse that can be described as: frustrating in that the
desire remained unexpressed and unfulfilled.” (Gender fluid, 26 years old)
“[I would define my sexual experience as] comfortable in the sense that I had the ability to
choose when and how to do it with no time or space limitations.” (Woman, 29 years old)
“The only times I masturbated I was anxious because I was living with my parents and I
didn’t feel comfortable.” (Woman, 31 years old)
Table 3. Significant univariate effects for presence and absence of disability on the values of the SR scale at p <.05 level.
95% Confidence Interval for
Difference
SMQ–Automatic Thought Item Presence/Absence of Disability Mean Differences Std. Error Sig. Lower Bound Upper Bound
3. It would be better to die than to be like this Disability .884 .199 .014 .101 .884
Nondisability .391
9. He/she is abusing me Disability 1.153 .228 .004 .210 1.105
Nondisability .496
12. Making love is wonderful Disability 3.500 .227 .013 -1.010 -.118
Nondisability 2.936
17. He/she is not respecting me Disability 1.307 .218 .001 .293 1.151
Nondisability .585
19. He only loves me if I’m good in bed Disability 1.230 .239 .007 .176 1.115
Nondisability .585
33. I must be able to have intercourse Disability 1.615 .273 .008 .190 1.264
Nondisability .888
45. I am not penetrating my partner Disability .846 .207 .024 .061 .875
Nondisability .378
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Table 4. List of items showing a significant association between disability condition (presence/absence) and types
of emotion (negative and positive) scale at p <.05 level.
SMQ–Automatic Thought Item χ(df) Sig.
9. He/she is abusing me 13.581 .001
16. I am only doing this because he/she asked me to 11.509 .003
17. He/she is not respecting me 13.097 .001
19. He only loves me if I’m good in bed 12.427 .002
25. He/she only wants to satisfy himself 12.830 .002
33. I must be able to have intercourse 8.162 .017
35. How can I get out of this situation? 16.585 .000
38. I don’t want to get hurt emotionally 15.894 .000
4. He/she only cares about me when he/she wants to have sex 7.480 .024
45. I’m not penetrating my partner 9.712 .008
48. If I refuse to have sex, he/she will cheat on me 7.229 .027
49. If he/she just whispers something romantic in my ear 2.614 .271
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Table 5. Frequency data about the salient stems above the first (positive) standard deviation of the TF-IDF scores for each of the five open-ended questions.
Stem F TF IDF TF-IDF Stem F TF IDF TF-IDF
Open-Ended question 1 (N = 31)
Suffer6 .00248 1.60944 .00399 Calm8 .00330 .51083 .00169
Depress8 .00330 .91629 .00303 Relax18 .00743 .22314 .00166
Asexual4 .00165 1.60944 .00266 Passion17 .00702 .22314 .00157
Repress4 .00165 1.60944 .00266 See4 .00165 .91629 .00151
Listless4 .00165 1.60944 .00266 Affect7 .00289 .51083 .00148
Intens26 .01074 .22314 .00240 Abstinence 7 .00289 .51083 .00148
Nervous6 .00248 .91629 .00227 Satisf15 .00620 .22314 .00138
Anxi22 .00909 .22314 .00203 Surrender2 .00083 1.60944 .00133
Comfort3 .00124 1.60944 .00199 Contrasting 2 .00083 1.60944 .00133
Confused 3 .00124 1.60944 .00199 Impotence 2 .00083 1.60944 .00133
Innovativ3 .00124 1.60944 .00199 Unwanted 2 .00083 1.60944 .00133
Loneliness 9 .00372 .51083 .00190 Insatiable 2 .00083 1.60944 .00133
Happy5 .00207 .91629 .00189 Argu2 .00083 1.60944 .00133
Melancholy5 .00207 .91629 .00189 Reinvent2 .00083 1.60944 .00133
Frustr20 .00826 .22314 .00184 Relief 2 .00083 1.60944 .00133
Sad20 .00826 .22314 .00184
Open-Ended Question 2 (N = 7)
Dream13 .00926 .51083 .00473 Transgress3 .00214 .91629 .00196
See4 .00285 .91629 .00261 Extreme3 .00214 .91629 .00196
BDSM 4 .00285 .91629 .00261 Intens9 .00641 .22314 .00143
Variety 2 .00142 1.60944 .00229
Open-Ended Question 3 (N = 10)
Privacy 8 .00806 .51083 .00412 Relax10 .01007 .22314 .00225
Shower 3 .00302 .91629 .00277 Calm4 .00403 .51083 .00206
Loneliness 5 .00504 .51083 .00257 Date2 .00201 .91629 .00185
Fatigue5 .00504 .51083 .00257 Movie2 .00201 .91629 .00185
Intens11 .01108 .22314 .00247 Leisure 2 .00201 .91629 .00185
Open-Ended Question 4 (N = 12)
Vibrator13 .00727 .51083 .00372 YouPorn 4 .00224 .91629 .00205
Movie7 .00392 .91629 .00359 Whatsapp 2 .00112 1.60944 .00180
Photo27 .01511 .22314 .00337 Chat 2 .00112 1.60944 .00180
Webcam 6 .00336 .91629 .00308 Lubricant 2 .00112 1.60944 .00180
Cell phone3 .00168 1.60944 .00270 Audio12 .00672 .22314 .00150
Stories 5 .00280 .91629 .00256 Pornhub 5 .00280 0,51083 .00143
Open-Ended Question 5 (N = 16)
Underst4 .00221 1.60944 .00356 Affect8 .00443 .51083 .00226
Know12 .00664 .51083 .00339 Kiss4 .00221 .91629 .00203
Emotion6 .00332 .91629 .00304 Attract7 .00387 .51083 .00198
Foreplay 6 .00332 .91629 .00304 Grant2 .00111 1.60944 .00178
Bonding 6 .00332 .91629 .00304 Imperfect2 .00111 1.60944 .00178
Tenderness 6 .00332 .91629 .00304 Patience 2 .00111 1.60944 .00178
Orientation 3 .00166 1.60944 .00267 Unlock me 2 .00111 1.60944 .00178
Love19 .01051 .22314 .00235 Dirty 2 .00111 1.60944 .00178
Row frequencies (F), term frequency (TF), inverse document frequency (IDF), and term frequency-inverse document frequency (TF-IDF) of the most relevant stems
extracted from answers to the five open-ended questions are reported. The asterisk indicates that only the stem word has been listed, i.e., a part of a word that can form
the basis of other words with similar meaning through the addition of suffixes.
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“I wish to see again as soon as possible the person with whom I like to make love.”
(Woman, 29 years old)
“Compared to the stress and frustration of the situation, the sexual activity provided some
relief.” (Woman, 26 years old)
Second question: Desire, arousal, and fantasies. For the question “How did you do with
your sexual desire and arousal? Have you noticed a change in your erotic fantasies?” seven
salient stems (Table 5) were clustered in three groups (Fig 1). Based on the common meaning
emerging from the stems belonging to the group, the three clusters were named as follows:
Cluster 1 “dream,” Cluster 2 “variety,” and Cluster 3 “opportunities for transgression.”
The first cluster, “dream”, indicates a phenomenon through which fantasies were expressed.
“Both desire and fantasies increased, expressed more during dreams (especially during
afternoon rest). Upon awakening, arousal was strong and long-lasting. It happened more
rarely before the lockdown.” (Woman, 32 years old).
The second cluster, “variety,” shows a wide sexual exploration of fantasies by the
participants.
“Yes, I started having other fantasies, from threesome to BDSM. I’ve always thought about
it, but during the lockdown I seriously thought about enacting them.” (Woman, 24 years
old)
Fig 1. Cluster dendrograms of extracted terms (open-ended questions). Cluster dendrograms are based on the Euclidean Distances’ Matrix of the 64 Salient
Stems for Open-Ended Question 1, 2, 3, and 5. A Hierarchical Cluster Analysis was performed to group similar terms in relation to their TF-IDF Index.
Euclidean distances are reported on a modified scale with units from 0 to 1 (0 = maximum proximity/similarity;1 = maximum distance/dissimilarity).
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The third cluster points out that, for some respondents, fantasies were experienced as an
“opportunity for transgression.”
“I have discovered and also experienced new fantasies related to the BDSM world and in
particular, submission.” (Woman, 24 years old)
“[When I was alone] I had moments of great excitement, teenage I would say. I haven’t
noticed excessive changes, but I have had an acceptance of more ‘extreme’ fantasies that
before I didn’t like.” (Man, 33 years old)
Third question: Masturbation. For the third question (“How did you experience your
masturbation during the lockdown period? How did the mode and amount of autoeroticism
change, if at all, during quarantine?”), 10 salient stems (Table 5) clustered into three groups
(Fig 1). The three clusters were named as follows: Cluster 1 “privacy,” Cluster 2 “need for
space,” and Cluster 3 “escaping from the room.”
The first cluster consists of only one very salient stem, “privacy.”
“Unfortunately, my moments of privacy have been abruptly reduced and I haven’t had the
opportunity to masturbate with the same tranquility and frequency as before.” (Woman, 27
years old)
The second cluster refers to the reduction of space and time for solitude and self-eroticism.
“Due to lack of space, privacy, or discomfort, desire has often been experienced with frus-
tration, as an impediment.” (Man, 28 years old)
The third cluster indicates the calming and relaxing role of masturbation during the quar-
antine period, as a way of “escaping from the room.”
“The amount of autoeroticism during quarantine has increased due to simply not being
able to meet my partner. It has been critical to release some stress, relax, and satisfy my sex
drive.” (Woman, 21 years old)
Fourth question: Use of sexual aids. None of the stems extracted from the fourth ques-
tion [“What experience have you had during this lockdown period with sex toys or other sex-
ual aids, such as sexually explicit materials and websites? Have you used technological aids to
engage in online sex individually or with your partner (e.g., sexting)?”] exceeded the first stan-
dard deviation. For this reason, we did not proceed with cluster analysis. Twelve stems with
higher TF-IDF are reported (Table 5), which give information about the variety of aids partici-
pants reported using.
“I have purchased and used sex toys for personal masturbation with great pleasure. I was
aware of them, but this period led me to equip myself with them for the future as well. I
often used technological support such as videos/photos/sexting with more or less close
friends.” (Man, 25 years old)
“Yes, we purchased a sex toy during quarantine. I didn’t own any before. The choice came
down to a wearable vibrator that could be managed remotely, so the partner could control
it remotely with an app.” (Woman, 27 years old)
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“Thanks to YouPorn’s offering, I initially viewed pornographic content often but later I pre-
ferred sexting with my partner.” (Woman, 21 years old)
“Pornhub premium free was a major discovery [. . .].” (Man, 45 years old)
Fifth question: What has been understood about one’s sexuality. For the last question
(“With respect to your sexuality and your experience of it in the period just past, what do you
feel you have understood that is important to you? Have you discovered new sensations with
respect to your body and your sexuality? What would you keep and what would you leave
behind?”), 16 salient stems (Table 5) were clustered in two groups (Fig 1). Based on the com-
mon meaning emerging from the stems belonging to the group, the two clusters were named
as follows: Cluster 1 “need for intimacy” and Cluster 2 “acceptance of sexuality.”
The first cluster, “need for intimacy,” expresses the general need to deepen intimacy with
one’s own sexuality and with one’s partner.
“Definitely I understood how necessary a good and beautiful understanding with my part-
ner outside the sexual sphere is, and that it is absolutely necessary to carve out spaces to
remember us and give us a common oxygen. And only afterwards to get closer with sex as
well.” (Woman, 31 years old)
The second cluster, “accepting sexuality,” refers to different facets of the same dimension:
accepting sexuality both as an aspect of one’s person and in its multiple meanings.
“During this period of quarantine with respect to sexuality, I learned to indulge my moods
by sharing them with my partner. I felt no shame for the lack of desire, the scarce excite-
ment.” (Woman, 29 years old)
“I realized that I had major issues with my sexuality. I’ve always felt dirty. I think my aware-
ness and change is a sign of growth and wanting to finally be okay. I am accepting that I am
a person who can spark sexual interest.” (Woman, 25 years old)
Discussion
Quantitative results drawn from the sociodemographic questionnaire and
the SMQ
The large number of people who participated in the survey in a short period of time, just 10
days, highlights the centrality and relevance of the theme proposed. The social restrictions
imposed by the lockdown should have had a relevant effect on affective and sexual dating,
especially in those adults and couples who could not live together.
Respondents, the majority of whom were female (generally more willing to engage in intro-
spective inquiries), especially identify with the statement that “making love is wonderful,” per-
ceiving their bodies as exciting, as well as the sexual activities enacted. Male participants also
shared these feelings, even adding that arousal was even a little more pronounced than before
the pandemic. The sexual experience, in a time of quarantine, was experienced with positive
characteristics, openness, an unproblematic relationship with the body, and awareness of, and
self-reflection on, one’s sexuality.
In contrast, the thoughts connected to worry (AT scale) are rather marginal, and even more
marginal are those thoughts connected to pain; very few of the respondents recognize them-
selves as having thoughts with self-evaluative connotations and of disgust and suffering
towards the interlocutor and the sexual activities performed.
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From the SMQ quantitative data emerge a series of further significant elements in a rather
marked way. First, the percentage of respondents who report having a disability (5.6%) mirrors
the Italian national average of people with disabilities, which, according to ISTAT (Italian
Institute of Statistics) [33], is 5.2%. These data suggest that adults with disabilities pay attention
to, and consider relevant, the topic of sexuality. This is by no means taken for granted if we
consider that, while adequate operational strategies to educate people with physical or mental
disabilities to sexuality and affectivity have been discussed and studied for some time now,
their existential condition still suffers from heavy taboos and concrete limitations in this fun-
damental area of the expression of their humanity [3437]. Indeed, sexuality represents an
essential component of one’s human identity, in emotional, physical, and psychological, as
well as in ethical and spiritual terms. Therefore, the adherence to the research on people with
disabilities and the self-reflection that emerged is particularly relevant. According to our
results (Tables 2and 3), respondents with disability reveal a marked inversion of the trend
with respect to the mean of the respondents about the thoughts in which people recognize
themselves (AT scale). Respondents with a disability seem to revolve around feeling abused,
inadequately respected, viewed more as sexual “objects” than as persons in a relationship, neg-
atively focused on performance and self-image, emotionally vulnerable and inadequately
acknowledged in terms of their needs. In face of such their self-image, which is characterized
by a certain amount of suffering and low self-esteem, on the other hand, people with disabili-
ties reported their arousal as being higher than the mean.
Thus, we could hypothesize that, among the participants, those who, in relation to their
condition of disability, do not consider themselves lovable, even though they perceive arousal,
experience as inadequate the movement towards the satisfaction of this need. Experiencing
their own image and performance as inadequate, participants with a disability show a particu-
larly sensitivity to the expression of acceptance and approval by a sexual partner, so much so
that they are emotionally dependent on them and attribute their own negative image to the
partner’s behavior. Thus, on the one hand, the painful experience with respect to low self-
esteem, linked to disability [36,38], could be projected onto the partner’s behaviors, while on
the other hand, the current condition of fragility may make people more vulnerable and sensi-
tive to criticism and rejection.
Human sexuality is often conditioned by the myth of “bodily perfection” [39], which makes
sexuality a right believed to be only reserved for people with healthy, perfect bodies but an
aberration if desired and experienced by and with people with disabilities [34,35]. This myth
not only informs nondisabled people but influences the thinking and behavior of people with
disabilities as well. Their emotional lives are experienced with fear in the face of the “normal”
world, where even an “automatic” thought of sexual arousal and desire for contact can be dan-
gerous and disturbing. Imperfection is ugly, not worthy of giving and receiving love, not even
thinking about it. When people with a disability have to face the emergence of sexuality, at
times resounding and powerful, another stereotype of an opposite sign also comes under
stress, which would presume in a person with disability a condition of perpetual infantiliza-
tion, without eros and without drives [37,40].
Consequently, the manifestation of sexuality and its normal events (desire, arousal, accep-
tance, rejection, satisfaction, frustration) can be experienced with greater difficulty and accom-
panied by painful emotions. Instead of being the moment of the definition of one’s identity
and freedom, such manifestations of sexuality can become the fracture of this identity, or a
painful and heavy identity to manage, perceived by the environment as inadequate, difficult,
and undesirable [41]. Much remains to be done on the educational level and for overcoming
stereotypes in this field [34,35]. It is perhaps relevant here to recall that:
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“Health promotion is the process of enabling people to increase control over, and to
improve, their health. To reach a state of complete physical, mental and social well-being, an
individual or group must be able to identify and to realize aspirations, to satisfy needs, and to
change or cope with the environment.” [WHO, 42]
Sexuality, it is not pleonastic to repeat, is an essential component of health and a right of
every human being.
In the sample examined, Catholic affiliation is well below the national average—74.4%
according to Ipsos Public Affairs [43]. Addressing a sexually explicit issue seems to attract
more people without religious affiliation, because religions have specific teachings about sex
that can condemn masturbation or sexual relationships outside of a heterosexual marriage [36,
44,45].
Tweeting sexual experience during quarantine: Qualitative results from the
five open-ended questions
The qualitative analysis performed on the tweets has revealed the emotional experience of the
participants emerged during the lockdown period. It was generally depressive; both in terms
of desire and the actual possibility to perform sexual activity as usual.
The expression of desire and arousal seems to have been shifted more to the level of the
imagination, where they could be expressed in much broader and freer terms, while also open-
ing to participants spaces of access to transgression and new sexual practices mediated by elec-
tronic devices and the Internet. As several surveys have shown [46,47], some of the most
common sexual fantasies, such as multipartner sex, BDSM, novelty, adventure and variety,
homoeroticism, and gender-bending, are found at the top even among our participants. Adap-
tive behaviors of coping with the frustration generated by the lockdown emerge among our
participants. In the presence of heavy experiences, participants allowed themselves to accept as
a possibility of transformation and change the restrictions made necessary by the pandemic.
Thus, a certain flexibility and fluidity in how respondents think about their gender and sexual
identity emerges, especially among female participants [47,48]. The possibility of autoerotism
becomes explicit. The open-ended question on this topic was welcomed with openness and a
wealth of qualitative details about the experience, while the opportunity for privacy time and
space was significantly emphasized, positively for those who experienced the lockdown in soli-
tude and as an active search for concrete possibilities for those who experienced it in cohabita-
tion with others [49]. A similar movement of creativity and exploratory aptitude can be
detected by the possibility of enriching autoerotic practices or sexuality with a partner with
aids such as sex toys and photo/video images, especially for sexual practices carried out at a dis-
tance, a new experience for many people, both within the affective copy and with casual part-
ners. On the whole, what emerges from the answers to the open-ended questions is—in the
face of the frustration and depressive climate generated by the lockdown to the detriment of
desire and expression of one’s habitual sexual life—an opening to new possibilities of expres-
sion of sexuality, accompanied by the rediscovery of the value of tenderness and affectivity and
a clearer awareness of one’s perception of oneself, one’s experience of sexuality, one’s needs,
desires, and margins for active and creative exploration.
In the first question about sexual activity, the stems contained in the three clusters refer pre-
dominantly to emotional states rather than to sexual behaviors, suggesting that participants,
when asked to provide an overview on their sexual activity during the lockdown period,
highlighted that the changes perceived concerned not so much the sexual behavior itself (e.g.,
frequency of masturbation, intercourse, fantasies, etc.), but rather the emotional experience
that the respondent associated with it.
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The first cluster, “suffering,” and the second one, “emotional-sexual flattening,” highlight a
general experience of suffering due to social restrictions, immobility, and the absence of pros-
pects for change in the long term that quarantine brought. The third cluster is the largest and
most uneven: Some items within it are closer to others than they are with the rest of them,
forming subgroups. However, these refer to the same phenomenon, the perception of sexual
restrictions, focusing on different aspects. First, participants look at the purely emotional expe-
riences arising from the possibility of expressing or not sexuality: The deprivation of a part
considered important for one’s life generated negative emotions, while, when sexual activity
was retained, it represented a source of happiness and stress relief. Secondly, the change in the
possibility of expressing sexuality pushed several participants to readjust their sexual repertoire
and habits, attempting to reinvent themselves and find new kinds of sexual satisfaction.
Thirdly, the experiences related to the possibility of expressing sexuality as a couple were
reported by respondents who were searching for passion and tenderness, as well as desiring to
see each other again. For other couples, sexual abstinence was experienced as a choice of loy-
alty to their partner, an additional sacrifice to the restrictions imposed.
In the second question about desire, arousal, and fantasies, “dream” is, for participants, the
privileged space for sexual fantasies and where a “variety” of new sexual roles, orientation, and
behaviors are experienced as an “opportunity for transgression.” Despite the fact that approxi-
mately 47% of participants reported being followers of a religion (see also S1 Table), dreams
and fantasies do not seem to be affected. Most religions (definitely Catholicism, Orthodoxy,
and Buddhism) have doctrines that are quite restrictive on sexuality. They have pretty much
told their followers that they should not do anything other than put penises in vaginas, and
even that, ideally, should only take place within the confines of a heterosexual, monogamous
marriage. Desires for any other sexual activities have been deemed unnatural, immoral, and
unhealthy, discouraging one from acting on them with threats of divine retribution [47]. How-
ever, from our sample it emerges that the lockdown condition itself was not experienced by
everyone as a reduction in sexual desire, fantasies, and arousal.
In the third question asking about masturbation, the first cluster consists of only one term,
“privacy,” a very influential dimension of sexual privacy and intimacy. If, in the first cluster,
privacy expresses a holistic category of personal life, in the second one it takes shape in domes-
tic spaces of life at the time of quarantine: “need for space.” It encompasses stems that reveal as
the lockdown as much as it has distanced people socially, so it has brought them exaggeratedly
closer together, in a promiscuity of spaces and times that deprive them of the necessary inter-
personal distance needed for an authentic shared and liberating sexual intimacy. Therefore,
self-eroticism was confined to the only place perceived as safe (i.e., the bathroom and shower).
Nonetheless, for other respondents, masturbation intensified and was seen as a means to relax
and calm down, a daily appointment with oneself, as shown by the third cluster “escape from
the room.” In this cluster, stems are associated with the positive role of masturbation as stress
relief.
For the fourth question about the use of sexual aids, the salient stems provide information
about the variety of aids participants reported using, which were purchased and used as tools
for coping with the lockdown. Participants said they had purchased vibrators, or accessed sex-
ually explicit Internet sites (e.g., YouPorn.com,Pornhub.com), or resorted to reading short
erotic stories or watching erotic films, as well as exchanging pictures and videos with their
partner (sexting). These findings align with data provided by Pornhub [50] in a report on sta-
tistics regarding access to its website. Pornhub recorded that Italian user traffic increased sig-
nificantly compared to the pre-COVID-19 average traffic in February 2020 (i.e., before the
outbreak), with a drastic 57% increase on March 12, 2020, when the platform offered free
access to the premium service.
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The last question was on awareness about sexuality. The stems loading in the first cluster
reveal that awareness of one’s sexual experience has increased emotional literacy and the value
of sexual intimacy about both oneself and one’s partner, a fundamental good not to be lost or
neglected. The testimonies collected from this group of tweets reveal that participants experi-
enced this exceptional time not only as a tragedy, painful and deadly, but also as an opportu-
nity for growth. Elements such as bonding, tenderness, emotions experienced with a partner,
and playful moments such as foreplay all contributed to full sexual satisfaction. As early as
2017, in a much-cited literature review on the effects of social isolation and loneliness on
health, Leig-Hunt and colleagues [51] found that a quality of relationships is crucial in the pre-
vention of psychological distress due to social isolation, than quantity of them. The second
cluster, “accepting sexuality,” is rather uneven; it includes additional groupings within it,
based on the greater proximity of certain items. However, it is possible to observe that these
refer to different facets of the same dimension: accepting sexuality, both as an aspect of one’s
person and in its multiple meanings. The participants emphasized the complexity of sexuality,
which can be understood not only as a physical relationship but also as part of a loving rela-
tionship, which focuses on gestures of intimacy, affection, and mutual attraction. Finally, some
participants report reintegrating sexuality into their lives during the lockdown period, setting
aside feelings of guilt and gaining an understanding that it can be an important dimension to
devote time to, allowing themselves to be “sexually interesting.”
During the review process of the present study, one of the reviewers pointed out to us a lim-
itation regarding the wording of the Open-ended e-Questionnaire on Sexual Experience.
Some of the five questions included more than one question, which might suggest a possible
answer. For example, question 2: “How did you do with your sexual desire and arousal? Have
you noticed a change in your erotic fantasies?”: The second question might suggest that there
was a change in sexual fantasies. This might have led respondents to not completely frank
answers, according to the reviewer.
Another limitation of the study concerns the use of the Kinsey scale to identify sexual orien-
tation. We used the (old) seven-item version which did not include to account for asexuality.
This may have limited some respondents in finding appropriate identification regarding their
sexual orientation.
Conclusions
In the present study, we investigated, through a phenomenological analysis, the sexual experi-
ence of young Italian adults in the lockdown condition experienced during phase one of the
Italian governmental measures for the containment of the COVID-19 pandemic.
Despite the difficulties related to isolation and physical distance from their partners, the
lockdown period offered to many an opportunity for self-awareness and reflection on their
sexual experience, allowing questions about their sexual needs and fantasies to surface to their
consciousness and feelings. The understanding, the bond, the emotions, and the affection that
were established with one’s partner were found to be a fundamental asset, not to be lost, and
contributed to full sexual satisfaction. At the same time, participants have rediscovered in the
relationship with their partners the value, richness, and complexity of sexual intercourse, com-
prised of play, foreplay (petting), kissing, and gestures of tenderness. In this way, participants
claimed to have overcome a forced sexual intercourse limited to penetration and orgasm
attainment alone and to have regained the meaning of masturbation as a normal and healthy
expression of their individual and couple sexuality.
From the initial conflict and confusion of the new existential condition due to physical and
social isolation or over-proximity, Italian adults turned to creativity in response to the
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pandemic tragedy, discovering new forms of intimacy, consisting of loving and erotic close-
ness as well as care and acceptancy of their own sexual bodies. Sexuality has thus been rede-
fined in terms of one’s personal search for identity, remaining one of the fundamental ways in
which a person expresses themselves in the world through the experience of pleasure even dur-
ing a tiring and painful quarantine.
Supporting information
S1 Table. Frequency information of total wordlist extracted from the answers to open-
ended questionnaire. Frequency information about words extracted from answers to open-
ended questions are reported. In the first column. word stems are shown. Frequencies (F(1–5).
total frequencies (F(total)). term frequencies (TF(1–5)). inverse document frequencies (IDF)
and term-frequency-inverse document frequencies (TF-IDF(1–5)) related to the five context
are reported for each term. The last row “Total” shows the measure of the length of each docu-
ment, where the latter is considered as the total number of stems for each open-ended question
multiplied by their frequency (F(1–5)).
(DOCX)
S2 Table. Euclidean distance matrix between stems with higher TF-IDF in question 1.
Euclidean distance between the 31 terms with higher TF-IDF in the text corpus of answers to
open-ended Question 1 are reported. The greater the Euclidean distance, the greater the dis-
tance/dissimilarity between items.
(DOCX)
S3 Table. Euclidean distance matrix between stems with higher TF-IDF in question 2.
Euclidean distance between the 7 terms with higher TF-IDF in the text corpus of answers to
open-ended Question 2 are reported. The greater the Euclidean distance, the greater the dis-
tance/dissimilarity between items.
(DOCX)
S4 Table. Euclidean distance matrix between stems with higher TF-IDF in question 3.
Euclidean distance between the 10 terms with higher TF-IDF in the text corpus of answers to
open-ended Question 3 are reported. The greater the Euclidean distance, the greater the dis-
tance/dissimilarity between items.
(DOCX)
S5 Table. Euclidean distance matrix between stems with higher TF-IDF in question 5.
Euclidean distance between the 16 terms with higher TF-IDF in the text corpus of answers to
open-ended Question 5 are reported. The greater the Euclidean distance, the greater the dis-
tance/dissimilarity between items.
(DOCX)
S6 Table. Agglomeration Schedule for Complete Linkage of stems with higher TF-IDF in
question 1. Summary of cluster solutions. At each stage, the cases with the smallest Euclidean
distance are combined; the coefficients indicating cluster heterogeneity change when a case is
combined with the cluster. The solution before the largest gap in the coefficient indicates the
best cluster solution (Stage 28).
(DOCX)
S7 Table. Agglomeration schedule for complete linkage of stems with higher TF-IDF in
question 2. Summary of cluster solutions. At each stage, the cases with the smallest Euclidean
distance are combined; the coefficients indicating cluster heterogeneity change when a case is
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combined with the cluster. The solution before the largest gap in the coefficient indicates the
best cluster solution (Stage 4).
(DOCX)
S8 Table. Agglomeration schedule for complete linkage of stems with higher TF-IDF in
question 3. Summary of cluster solutions. At each stage, the cases with the smallest Euclidean
distance are combined; the coefficients indicating cluster heterogeneity change when a case is
combined with the cluster. The solution before the largest gap in the coefficient indicates the
best cluster solution (Stage 7).
(DOCX)
S9 Table. Agglomeration schedule for complete linkage of stems with higher TF-IDF in
question 5. Summary of cluster solutions. At each stage, the cases with the smallest Euclidean
distance are combined; the coefficients indicating cluster heterogeneity change when a case is
combined with the cluster. The solution before the largest gap in the coefficient indicates the
best cluster solution (Stage 14).
(DOCX)
S10 Table. Frequencies of participants’ responses to sociodemographic questionnaire for
binary gender (male/female) derived from responses to the question “sex as assigned at
birth”.
(DOCX)
Author Contributions
Conceptualization: Stefano Federici, Rosella De Leonibus, Anna Maria Acocella, Adriana
Giammaria.
Data curation: Stefano Federici, Alessandro Lepri, Alessandra Castellani Mencarelli, Evel
Zingone.
Formal analysis: Alessandro Lepri, Alessandra Castellani Mencarelli, Evel Zingone.
Investigation: Stefano Federici, Rosella De Leonibus, Anna Maria Acocella, Adriana
Giammaria.
Methodology: Stefano Federici, Alessandro Lepri, Alessandra Castellani Mencarelli, Evel Zin-
gone, Anna Maria Acocella, Adriana Giammaria.
Supervision: Stefano Federici, Rosella De Leonibus, Anna Maria Acocella.
Writing – original draft: Stefano Federici, Alessandro Lepri, Alessandra Castellani Mencar-
elli, Evel Zingone.
Writing – review & editing: Stefano Federici, Alessandra Castellani Mencarelli, Rosella De
Leonibus.
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... The COVID-19 pandemic has affected almost every aspect of life, including economics, education, industries, and individuals' sexual life (Masoudi et al., 2022). Due to pandemic, most people in the early phase of COVID-19 were not able to meet their close and causal partners because of lockdowns and social distancing policies imposed by governments (Ballester-Arnal et al., 2021;Federici et al., 2022;Sansone et al., 2021). These restrictions also limited recreational and sexual interaction with partners. ...
... In xxx.e6 another study, Bowling et al. (2021) stated that the pandemic has changed the purpose of sex, increased stress, changed home responsibilities and living situations, and also altered time spent with one's partner, which has impacted people by either decreasing or increasing their sex desire or drive. Furthermore, Federici et al. (2022) reported that disabled individuals were affected by low self-esteem, feelings of suffering, and inadequacy. In addition, Vora et al. (2020) reported consequences in the form of increases in the incidence of violence against women (especially in India). ...
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Background Social-distancing in the wake of the COVID-19 pandemic may affect sexual behavior of men who have sex with men (MSM). In early March 2020, Israel imposed travel restrictions and limited social contacts to household members only. The effects of these restrictions on MSM sexual behavior and mental health are unknown. Aim To assess sexual behaviors and mental health of Israeli MSM during social-distancing, and to compare sexual behaviors before and during social distancing, due to the COVID-19. Methods Data was collected through anonymous web-based questionnaires in a popular geospatial application used by MSM between March and April 2020 during the social-distancing period. Outcomes The dependent variable was casual sex, in violation of Social-distancing regulations. Independent variables were demographic characteristics; sexual behaviors before and during social-distancing restrictions; and mental health. Results Of the 2,562 participants, 1,012 (39.5%) continued to meet new casual sex partners during this period. Being of a younger age, single, and with higher levels of mental distress predicted engagement in casual sex during the social-distancing period. MSM reduced their sexual risk and limited sexual repertoire – in particular, kissing with their sexual partners. Participants also spent more time in dating applications than in the pre- social-distancing, and increased their use of sex-phone, web-cams and porn consumption. They perceived the threat of SARS-CoV-2 to be greater than that of HIV: only 3.2% could imagine themselves having sex with a partner who is infected with SARS-CoV-2 compared with 30.1% in case of HIV, p<0.01. Clinical Implications MSM reduced their risk behaviors during social-distancing, due to the threat of COVID-19. Casual sex during social-distancing was associated with negative feelings of mental distress. Future public health response in the future waves of COVID-19 morbidity should strike a balance between containment measures, and the need for social-distancing with its possible mental and social burdens. Strengths and Limitations This is the first study in Israel, and one of the few in the world to examine sexual behavior among MSM during the COVID-19 social-distancing. It involved a relatively large sample, through convenience sampling, which limits causality. Findings should be interpreted cautiously- specifically since COVID-19 related behaviors and circumstances may change rapidly. Conclusion The negative feelings of distress due to social-distancing should be considered as a potential barrier to adherence among vulnerable populations, such as MSM. Future public health response should strike a balance between containment measures and its possible mental, social and financial burdens.