The new coronavirus, which was first reported in December 2019 in Wuhan province of China and named severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in January 2020, rapidly spread worldwide. 1 Since then, SARS-CoV-2 has become a major health crisis all over the world. In early March 2020, the World Health Organization declared that corona virus disease 2019 (COVID-19) as a pandemic. 2 At the time of writing this article, more than 15 million people have been infected and more than 630,000 people have died in over 200 countries around the world. Although many vaccines and drug studies are being carried out, currently we do not have a specific agent with a high antiviral activity that can fight against the virus. 3 For this reason, in many states, citizens were encouraged or insisted on self-isolation, following the social distancing rules, wear masks in public areas, and stay home unless necessary. Moreover, curfews have been imposed in some countries particularly where the COVID-19 is prevalent.
Psychological and mental health disorders are common during widespread epidemics. 4 In the COVID-19 pandemic, anxiety and depression symptoms (experienced by 16-28% of the population) and self-reported stress (experienced by 8% of the population) have been common psychological reactions. 5 Although changes in sexual activity and behaviour are the result of a very complex process, it is common knowledge that mental health and psychological factors are directly related with individual's sexual activity. 6, 7 In addition, decreased sexual activity can have a negative effect on an individual's quality of life and increases the likelihood of depression. 8, 9 Despite this knowledge, very few articles have investigated the effects of the COVID-19 pandemic on sexual life. [10] [11] [12] Reducing in the sexual activity and related factors were determined in a recent study which was conducted in the British public during the COVID-19 pandemic. 10 Moreover, newly detailed reports were presented about the challenges in the practice of sexual medicine from several countries as sexual health is being an important healthcare issue. 13 We hypothesized that sexual functioning may worsen due to strict social distancing rules and the contagious nature of the disease among individuals who have no medical history of COVID-19 during the pandemic period. In addition, we also hypothesized that the population density of the cities where individuals live would also have a negative effect on sexual functioning during the COVID-19 pandemic. In this context, this study aims to investigate the effects of the COVID-19 pandemic on sexual functioning via an internet-based questionnaire in Turkish individuals who declared no medical history of COVID-19. We J o u r n a l P r e -p r o o f thought that reporting the changes in sexual activity during COVID-19 pandemic from such a cosmopolitan country like Turkey might contributed to the body of knowledge on this topic. The participants who declared a COVID-19 history (n=25), those living in the same house with a person who had a COVID-19 history (n=18), those who did not answer all the questions of the survey (n=434), those who declared unrealistic and/or extreme values for the number of sexual intercourse and/or masturbation frequency (e.g. ≥50 in a week) (n=33), and those with any known psychiatric disease (n=28) were excluded from the study (Figure 1) . A total of 1356 participants who met the inclusion criteria were included in the statistical analysis.
The study population was divided into two subgroups based on the population density of the cities in which the individuals lived to evaluate whether population density has any effect on the sexual functions of the participants during the COVID-19 pandemic. Subgroup A includes the participants who live in the cities with a population of over 4,000,000 (Istanbul, Ankara, and Izmir), while Subgroup B includes the rest of the participants who live in the other cities in Turkey with a population of under 4,000,000. The subgroups were compared in terms of changes in the sexual functioning of the participants during the COVID-19 pandemic.
Statistical analysis was performed using the Statistical Package for the Social Sciences Continuous variables were expressed in mean and standard deviation, while categorical variables were expressed in number and frequency. The Student t-test and Pearson chi-square and tests were used wherever possible. A two-sided p value of <0.05 was considered statistically significant.
The mean age of the participants was 33.16 ± 8.31 years. There were 685 (50.5%) females and 671 (49.5%) males. Demographic features, economic and working status, and changes in the sexual functioning of the participants during COVID-19 pandemic are summarized in Table 1 . 26.6% (361) of the participants was health care workers and 66.8% Table 1) .
When the participants were compared according to the decrease in the number of weekly sexual intercourse, no significant difference was observed between age, gender, and body mass index (p>0.05, for each). In contrast, there was a statistically significant difference between the participants according to the decrease in the number of weekly sexual intercourse when they compared in terms of smoking status, alcohol consumption, marital and parental status, being a health care worker, having a regular sexual partner, and the working status during the COVID-19 pandemic (p<0.05, for each) ( Table 2 ). There was also a statistically significant difference in terms of sexual intercourse/masturbation duration and sexual desire status of the participants when they compared according to the decrease in the number of weekly sexual intercourse (p<0.001, for each) ( Table 2 ). There was a statistically significant difference between the participants according to the decrease in the sexual desire when they compared in terms of age, gender, smoking status, marital and parental status, having a regular sexual partner, and the working status during the COVID-19 pandemic (p<0.05, for each).
When the subgroups were compared in terms of sexual parameters, it was observed that there was a statistically significant difference between the groups for changing in the number of sexual intercourse, the number of masturbation, and sexual desire during the COVID-19 pandemic (p<0.05, for each) ( Table 3 ).
Although the study population had a relatively young mean age, our study results showed a decline in sexual functioning during the COVID-19 pandemic. Smoking, being single, not having a child, having a regular sexual partner, and being unemployed in the COVID-19 pandemic was associated with a decline in both sexual intercourse frequency and sexual desire. Age and gender were not associated with a decline in the mean number of sexual intercourse, however, being older and a woman was associated with a decline in sexual desire. In addition to that, living in a metropolitan area is associated with a decline in both sexual intercourse frequency and sexual desire during the COVID-19 pandemic according to our study results. This difference may be attributed to the fact that prevention rules (selfisolation, social distancing, wearing a mask, and curfew, etc.) for disease transmission during J o u r n a l P r e -p r o o f the pandemic would be applied a bit stricter in these crowded cities when compared to the rural areas. In addition, higher COVID-19 cases reported in big cities may have affected individuals' sexuality.
Many studies have reported that frequent sexual intercourse is beneficial to psychological health, improves quality of life and reduces the risk for certain cancers and deadly coronary diseases. 16, 17 In addition, a UK-based study reported that increased sexual activity was associated with a greater enjoyment of life. 18 In light of these data, our study results suggest that the quality and enjoyment of the life of the participants was negatively affected by the COVID-19 pandemic.
In a study with 868 participants which was conducted in Britain during the COVID-19 pandemic, being sexually active, which was defined as having at least one sexual intercourse per week, was related to being a young male, being married or in a domestic partnership, consuming alcohol and practicing self-isolation/social distancing for a high number of days. 10 Similarly, alcohol consumption, marital status, having a regular sexual partner, and being a woman was associated with worsening sexual functions according to our study results during the COVID-19 pandemic. Interestingly, in our study population, the mean number of sexual intercourse tended to decrease while the mean number of masturbation had increased values when compared to pre-pandemic period. These results might suggest that individuals were afraid of disease transmission during sexual intercourse and preferred to satisfy themselves in terms of sexuality without needing a partner.
In a China-based study which was evaluated the changes in sexual behaviours during the COVID-19 pandemic, 37% of the participants reported a decrease in overall sexual frequency. 12 In this study, the authors reported that age, partner relationship, and sexual desire were closely related to sexual frequency. In our study, no statistically significant relationship was found between age and a decline in sexual intercourse frequency, while there was a statistically significant relationship between age and a decline in sexual desire. The participants who declared a decline in sexual desire had a higher mean age than those who did not declare. One of the important findings of our study was that people living in big metropolitan areas suffered a decline both in sexual intercourse frequency and sexual desire during the COVID-19 pandemic. This may be due to a hesitation for being sexually active in big metropolitan areas with a higher population density where the COVID-19 cases were more common. We think it would be valuable for sexual health professionals to focus on this J o u r n a l P r e -p r o o f issue since it seems health care workers affected less in terms of a decline in sexual intercourse frequency.
In contrast to current knowledge on this topic, Yuksel et al. 11 reported an increased frequency of sexual intercourse and sexual desire in females during the COVID-19 pandemic.
The patient population in this study was firstly evaluated for the relationship between urinary incontinence and sexual functions 6 to 12 months ago. It is a well-known fact that urinary incontinence has a negative effect on sexual functions in females and the treatment of urinary incontinence can improve sexual functions. 19, 20 The reason for the inconsistent results may be that this patient population was treated for urinary incontinence, therefore it seems logical their FSFI scores were better when compared to their previous results. In another study from Italy, which was evaluated the sexual functions and quality of life in reproductive-age women during the COVID-19 pandemic, decreased FSFI scores were observed similar to our study results. 21 Working outside the home, university education level, and parity ≥1 were reported as independent risk factors for lower FSFI scores. 21 Although there is no proven relationship between unemployment and sexual activity, it is well known that unemployment increases the risk of depression. 22, 23 Both the effects of the global health crisis and the psychological problems caused by unemployment may have been reflected in the results of the present study. Unfortunately, we did not evaluate the anxiety and/or depression status of the participants by validated questionnaires. In fact, our aim was to facilitate filling the survey by participants in these unexpected hard times like the COVID-19 pandemic. In this context, we chose to exclude the participants who had a known psychiatric disease from the study. Therefore, we can not give any additional information between the psychiatric status of an individual and sexual functions of participants during the COVID-19 according to our study results. This might be an interesting topic for further research.
This study has some potential limitations. First, all subdomains of the international validated scales for examining sexual functions such as IIEF and FSFI were not evaluated.
Second, we did not evaluate the anxiety and/or depression status of the participants by validated questionnaires such as Beck Anxiety/Depression Inventory, and State and Trait Anxiety Inventory, etc. It is worth to mention, self-reporting of psychiatric disorders via an internet-based questionnaire might have led to selection bias. In addition, sexual intercourse frequency and sexual desire perception of the individuals might be changed during the COVID-19 pandemic. Therefore, it is also worth to mention, due to the self-reporting of sexual functioning might have led to recall bias. Unfortunately, our study results insufficient J o u r n a l P r e -p r o o f to discriminate the reasons for how COVID-19 distress mediated among the individuals (fear of contagion, depressed mood, social stressors exacerbated by the pandemic, etc.). Finally, the medical history of COVID-19 disease was not evaluated by an objective test like PCR.
Nonetheless, fear of COVID-19 disease transmission is still common in the public so that we do not think this situation was affected our study results. However, this study was conducted with a higher number of participants and investigated a wide range of variables compared to previous studies. Therefore, our study results might contribute to the body of knowledge on changing in sexual functions of the individuals during the COVID-19 pandemic period.
Although the population in this study had a relatively young mean age, the results showed a decline in sexual functioning during the COVID-19 pandemic period. The negative effects of the COVID-19 pandemic on sexual health were observed in our study population.
Smoking, being single, not having a child, having a regular sexual partner, and being unemployed in the COVID-19 pandemic was associated with a decline in both sexual intercourse frequency and sexual desire. Living in a metropolitan area is associated with a decline in both sexual intercourse frequency and sexual desire during the COVID-19 pandemic. We believe that our study results can be used to raise public awareness on the importance of sexual health, which is linked to the quality of life, during the COVID-19 pandemic.
The authors declare no conflict of interest.
J o u r n a l P r e -p r o o f 