==== Front PLoS One PLoS One plos PLoS ONE 1932-6203 Public Library of Science San Francisco, CA USA 10.1371/journal.pone.0268079 PONE-D-21-17508 Research Article Biology and Life Sciences Psychology Emotions Social Sciences Psychology Emotions People and Places Population Groupings Ethnicities European People Italian People Medicine and Health Sciences Medical Conditions Infectious Diseases Viral Diseases Covid 19 Medicine and Health Sciences Epidemiology Pandemics Research and Analysis Methods Research Design Survey Research Questionnaires Medicine and Health Sciences Medical Conditions Disabilities Medicine and Health Sciences Epidemiology Quarantines Medicine and Health Sciences Public and Occupational Health Behavioral and Social Aspects of Health The sexual experience of Italian adults during the COVID-19 lockdown Sexual experience during the COVID-19 https://orcid.org/0000-0001-5681-0633 Federici Stefano Conceptualization Data curation Investigation Methodology Supervision Writing – original draft Writing – review & editing 1 2 * Lepri Alessandro Data curation Formal analysis Methodology Writing – original draft 1 https://orcid.org/0000-0002-6366-7959 Castellani Mencarelli Alessandra Data curation Formal analysis Methodology Writing – original draft Writing – review & editing 1 2 Zingone Evel Data curation Formal analysis Methodology Writing – original draft 3 De Leonibus Rosella Conceptualization Investigation Supervision Writing – review & editing 3 Acocella Anna Maria Conceptualization Investigation Methodology Supervision 3 https://orcid.org/0000-0002-3188-2590 Giammaria Adriana Conceptualization Investigation Methodology 4 1 Department of Philosophy, Social & Human Sciences and Education, University of Perugia, Perugia, Italy 2 Myèsis, Research and Development Company, Rome, Italy 3 Expressive Gestalt Psychotherapy Institute of Perugia, Perugia, Italy 4 Independent Researcher, Udine, Italy Jonason Peter Karl Editor University of Padova, ITALY Competing Interests: The authors have declared that no competing interests exist. * E-mail: maldonadoerica@example.com 5 5 2022 2022 5 5 2022 17 5 e026807927 5 2021 21 4 2022 © 2022 Federici et al 2022 Federici et al https://creativecommons.org/licenses/by/4.0/ 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. 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. The authors received no specific funding for this work. Data AvailabilityAll 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. (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. OutbreaksCOVID-19 Data Availability 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. (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. ==== Body pmcIntroduction 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 system. 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 subjects 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 government 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 interventions 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 information pertaining to the disease [4, 6]. Moreover, feelings of isolation, abandonment, and stigmatization 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 outbreak and related restrictions [3, 9–12] 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 outcome [7, 8, 10–12]. 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 status by applying behaviors to protect oneself and others, taking a positive attitude toward the overall situation, and seeking distractions in daily activities [6, 8, 10–12]. For instance, the use 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 communicative 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 relationships, access to healthcare and treatment, and the sexual and reproductive rights of all individuals. 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 Döring [16] on recent global media narratives (print, radio, and television, Facebook, YouTube, Instagram, and Twitter) and scientific observations and predictions 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. Döring [16] stated that it is gratifying that issues of sexual and reproductive health and rights have entered mainstream media content so fast. It is noteworthy 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 [18–20]. Other positive effects were found by a group of Southeast Asian researchers [21] on the frequency 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 happiness 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 Chinese 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 sexual 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 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 contraception 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 behaviors (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 experiences—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, implications, 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 Panzeri 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 Italian 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 sexuality might have different impacts on sexual arousal and desire. In summary, we hypothesize positive relationships between the following factors: Negative feelings related to anxiety and depression might affect sexual interest and satisfaction, leading to a more conscious way of experiencing sexual life and habits; Restrictions on participation and limitations on activities might affect the frequency and perceived quality of sexual relations; Changes in sexual intercourse and masturbatory activities may have occurred with the implementation of sexual tools and toys; 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 Italian on the following five topics: 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."); desire, arousal, and fantasies ("How did you do with your sexual desire and arousal? Have you noticed a change in your erotic fantasies?"); 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?"); 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)?"); 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 responses to maldonadoerica@example.com. 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 version 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 eliminating 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 section 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) disability/nondisability of the respondent, and (xii) disability/nondisability of child(ren). The section 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 relationship 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 following 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; sociodemographic 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 platform, and used by researchers for data processing. The questionnaire could be completed in an estimated time of 20 minutes. 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, frequencies, 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 conducted 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 Document 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 (sexual activity; desire, arousal, and fantasies; masturbation; use of sexual aids; awareness of sexuality). 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 frequency of the same stem among all 2,315 tweets gathered. Given a collection C of documents d, the TF-IDF value for each term t in a document d ∈ C is calculated as: TF‐IDF(t,d,C)=TF(d,t)*IDF(t,C), where TF (d, t) indicates the number of times a target term t appears in document d, and IDF is equal to log(N/n), where N indicates the number of documents in C and n the number of documents where t is used. In this study case, the TF part of the formula, the collection C is the total number of documents (C = 5), the term t corresponds to each of the roots (e.g., "abbracci*"), and the document d is 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, N is equal to the number of open-ended questions (N = 5) and n is 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 (S2–S5 Tables). For the choice of cluster solution (i.e., number of final clusters), the variation in the agglomeration coefficient was observed (S6–S9 Tables). This 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 number 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 participants 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 disability, 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 participants (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 quintile (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 collected 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. 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/femininity" (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 significantly 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, turning 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 wonderful") 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 partner") obtaining the lowest mean score (.40). Sex differences on SMQ scales A t-test was computed to investigate the effect of the independent 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. 10.1371/journal.pone.0268079.t001 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 -2042885767 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 -2042885767 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 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 respondents through a five-point Likert-type scale anchored by 1 (never) to 5 (always). Only the variable "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 maldonadoerica@example.com. As shown in Table 2, significant differences in values among 17 items were found. 10.1371/journal.pone.0268079.t002 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 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. 10.1371/journal.pone.0268079.t003 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 A chi-square test was computed on the ER scale. As displayed in Table 4, significant differences in values among 12 items were found. 10.1371/journal.pone.0268079.t004 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 Qualitative analysis of the five open questions Before proceeding with the qualitative analysis, the authors (ACM and EZ) evaluated the pertinence of responses to the five questions. In agreement with all authors, the evaluators adopted 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 people, 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 collected 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. 10.1371/journal.pone.0268079.t005 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) Suffer* 6 .00248 1.60944 .00399 Calm* 8 .00330 .51083 .00169 Depress* 8 .00330 .91629 .00303 Relax* 18 .00743 .22314 .00166 Asexual* 4 .00165 1.60944 .00266 Passion* 17 .00702 .22314 .00157 Repress* 4 .00165 1.60944 .00266 See* 4 .00165 .91629 .00151 Listless* 4 .00165 1.60944 .00266 Affect* 7 .00289 .51083 .00148 Intens* 26 .01074 .22314 .00240 Abstinence 7 .00289 .51083 .00148 Nervous* 6 .00248 .91629 .00227 Satisf* 15 .00620 .22314 .00138 Anxi* 22 .00909 .22314 .00203 Surrender* 2 .00083 1.60944 .00133 Comfort* 3 .00124 1.60944 .00199 Contrasting 2 .00083 1.60944 .00133 Confused 3 .00124 1.60944 .00199 Impotence 2 .00083 1.60944 .00133 Innovativ* 3 .00124 1.60944 .00199 Unwanted 2 .00083 1.60944 .00133 Loneliness 9 .00372 .51083 .00190 Insatiable 2 .00083 1.60944 .00133 Happy* 5 .00207 .91629 .00189 Argu* 2 .00083 1.60944 .00133 Melancholy* 5 .00207 .91629 .00189 Reinvent* 2 .00083 1.60944 .00133 Frustr* 20 .00826 .22314 .00184 Relief 2 .00083 1.60944 .00133 Sad* 20 .00826 .22314 .00184 Open-Ended Question 2 (N = 7) Dream* 13 .00926 .51083 .00473 Transgress* 3 .00214 .91629 .00196 See* 4 .00285 .91629 .00261 Extreme* 3 .00214 .91629 .00196 BDSM 4 .00285 .91629 .00261 Intens* 9 .00641 .22314 .00143 Variety 2 .00142 1.60944 .00229 Open-Ended Question 3 (N = 10) Privacy 8 .00806 .51083 .00412 Relax* 10 .01007 .22314 .00225 Shower 3 .00302 .91629 .00277 Calm* 4 .00403 .51083 .00206 Loneliness 5 .00504 .51083 .00257 Date* 2 .00201 .91629 .00185 Fatigue* 5 .00504 .51083 .00257 Movie* 2 .00201 .91629 .00185 Intens* 11 .01108 .22314 .00247 Leisure 2 .00201 .91629 .00185 Open-Ended Question 4 (N = 12) Vibrator* 13 .00727 .51083 .00372 YouPorn 4 .00224 .91629 .00205 Movie* 7 .00392 .91629 .00359 Whatsapp 2 .00112 1.60944 .00180 Photo* 27 .01511 .22314 .00337 Chat 2 .00112 1.60944 .00180 Webcam 6 .00336 .91629 .00308 Lubricant 2 .00112 1.60944 .00180 Cell phone* 3 .00168 1.60944 .00270 Audio* 12 .00672 .22314 .00150 Stories 5 .00280 .91629 .00256 Pornhub 5 .00280 0,2042885767 Open-Ended Question 5 (N = 16) Underst* 4 .00221 1.60944 .00356 Affect* 8 .00443 .51083 .00226 Know* 12 .00664 .51083 .00339 Kiss* 4 .00221 .91629 .00203 Emotion* 6 .00332 .91629 .00304 Attract* 7 .00387 .51083 .00198 Foreplay 6 .00332 .91629 .00304 Grant* 2 .00111 1.60944 .00178 Bonding 6 .00332 .91629 .00304 Imperfect* 2 .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 Love* 19 .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. First question: An overview of sexual activity during the lockdown For the first question ("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). 10.1371/journal.pone.0268079.g001 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). 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." 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: "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) "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) 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 frustration, as an impediment." (Man, 28 years old) The third cluster indicates the calming and relaxing role of masturbation during the quarantine 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 question ["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)?"] exceeded the first standard 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 participants 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) "Thanks to YouPorn's offering, I initially viewed pornographic content often but later I preferred 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
{'source': 'PubMedDataset'}