JMIR Preprints Li et al

Impact of the COVID-19 pandemic on sexual and

reproductive health: A Cross-sectional Online Survey

Guanjian Li, Dongdong Tang, Bing Song, Chao Wang, Shen Qunshan, Chuan Xu,
Hao Geng, Huan Wu, Xiaojin He, Yunxia Cao

Submitted to: Journal of Medical Internet Research

on: June 02, 2020

Disclaimer: © The authors. All rights reserved. This is a privileged document currently under peer-review/community
review. Authors have provided JMIR Publications with an exclusive license to publish this preprint on it's website for
review purposes only. While the final peer-reviewed paper may be licensed under a CC BY license on publication, at this
stage authors and publisher expressively prohibit redistribution of this draft paper other than for review purposes.

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JMIR Preprints Li et al

Table of Contents

Original Manuscript....................................................................................................................................................................... 4
Supplementary Files..................................................................................................................................................................... 19
Figures ......................................................................................................................................................................................... 20
Figure 1...................................................................................................................................................................................... 21

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JMIR Preprints Li et al

Impact of the COVID-19 pandemic on sexual and reproductive health: A

Cross-sectional Online Survey

Guanjian LiMD, ; Dongdong TangMD, ; Bing SongMD, PhD, ; Chao WangMD, ; Shen QunshanMD, ; Chuan
XuMD, ; Hao GengMD, ; Huan WuMD, PhD, ; Xiaojin HeMD, PhD, ; Yunxia CaoMD, PhD,

Corresponding Author:
Yunxia CaoMD, PhD,
Phone: +8615395104659
Fax: 86 055165161058
Email: caoyunxia6@126.com

Abstract

Background: In the past few months, the coronavirus disease (COVID)-19 pandemic has caused extensive economic and social
damage.
Objective: The purpose of this study was to assess the impact of (COVID)-19 pandemic and related containment measures on
sexual and reproductive health.
Methods: From May 1 to 5, 2020, we recruited 3,500 young Chinese online. Aspects of sexual and reproductive health obtained
using a study-specific questionnaire.
Results: Due to the COVID-19 pandemic and related containment measures, about 31% (n=298) participants reported a
deterioration of partner relationship during the pandemic; 22% (n=212) participants reported a decrease in sexual desire; 41%
(n=396) participants experienced a decrease in the sexual frequency; 30% (n=291) participants reported an increase in the
frequency of masturbation and 20% (n=192) participants reported a decrease in consumed alcohol before or during sexual
activities. COVID-19 also caused disruption in reproductive health services such as prenatal and postnatal care, safe childbirth,
safe abortion, contraception and the management of sexually transmitted infections.
Conclusions: Our results show that due to COVID-19 pandemic and related containment measures, many young participants
have wide ranging issues affecting their sexual and reproductive health. Measures should be put in place to safeguard the sexual
and reproductive health of young people during this pandemic.
(JMIR Preprints 02/06/2020:20961)
DOI: https://doi.org/10.2196/preprints.20961

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Original Manuscript

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JMIR Preprints Li et al

Original Paper
Guanjian Li1,2, MD; Dongdong Tang1,2, MD; Song Bin3,4, M.D, PhD; Chao Wang1,5, MD; Qunshan
Shen1,5, MD; Chuan Xu1,2, MD; Hao Geng1,2, MD; Huan Wu3,4, M.D, PhD; Xiaojin He3,4, M.D, PhD;
Yunxia Cao1,2, M.D, PhD
1
Reproductive Medicine Center, Department of Obstetrics and Gynecology, the First Affiliated
Hospital of Anhui Medical University, Anhui, China
2
National Health Commission Key Laboratory of Study on Abnormal Gametes and Reproductive
Tract, Anhui, China
3
Key Laboratory of Population Health Across Life Cycle, Ministry of Education of the People’s
Republic of China, Anhui, China
4
Anhui Province Key Laboratory of Reproductive Health and Genetics, Anhui, China.
5
Biopreservation and Artificial Organs, Anhui Provincial Engineering Research Center, Anhui
Medical University, Anhui, China

X.H. and Y.C. contributed equally to this work.

Corresponding Author:
Yunxia Cao, M.D, PhD
The First Affiliated Hospital of Anhui Medical University
81 Meishan Road 230000, Hefei, Anhui, China
Phone: 86 15395104659
Email: caoyunxia6@126.com

Impact of the COVID-19 pandemic on sexual and reproductive

health: A Cross-sectional Online Survey
Abstract
Background: In the past few months, the coronavirus disease (COVID)-19 pandemic has caused
extensive economic and social damage.
Objective: The purpose of this study was to assess the impact of (COVID)-19 pandemic and related
containment measures on sexual and reproductive health.
Methods: From May 1 to 5, 2020, we recruited 3,500 young Chinese online. Aspects of sexual and
reproductive health obtained using a study-specific questionnaire.
Results: Due to the COVID-19 pandemic and related containment measures, about 31% (n=298)
participants reported a deterioration of partner relationship during the pandemic; 22% (n=212)
participants reported a decrease in sexual desire; 41% (n=396) participants experienced a decrease in
the sexual frequency; 30% (n=291) participants reported an increase in the frequency of
masturbation and 20% (n=192) participants reported a decrease in consumed alcohol before or
during sexual activities. COVID-19 also caused disruption in reproductive health services such as
prenatal and postnatal care, safe childbirth, safe abortion, contraception and the management of
sexually transmitted infections.
Conclusions: Our results show that due to COVID-19 pandemic and related containment measures,
many young participants have wide ranging issues affecting their sexual and reproductive health.
Measures should be put in place to safeguard the sexual and reproductive health of young people
during this pandemic.

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Keywords: COVID-19; novel coronavirus; sexual behaviour; sexual health; reproductive health

Introduction
In the past few months, the coronavirus disease (COVID-19) pandemic and related containment
measures have caused extensive economic and social damage to many countries, including China
and the United States[1-3].

From February to April, all schools and many businesses in China were closed. Everyone was
required to implement "social distance", and the government restricted travel, parties and outdoor
activities[4, 5]. In addition, many provinces have implemented guidelines to reduce pressure on the
healthcare system, include suspension of non-emergency medical care and elective surgeries[6].
These disruptions have had a significant impact on the physical and mental health, and quality of life
of individuals[7, 8].

So far, there is little report about the effects of COVID-19 on sexual and reproductive health[9, 10].
Sexually active young people may be more vulnerable, and various aspects of their reproductive and
sexual health may be affected. These include sexual relationships, sexual behaviors, health care
access and reproductive rights. On the one hand, many young people are facing economic and
psychological pressure caused by losing their jobs or suspension of schooling due to evacuation. On
the other hand, separation from sexual partners and lack of access to comprehensive health care
services may increase the risk of experiencing negative sexual health outcomes.

To better understand how sexual and reproductive health was affected during the COVID-19
pandemic, this study conducted a series of preliminary analyses using data from an internet-based
survey among Chinese youth.

Methods
Participant Recruitment
This cross-sectional online survey was conducted on the research platform established and managed
by Questionnaire Star. Questionnaire Star is an online questionnaire survey platform, which can
spread health knowledge to the general population and has 82,000,000 users in China. A 20-item
survey was constructed to assess changes in people's sexual and reproductive health during the
COVID-19 pandemic. Between May 1 and 5, 2020, 3,500 participants from China received links and
emails from Wechat (similar to “WhatsApp”) or Weibo (similar to “Twitter”) software, inviting them
to participate in a confidential 20-minute online survey about sexual and reproductive health on the
Questionnaire Star platform.
Data Collection
Multiple reminders were sent through messaging software, and the invitation letter stated that the
current survey was for participants who were sexually active. Approximately $5 was offered as
incentives for participants who completed the questionnaire. A missed answer reminder component
prompted participants about the unfinished project in real time, and incomplete questionnaires were
not submitted to the system.

Of those invited, 35.7% of individuals completed the survey (n=1249). Before entering the online

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survey system, all participants reviewed the electronic consent page and approved online. The
research was approved by the Ethics Review Committee of Anhui Medical University for research
and publication purposes.

The self-administered questionnaire collected data on age, race, education, current financial status,
SARS-CoV-2 viral infection of themselves and those around them, self-rated health, accommodation
before and during the pandemic, medical and surgical history of the participants and their partners,
pregnant (if female), whether experienced abortion or not, sexual orientation, whether in an exclusive
relationship, partnership, sexual desire, frequency of sexual intercourse, sexual satisfaction,
consumed alcohol before or during sexual activities, frequency of masturbation, frequency of use of
pornographic content, proportion of condom use (in sexual encounters), risky sexual behavior, and
sexually transmitted diseases. Symptoms were assessed for "during the COVID-19 pandemic".

Participants were included in the current analysis if they were between 15 and 35 years old, live in
China, and reported penetrative sex (defined as a penis inserted into the vagina or anus) at least once
at any time in the past six months （ n=1076 ） . Foreigners (n=11), homosexual or bisexual individuals
(n=16), participants who themselves or their partners had contact with someone with COVID-19
disease (n=2), who themselves or their partners have systemic diseases (n=23) and other serious
conditions that led to sexual dysfunction (n=10) were excluded because their experience might be
different, and their representation in the sample was small.

Due to the complexity of physiological conditions and interference factors, sexually transmitted
diseases (n=8), pregnancy status (n=25) and recent abortions (n=6) were also excluded from the
sexual health analysis, but the COVID-19 related impacts on several aspects of their reproductive
health and rights were measured. Participants who reported pregnancy were asked "Have you
experienced any difficulties in obtaining maternal care or delivery services due to COVID-19 or the
plans to manage it?"; Participants who reported recent abortion were asked "Have you experienced
any difficulties in obtaining abortion or post-abortion care due to COVID-19 or the plans to manage
it?". Participants who reported sexually transmitted diseases were asked "Have you experienced any
difficulties in obtaining medical advice or management due to COVID-19 or the plans to manage
it?"; All participants who answered "yes" were invited to give a specific description of their
difficulties. Apart from that, all participants were asked to fill in a response to "Have you
experienced a shortage of contraceptives during the pandemic?"

Results
User Statistics
A total 967 participants were included in the sexual health analysis. The characteristics of the study
participants are shown in Table 1. The mean age was 26.6±4.86 years (ranges from 16 to 35), and
55.9% (n=541) were male. All the participants were Han Chinese. Of the 967 participants, almost
half reported a recent deterioration of financial situation, and 8% (n=75) reported a poor state of
health status.

COVID-19-related impact on sexual health

COVID-19-related impact on sexual health is summarized in Table 2. About 68.8% (n=665) of the
students included in the analysis reported that they were currently in an exclusive relationship. There
were significant differences in sexual health and outcomes between students in an exclusive
relationship and the ones that not in an exclusive relationship.

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Of the participants included in the analysis, 31% (n=298) reported partner relationship deterioration
during the pandemic, 22% (n=212) reported a decrease in sexual desire, 41% (n=396) experienced a
decrease in sex frequency, and 20% (n=192) reported a recent decrease in consumed alcohol before
or during sexual activities. In addition, 10% (n=94) participants have reported a decrease in risky
sexual behavior.

With regard to frequency of masturbation, 30% (n=291) of participants reported an increase in

masturbation during the pandemic, while 23% (n=227) participants reported an increase in the use of
pornography.

COVID-19 related impacts on reproductive health

COVID-19 related impacts on reproductive health matters are shown in figure 1. Nine participants
who were pregnant reported having difficulties in accessing maternal care or delivery services due to
COVID-19 or its management plan. These difficulties included shortage of hospital beds available
for childbirth, restrictions on the number of people accompanying pregnant women for examination
or hospitalization, and failure to get timely prenatal examination.

Participants who reported recent abortion mainly reported difficulties in making appointments for
doctors and surgeries. Three participants who reported sexually transmitted diseases experienced
difficulties in obtaining medical management, mainly booking of doctor’s appointment and access to
medicines such as antibiotics.

In the current study, condom usage was unchanged due to COVID-19. However, 8.9% (n=86) of
participants said they had experienced a shortage of contraceptives.

Table 1. Demographic participant characteristics (N=967).

Items Total Male Female F P
(N=967) (N=541) (N=426)
Age (year)
15-25 389(0.40) 229(0.43) 160(0.36) 2.256 0.133
25-35 578(0.60) 312(0.57) 266(0.64)
Education level
college or below 491(0.47) 263(0.45) 228 (0.50) 3.103 0.212
bachelor 405(0.42) 240(0.44) 165(0.40)
master or above 71(0.10) 38(0.11) 33(0.10)
Current financial
situation fine 221(0.23) 134(0.25) 87(0.20) 21.148 0.001
unchanged 330(0.34) 151(0.28) 179(0.42)
deteriorate 416(0.43) 256(0.47) 160(0.38)
Self-rated health
fine 282(0.29) 154(0.28) 128(0.30) 2.755 0.252
general 610(0.63) 351(0.65) 259(0.61)
poor 75(0.08) 36(0.07) 39(0.09)
Accommodation
(Before pandemic) campus dormitory 416(0.43) 229(0.42) 187(0.44) 0.514 0.773

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house with parents 348(0.36) 200(0.37) 148(0.35)

house without parents 203(0.21) 112(0.21) 91(0.21)
Accommodation
(During pandemic) house with parents 706(0.73) 403(0.74) 303(0.71) 1.369 0.242
house without parents 261(0.27) 138(0.26) 123(0.29)

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Table 2. COVID-19 related impacts on sexual health (N=967).

Items Total In an exclusive Not in an exclusive F P
(N=967) relationship relationship (N=302)
(N=665)
Partner relationship
fine 205(0.21) 133(0.20) 72(0.24) 40.757 0.001
general 464(0.48) 285(0.43) 179(0.59)
deteriorate 298(0.31) 247(0.37) 51(0.17)
Sexual desire
increase 126(0.13) 86(0.13) 40(0.13) 42.522 0.001
unchanged 629(0.65) 395(0.59) 234(0.77)
reduce 212(0.22) 184(0.28) 28(0.09)
Sexual frequency
increase 223(0.23) 175(0.26) 48(0.16) 153.383 0.001
unchanged 348(0.36) 304(0.46) 44(0.15)
reduce 396(0.41) 186(0.28) 210(0.70)
Sexual satisfaction
increase 115(0.12) 54(0.08) 61(0.20) 33.188 0.001
unchanged 709(0.73) 498(0.75) 211(0.70)
reduce 143(0.15) 113(0.17) 30(0.10)
Consumed alcohol before or
during sexual activities
increase 58(0.06) 44(0.07) 14(0.05) 132.014 0.001
unchanged 717(0.74) 555(0.83) 162(0.54)
reduce 192(0.20) 66(0.10) 126(0.42)
Frequency of masturbation
increase 291(0.30) 189(0.28) 102(0.34) 21.993 0.001
unchanged 261(0.27) 206(0.31) 55(0.18)
reduce 106(0.11) 78(0.12) 28(0.09)
never 309(0.32) 192(0.29) 117(0.39)
Frequency of pornography
use
increase 227(0.23) 123(0.19) 104(0.34) 30.706 0.001
unchanged 330(0.34) 242(0.36) 88(0.29)
reduce 115(0.12) 89(0.13) 26(0.09)
never 295(0.31) 211(0.32) 84(0.28)
Proportion of condom use
increase 97(0.10) 61(0.09) 36(0.12) 5.250 0.072
unchanged 735(0.76) 501(0.75) 234(0.77)
reduce 135(0.14) 103(0.16) 32(0.11)
Risky sexual behaviors
increase 4(0.01) 3(0.01) 1(0.01) 18.873a 0.001
unchanged 76(0.08) 55(0.08) 21(0.07)
reduce 94(0.10) 46(0.07) 48(0.16)
never 793(0.82) 561(0.84) 232(0.77)
Chi-square test was performed between exclusive relationship group and non- exclusive relationship group; aThe

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"increased" data were merged into "unchanged".

Figure 1. COVID-19 related impacts on reproductive health and rights.

Discussion
Principal Results
The COVID-19 pandemic and related containment measures have widely impacted personal health
and health care systems. Our study provides preliminary evidence on the direct impact of these
factors on sexual and reproductive health.

Our results show that many young people had decreased sexual desire and decreased frequency of
sexual intercourse due to COVID-19. In addition, a relatively large number of participants reported a
significant reduction in alcohol-related sexual consequences and risky sexual behavior. Increased
family supervision or interference, overall smaller personal freedom, poor mental health and
partnership are likely contributors to the changes in sexual behavior.

We found that many participants reported an increase in masturbation frequency and use of
pornography. This may have helped some people achieve sexual satisfaction without risk. However,
it should be realized that high-frequency pornography use may be negatively impacting their sexual
function and quality of life[11]. High frequency of masturbation rate is also related to the decrease in
life and sexual satisfaction[12].

Our research also provides preliminary evidence of certain interference or interruption of

reproductive health services caused by COVID-19, such as prenatal and postnatal examination, safe
delivery, safe abortion, contraception and the management of sexually transmitted infections. In
addition, we found that even in a country with a sound drug supply system such as China,

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contraceptives in some areas were out of stock and or in short supply during the pandemic.

Limitations
The limitations of the current study include the use of self-designed questionnaires and reliance upon
self-reporting and the constantly changing prevalence of COVID-19, which means that our findings
only provided cross-sectional data based on local convenient samples. Further large-scale
longitudinal studies are needed to understand the impact of the epidemic on sexual and reproductive
health in different countries and regions.
Conclusions
COVID-19 pandemic and related containment measures affects young people's sexual health, and
targeted interventions are needed to improve sexual their health and well-being. In addition, as the
whole society is currently focusing on the response to COVID-19, the health care system providing
basic reproductive health services and supply chain operations have been disrupted. Basic
reproductive health and rights should be more respected and protected during the pandemic.

Acknowledgements
The authors acknowledge all participants and health providers who participated in this study. This
work was supported by the Non-profit Central Research Institute Fund of Chinese Academy of
Medical Sciences (grant number 2019PT310002).
Conflicts of Interest
None declared.

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Supplemental questionnaire
（The English version of the questionnaire）

Your gender:
Your age:
Your ethnicity:

1. What is your education level?

A. college or below
B. bachelor
C. master or above

2. What was your current financial situation during the COVID-19 pandemic?
A. Improved
B. Unchanged
C. Deteriorate

3. In general, would you say your health is?

A. fine

B. general

C. poor

4. (1) Have you or your partner ever had a COVID-19 disease?

A. Yes

B. No

4. (2) Have you or your partner ever had contact with a person with a COVID-19 disease?

A. Yes

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B. No

5. What was your accommodation type before the COVID-19 pandemic?

A. campus dormitory
B. house with parents
C. house without parents

6. What was your accommodation type during the COVID-19 pandemic?

A. house with parents

B. house without parents

7. Have you had sex in the past six months?

A. Yes
B. No

8. Are you currently in an exclusive relationship where you are emotionally involved during the

COVID-19 pandemic?

A. Yes
B. No

9. What is your sexual orientation?

A. Heterosexual
B. Bisexual
C. Homosexual
D. Asexual

10. Are you in the following state (multiple choice)

A. Serious systemic diseases (Respiratory system, digestive system, circulatory system, nervous
system, motor system, urogenital system, endocrine system, immune system, cancer, Mental
disorders, etc)
B. Sexually transmitted disease (Syphilis, AIDS, condyloma, neisseria gonorrhoeae, chlamydial

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trachomatis genital infection, nongonococcal urethritis, others)

C. Other serious conditions that lead to sexual dysfunction
D. Pregnant or recent childbirth
E. Recent abortion
F. Any important medical histories and surgical histories that need to be disclosed (detail
information)

11. How about your partner relationship during the COVID-19 pandemic?
A. Fine
B. General
C. Deteriorate

12. How about your sexual desire during the COVID-19 pandemic?
A. Increased
B. Reduced
C. Unchanged

13. How about the frequency of your sexual behavior during the COVID-19 pandemic?
A. Increased
B. Reduced
C. Unchanged

14. How about your sexual satisfaction during the COVID-19 pandemic?
A. Increased
B. Reduced
C. Unchanged

15. How about your consumed alcohol before or during sexual activities during the COVID-19
pandemic?
A. Increased
B. Reduced
C. Unchanged

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16. How did your masturbation frequency change during the pandemic?
A. Increased
B. Reduced
C. Unchanged
D. Never had

17. During the COVID-19 pandemic, how did the frequency of your pornography use change?
A. Increased
B. Reduced
C. Unchanged
D. Never had

18. How did your condom use proportion (in sexual encounters) change during the pandemic?
A. Increased
B. Reduced
C. Unchanged

19. How is your risky sexual behaviors (defined as inconsistent condom use, "casual" sexual
partnerships, or multiple sexual partnerships) during the COVID-19 pandemic?
A. Increased
B. Reduced
C. Unchanged
D. Never had

20. Have you experienced a shortage of contraceptives during the pandemic?

A. Yes
B. No

(Optional questions, for pregnancy or recent childbirth) Have you experienced any difficulties in
obtaining maternal care or delivery services due to COVID-19 or the plans to manage it?
A. Yes
( Detail information: )
B. No

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(Optional questions, for recent abortion) Have you experienced any difficulties in obtaining abortion
or post-abortion care due to COVID-19 or the plans to manage it?
A. Yes
( Detail information: )
B. No

(Optional questions, for who have sexually transmitted diseases) Do you experienced any difficulties
in obtaining medical advice or management due to COVID-19 or the plans to manage it?
A. Yes
( Detail information: )
B. No

https://preprints.jmir.org/preprint/20961 [unpublished, non-peer-reviewed preprint]

JMIR Preprints Li et al

Supplementary Files

https://preprints.jmir.org/preprint/20961 [unpublished, non-peer-reviewed preprint]

JMIR Preprints Li et al

Figures

https://preprints.jmir.org/preprint/20961 [unpublished, non-peer-reviewed preprint]

 JMIR Preprints Li et al

COVID-19 related impacts on reproductive health and rights.

https://preprints.jmir.org/preprint/20961 [unpublished, non-peer-reviewed preprint]

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