Abstract

This article is an integral part of the research “Violence in the context of COVID-19: global challenges and vulnerabilities”, which proposes a critical reflection on situations of gender-based violence increased by social distancing protocols, required by the COVID-19 pandemic. Based on a 2020 literature survey, we have analyzed recommendations made by researchers and institutions from different countries around the world, with the aim of systematizing and disseminating strategies to deal with this scenario. The material is organized into two thematic areas, namely: gender policies and intersectoral actions; and strategies to face violence against women and children in the health and social work field. The recommendations are focused on the development of actions by States/governments, service networks and society in general. Part of the recommendations suggest increasing or adapting existing surveillance actions and part of them contribute with creative proposals, guiding promotional and preventive actions at an individual and collective level. The adoption of teleassistance, media campaigns raising awareness that violence is unjustifiable and the development of reporting strategies through signs and codes have been reiterated in the literature.

Key words:
Violence against women; COVID-19; child abuse

Introduction

This article is a part of the research “Violence in the context of COVID-19: global challenges and vulnerabilities” and aims to analyze the recommendations presented by researchers and healthcare institutions on violence against girls and women at the time of the pandemic. Therefore, national and international literature was reviewed in order to systematize the academic production of 2020.

In February 2020, the World Health Organization (WHO) declared COVID-19 as a pandemic. In this scenario, data from the Center for Global Development¹1 Peterman A, O'Donnell M; Palermo T. COVID-19 and violence against women and children: what have we learned so far? Center for Global Development (CGD) 2020; 22 jun. point to a global increase in violence against women and girls, perpetrated especially by family members and intimate partners in the domestic sphere. The isolation at home imposed by the quarantine, although necessary, turned out to be a risky measure for some women. The literature produced has highlighted the forced coexistence of women with possible aggressors, lower income, housework overload, unemployment, alcohol/other drug abuse and access to firearms as factors that potentiate the aggravation of domestic conflicts²2 Vieira PR, Garcia LP, Maciel ELN. The increase in domestic violence during the social isolation: what does it re-veals? Rev Bras Epidemiol 2020; 23:e200033.

3 Marques ES, Moraes CL, Hasselmann MH, Deslandes SF, Reichenheim ME. Violence against women, children, and adolescents during the COVID-19 pandemic: Overview, contributing factors, and mitigating measures. Cad Saude Publica 2020; 36(4):e00074420.^-44 Langeani B, Pollachi N. Menos armas, mais jovens! Violência armada, violência policial e comércio de armas. Rio de Janeiro: Instituto Sou da Paz; 2021..

Based on the increased requests for help in service channels, UN Women⁵5 ONU Mulheres. Acabar com a violência contra as mulheres no contexto do COVID-19 [Internet]. 2020. [acessado 2020 mar 30]. Disponível em: https://www.onumulheres.org.br/noticias/acabar-com-a-violencia-contra-as-mulheres-no-contexto-do-COVID-19/
https://www.onumulheres.org.br/noticias/... has identified that the increase in domestic violence in the world has not been accompanied by an increase in police reports, which have fallen. The closure of several institutions/services limited women’s access to protection networks and reporting channels.

Within this global and complex phenomenon, the association of physical, sexual and psychological violence appears in recurrent and overlapping episodes, to which other forms of aggression⁶6 Guimarães MC, Pedroza RLS. Violência contra a mulher: problematizando definições teóricas, filosóficas e jurídicas. Psicol Soc 2015; 27(2):256-266., which can lead to lethal violence, are added. The United Nations Office on Drugs and Crime⁷7 United Nations Office on Drugs and Crime. Global Study on Homicide 2019. Vienna: ONU; 2019. estimates that 87,000 killings of women occurred in 2017 and 58% were perpetrated by intimate partners or family members. The highest rates have been observed in Africa (3.1 deaths/100,000 inhabitants) and in the Americas (1.6 deaths/100,000 inhabitants).

This framework reiterates that violence against women and girls is a global public health issue, prompting the proposition of strategies focused on helping and protecting victims. However, it is important to highlight that, depending on their race/ethnicity, social class, age, sexuality and disability, the risks of suffering violence are exacerbated. Recent epidemics, such as Zika and Ebola, indicate that health crises exacerbate existing inequalities⁸8 Hall MC, Prayag G, Fieger,P Dyason D. Beyond panic buying: consumption, displacement and COVID-19. J Serv Management 2020; 32(1):113-128.. It is estimated that more than a decade will be needed for poorer women to overcome the devastation generated by the COVID-19 pandemic⁹9 Oxfam. O vírus da desigualdade [Internet]. 2021. [acessado 2023 mar 25]. Disponível em: https://www.oxfam.org.br/o-virus-da-desigualdade/
https://www.oxfam.org.br/o-virus-da-desi... , requiring effective actions to reduce violence. Hence the importance of analyzing proposals from various countries to face it. The production of knowledge about these recommendations can contribute to the improvement of local policies and the capacity to respond to new crises.

Method

The leading question was What were the recommendations aimed at preventing and facing violence against women and girls in the COVID-19 pandemic? For that, an integrative review of national and international literature was carried out based on different databases. When choosing the descriptors, an intersectional perspective, and a broad set of types of violence were considered.

The material collected was submitted to a thematic content analysis¹⁰10 Bardin L. Análise de conteúdo. São Paulo: Edições 70; 2011. and involved: pre-analysis, exploration of the collected material and processing of the results, inferences and interpretation. Based on that, it was possible to establish the thematic axes organizing all the material and guiding the analysis. It is worth clarifying that articles on violence specifically against girls were not found, with the authors having chosen the category of children and adolescents in general.

Results

Were located 14 articles on SciELO, 143 on VHL, 244 on Scopus, 121 on Web of Science and 126 on Pubmed, totaling 648 results. After excluding repetitions, letters and editorials and checking the relevance of the articles, we reached a final collection of 125 studies (Chart 1, available at: https://doi.org/10.48331/scielodata.YENGGN). We have noticed that a considerable part of the articles do not inform the location of the study, working with a broad perspective, predominating studies focused on the United States, Brazil, India and a plurality of other countries.

A reflective reading of the material makes it possible to state that the recommendations are focused on the development of strategies to face the pandemic by States/governments and society in general, which break down into general and more specific policies, aimed at vulnerable groups, such as migrants were, pregnant/postpartum women and the LGBTI+ population. A concern about the development of research, the implementation of support systems, and networks to support women and children who experience situations of domestic violence, is verified. Support for health care professionals also stood out. A significant part is directed towards mental health interventions. The need for cooperation between civil society and governments and adaptations of public security and the judicial system are also mentioned. The adoption of gender perspectives in public policies was also recommended, as the pandemic affects men and women differently.

The main findings are organized in three thematic areas. The first, Adoption of a gender perspective in public policies, addresses broad policies and the importance of applying a gender perspective in the face of inequalities in the context of the pandemic. The second, Networks to Face Violence against Women, is directed towards social work, health care services, justice, and public safety, with an emphasis on call center services. It recommends the promotion of social awareness actions and values the formation of social networks in support of victims. The third, Children and youth care and protection, covers violence against children and adolescents.

Adoption of a gender perspective in public policies

Several articles emphasize the importance of using the gender perspective to address the social disparities that have increased as a result of the pandemic¹¹11 Wenham C, Smith J, Davies SE, Feng H, Grépin KA, Harman S, Herten-Crabb A, Morgan R. Women are most affected by pandemics - lessons from past outbreaks. Nature 2020; 583(7815):194-198.

12 Dahal M, Khanal P, Maharjan S, Panthi B, Nepal S. Mitigating violence against women and young girls during COVID-19 induced lockdown in Nepal: a wake-up call. Global Health 2020; 16(1):84.

13 Gausman J, Langer A. Sex and Gender Disparities in the COVID-19 Pandemic. J Women's Health 2020, 29(4):465-466._-¹⁴14 Moreira LE, Alves JS, Oliveira RG, Natividade C. Women in a pandemic context: a theoretical-political essay about house and warfare. Psicol Soc 2020; 32:e0200144.. For Dahal et al.¹²12 Dahal M, Khanal P, Maharjan S, Panthi B, Nepal S. Mitigating violence against women and young girls during COVID-19 induced lockdown in Nepal: a wake-up call. Global Health 2020; 16(1):84., interventions to reduce gender inequality and its effects should focus on addressing the causes of violence shaped by structural, political, social and economic aspects. Gausman et al.¹³13 Gausman J, Langer A. Sex and Gender Disparities in the COVID-19 Pandemic. J Women's Health 2020, 29(4):465-466. understand that governments should collect gender-disaggregated data on all aspects of the national response, from incidence and mortality rates, social protection and employment schemes, to access to health care services. DeMulder et al.¹⁵15 DeMulder J, Kraus-Perrotta C, Zaidi H. Sexual and gender minority adolescents must be prioritised during the glob-al COVID-19 public health response. Sex Reprod Health Matters 2020; 28(1):1804717. suggest going beyond the cisheteronormative framework that prevails in public health policies, so that data on sexual and gender minorities are accounted for. Moreira et al.¹⁴14 Moreira LE, Alves JS, Oliveira RG, Natividade C. Women in a pandemic context: a theoretical-political essay about house and warfare. Psicol Soc 2020; 32:e0200144. highlight the importance of gender when studying the different aspects of the pandemic and social isolation, also incorporating mental health issues with regard to work and care, remote tasks, free time and institutional responses to the disease.

For Hamadani et al.¹⁶16 Hamadani JD, Hasan MI, Baldi AJ, Hossain SJ, Shiraji S, Bhuiyan MSA, Mehrin SF, Fisher J, Tofail F, Tipu SMMU, Gran-tham-McGregor S, Biggs BA, Braat S, Pasricha SR. Immediate impact of stay-at-home orders to control COVID-19 transmission on socioeconomic conditions, food insecurity, mental health, and intimate partner violence in Bang-ladeshi women and their families: an interrupted time series. Lancet Glob Health 2020; 8(11):e1380-e1389., although the social lockdowns recommended during the pandemic have posed risks to the well-being of women and their families in all social strata, including in rural areas, it is the most vulnerable population that should receive greater attention from governments. Social policies geared towards this population, in order to ensure their survival and thereby reduce violence during the pandemic, are considered strategic actions. Some authors¹⁷17 Marques ES, Moraes CL, Hasselmann MH, Deslandes SF, Reichenheim ME. A violência contra mulheres, crianças e adolescentes em tempos de pandemia pela COVID-19: panorama, motivações e formas de enfrentamento. Cad Saude Publica 2020; 36(4):e00074420.^,1818 Yenilmez MI. The COVID-19 pandemic and the struggle to tackle gender-based violence. J Adult Protect 2020; 22(6):391-399. propose that governments develop actions at different levels to face violence against women and girls, concomitantly with health policies. Yenilmez¹⁸18 Yenilmez MI. The COVID-19 pandemic and the struggle to tackle gender-based violence. J Adult Protect 2020; 22(6):391-399. also advocates intersectoral and networked action, and Stoianova et al.¹⁹19 Stoianova T, Ostrovska L, Tripulskyir G. COVID-19: pandemic of domestic violence. Law Journal 2020; 9(2):111-136. highlight the importance of legislation amendments aimed at tackling the problem of domestic violence.

Farooq et al.²⁰20 Farooq SM, Sachwani SAA, Haider SI, Iqbal AS, Parpio YN, Saeed H. Mental health challenges and psycho-social in-terventions amid COVID-19 pandemic: a call to action for Pakistan. J Coll Physicians Surg Pak 2020; 30(1):S59-S62. recommend supportive actions, for three to six months after social isolation, that include mental health screening services for counseling, along with the provision of basic services and food supply. Gopal²¹21 Gopal DP. Non-COVID-19 general practice and our response to the pandemic. BJGP Open 2020; 4(2):bjgpopen20X101095. points out that more deprived populations have lower life expectancy and need more time to recover from illness compared to less deprived populations. This is the approach adopted by Shammi et al.²²22 Shammi M, Bodrud-Doza MD, Islam AR, Rahman M. Strategic assessment of COVID-19 pandemic in Bangladesh: comparative lockdown scenario analysis, public perception, and management for sustainability. Environ Develop Sustain 2021;23(4):6148-6191., who highlight the need to guarantee basic support for the population in need, through strategic planning and multisectoral collaboration, involving the support of international organizations. In turn, Viveiros et al.²³23 Viveiros N, Bonomi AE. Novel coronavirus (COVID-19): violence, reproductive rights and related health risks for women, opportunities for practice innovation. J Fam Violence 2022; 37(5):753-757. recommend prioritizing the needs of women, especially minorities, in medical, social and legal settings, using innovative intervention and virtual advocacy services, urging legislators to pass legislation to support women. Some countries have adopted restrictive measures on the sale and consumption of alcohol, in addition to controlling the use and storage of firearms by owners. Duncan et al report that the presence of a firearm in the home increases the risk of homicide and suicide for everyone in the household. There is a unanimous understanding that, during periods of greater social distress, violence increases, which requires prioritizing the identification of vulnerable groups and adequate care for survivors.

Networks to face violence against women

In this topic, we outline some of the recommendations towards policies and specialized services to assist women in situations of violence. Concern about mental health deserves attention, in addition to the importance of informal support networks and the need for campaigns to raise awareness about the phenomenon.

The need for a national guideline on how to deal with cases of violence, with standardized procedures and budget allocation, was reinforced by Ghosh et al.²⁵25 Ghosh R, Dubey MJ, Chatterjee S, Dubey S. Impact of COVID-19 on children: Special focus on the psychosocial as-pect. Minerva Pediatr 2020; 72(3):226-235. In this sense, Evans et al.²⁶26 Evans ML, Lindauer M, Farrell ME. A Pandemic within a pandemic - intimate partner violence during COVID-19. N Engl J Med 2020; 383(24):2302-2304. warn of the importance of government agencies paying attention to the social determinants of health, since, depending on social class, for example, access to resources differs. This author also draws attention to the post-pandemic period, as peaks in domestic violence are often sustained for a long time after the occurrence of disasters. It is worth alerting to the need to expand the frontline workforce and the number of vacancies in shelters and the recognition of these network services as essential²2 Vieira PR, Garcia LP, Maciel ELN. The increase in domestic violence during the social isolation: what does it re-veals? Rev Bras Epidemiol 2020; 23:e200033.^,1212 Dahal M, Khanal P, Maharjan S, Panthi B, Nepal S. Mitigating violence against women and young girls during COVID-19 induced lockdown in Nepal: a wake-up call. Global Health 2020; 16(1):84.^,1313 Gausman J, Langer A. Sex and Gender Disparities in the COVID-19 Pandemic. J Women's Health 2020, 29(4):465-466.^,2424 Duncan TK, Weaver JL, Zakrison T L, Joseph B, Campbell BT, Natal A. Britton MD, Stewart R, Kuhls B. Domestic vio-lence and safe storage of firearms in the COVID-19 Era. Ann Surge 2020; 272(2):e55-e57.^,2727 Sharma A, Borah SB. COVID-19 and domestic violence: an indirect path to social and economic crisis. J Fam Vio-lence 2020; 37(5):759-765.

28 Mahase E. COVID-19: EU states report 60% rise in emergency calls about domestic violence. BMJ 2020; 369:m1872.

29 Galea S, Merchant RM, Lurie N. The mental health consequences of COVID-19 and physical distancing: the need for prevention and early intervention. JAMA Intern Med 2020; 180(6):817-818.^-3030 Walters J. COVID-19 shelter-at-home orders: impacts and policy responses in the context of intimate partner vio-lence. World Med Health Policy 2020; 12(4):533-539.. For Dahal et al.¹²12 Dahal M, Khanal P, Maharjan S, Panthi B, Nepal S. Mitigating violence against women and young girls during COVID-19 induced lockdown in Nepal: a wake-up call. Global Health 2020; 16(1):84., other social safety nets such as paid leave, unemployment insurance, direct cash or maintenance payments for the poor must be put in place to overcome the economic burden, which can reduce violence during the pandemic. According to the author, it is crucial to consider the COVID-19 pandemic as a critical inflection point for the implementation of planning and action guidelines to face domestic violence.

A series of advice focused on the service network can be listed based on Ghoshal’s paper³³33 Ghoshal R. Twin public health emergencies: COVID-19 and domestic violence. Indian J Med Ethics 2020; 5(3):195-199., namely: application of LIVES established by WHO; availability of telephone lines; telehealth service and provision of shelters/safe places. Regarding LIVES, it is a psychological first aid protocol that ranges from listening and crediting the woman’s experience to intersectoral referrals and the establishment of a safety plan that takes into account the specific context of each woman. With regard to the availability of telephone lines and other platforms, the purpose is to offer preliminary advice, emotional support and connection with social and legal support services. Other researchers such as Dahal et al.¹²12 Dahal M, Khanal P, Maharjan S, Panthi B, Nepal S. Mitigating violence against women and young girls during COVID-19 induced lockdown in Nepal: a wake-up call. Global Health 2020; 16(1):84. call for the wide dissemination of those channels in the mass media and even in community media, radios and online pages. As well pointed out by Ferreira³⁴34 Ferreira VC, Silva MRF, Montovani EH, Colares LG, Ribeiro AA, Stofel NS. Saúde da mulher, gênero, políticas públicas e educação médica: agravos no contexto de pandemia. Rev Bras Educ Med 2020; 44(Supl. 1):el147., the community agents themselves can help in this dissemination and direction.

As for the telehealth service, it requires the implementation of policies to promote security and privacy during the service³⁵35 Ragavan MI, Culyba AJ, Muhammad FL, Miller E. Supporting adolescents and young adults exposed to or experienc-ing violence during the COVID-19 pandemic. J Adolesc Health 2020; 67(1):18-20.^,3636 Jack SM, Munro-Kramer ML, Williams JR, Schminkey D, Tomlinson E, Jennings Mayo-Wilson L, Bradbury-Jones C, Campbell JC. Recognizing and responding to intimate partner violence using telehealth: practical guidance for nurses and midwives. J Clin Nurs 2020; 30(3-4):588-602., in addition to enabling equitable access to such technology. Tener et al.³⁷37 Tener D, Marmor A, Katz C, Newman A, Silovsky JF, Shields J, Taylor. How does COVID-19 impact intrafamilial child sexual abuse? Comparison analysis of reports by practitioners in Israel and the US. Child Abuse Neglect 2020; 116(Pt. 2)104779. also reinforce the benefits of using teleforensic services.

Regarding the provision of shelters/safe places, Ghosh et al.²⁵25 Ghosh R, Dubey MJ, Chatterjee S, Dubey S. Impact of COVID-19 on children: Special focus on the psychosocial as-pect. Minerva Pediatr 2020; 72(3):226-235. mention some experiences they consider successful, such as those carried out by France, which made hotels that were empty due to lockdowns available, and Spain, which used drugstores as places where women could leave messages with requests for help, in case they were unable to trigger the formal network to face violence.

Several authors²⁵25 Ghosh R, Dubey MJ, Chatterjee S, Dubey S. Impact of COVID-19 on children: Special focus on the psychosocial as-pect. Minerva Pediatr 2020; 72(3):226-235.^,3838 Slakoff DC, Aujla W, Penzeymoog E. The role of service providers, technology, and mass media when home isn't safe for intimate partner violence victims: best practices and recommendations in the Era of COVID-19 and beyond. Arch Sex Behav 2020; 49(8):2779-2788. reinforce the support of the network when preparing a security plan for each victim, which must include who to contact for help, the most secure rooms in the house, which personal items should be put together in case of a quick exit, how to use the technology safely, which organizations’ websites have quick escape resources, code words or signs agreed with family members, friends and/or neighbors, in addition to the development of digital tools that can help, for example, in filing legal documents online. For Emezue³⁹39 Emezue C. Digital or digitally delivered responses to domestic and intimate partner violence during COVID-19. JMIR Public Health Surveill 2020; 6(3):e19831., mapping current digital solutions in response to domestic violence is an immediate priority to understand the issues around acceptance, coverage and use.

The application of validated instruments in the domestic violence screening routine and the subsequent referral of cases to specific assistance services are indicated by Tochie et al.⁴⁰40 Tochie JN, Ofakem I, Ayissi G, Endomba FT, Fobellah NN, Wouatong C, Temgoua MN. Intimate partner violence dur-ing the confinement period of the COVID-19 pandemic: exploring the French and Cameroonian public health poli-cies. Pan Afr Med J 2020; 35(Suppl. 2):54. and Cohen et al.⁴¹41 Cohen MA, Powell AM, Coleman JS, Keller JM, Livingston A, Anderson JR. Special ambulatory gynecologic consider-ations in the era of coronavirus disease 2019 (COVID-19) and implications for future practice. Am J Obstet Gynecol MFM 2020; 223(3):372-378. Da Silva et al.⁴¹41 Cohen MA, Powell AM, Coleman JS, Keller JM, Livingston A, Anderson JR. Special ambulatory gynecologic consider-ations in the era of coronavirus disease 2019 (COVID-19) and implications for future practice. Am J Obstet Gynecol MFM 2020; 223(3):372-378. suggest using digital technologies as possible tools to help with this task. In turn, Sharma et al.²⁷27 Sharma A, Borah SB. COVID-19 and domestic violence: an indirect path to social and economic crisis. J Fam Vio-lence 2020; 37(5):759-765. point to the importance of agility and speed in the processes of reporting violence, seeking to understand the heterogeneity of situations and the different degrees of vulnerability, resulting from situations such as migration, illness, old age, among others. Digital monitoring of victims is also advocated by these authors.

Being attentive to pregnant and postpartum women, Farewell⁴³43 Farewell CV, Jewell J, Walls J, Leiferman JA. A mixed-methods pilot study of perinatal risk and resilience during COVID-19. J Prim Care Community Health 2020; 11:2150132720944074. points to the difficulties reported by this public when in the presence of symptoms of stress, depression and anxiety. With that, he proposes an intervention work (based on results of a pilot study) to support this vulnerable population. On the other hand, in an article focused on the mental health of migrant population, Dalexis et al.⁴⁴44 Dalexis RD, Cénat, JM. Asylum seekers working in Quebec (Canada) during the COVID-19 pandemic: tisk of deporta-tion, and threats to physical and mental health. Psychiatry Res 2020; 292:113299. highlight the urgency of legalizing the migration documentation for those individuals as a way of mitigating the problem.

Most articles focused on health care services recommend using telemedicine and identifying signs of violence in clinical consultations. Cohen et al.⁴¹41 Cohen MA, Powell AM, Coleman JS, Keller JM, Livingston A, Anderson JR. Special ambulatory gynecologic consider-ations in the era of coronavirus disease 2019 (COVID-19) and implications for future practice. Am J Obstet Gynecol MFM 2020; 223(3):372-378. point to the need to ensure continuous access to health care and advocate the use of validated instruments for screening cases of violence and depression, as already noted above. Hudson et al.⁴⁵45 Hudson LC, Lowenstein EJ, Hoenig LJ. Domestic violence in the coronavirus disease 2019 era: insights from a survi-vor. Clin Dermatol 2020; 38(6):737-143. point to the limitations of telemedicine for diagnosing domestic violence, the importance of taking an adequate case history, and the skill needed to assess victims in a compassionate and sensitive way. Johnson et al.⁴⁶46 Johnson K, Green L, Volpelier M, Kidenda S, Mchale T, Naimer K, Mishori R. The impact of COVID-19 on services for people affected by sexual and gender-based violence. Int J Gynecol Obstetr 2020; 150(3):285-287. provide recommendations on safely implementing clinical care and forensic medical documentation of survivors of sexual and gender-based violence.

Coulthard et al.⁴⁷47 Coulthard P, Hutchison I, Bell AJ, Coulthard DI, Kennedy H. COVID-19, domestic violence and abuse, and urgent dental and oral and maxillofacial surgery care. British Dent J 2020; 228 (12):923-926. emphasize the need for dental teams to question the cause of injuries and carry out a risk assessment for the patient, in addition to their treatment. Matoori et al.⁴⁹49 Matoori S, Khurana B, Balcom MC, Froehlich JM, Janssen S, Forstner R, King AD, Koh DM, Gutzeit A. Intimate part-ner violence crisis in the COVID-19 pandemic: how can radiologists make a difference? Eur Radiol 2020; 30(12):6933-6936. stress the importance of reviewing protocols for emergency and radiology teams to identify intimate partner violence, as well as their training. In another paper, he points out that most of the fractures resulting from this type of violence occur on the face, fingers, and upper part of the torso and that they can be easily interpreted as routine trauma. With that, it guides the careful review of the medical history of suspected cases and the relevant referrals. We also highlight a set of recommendations prepared by the WHO: 1) provision of information on available services, indicating location, opening hours, contact details and availability of remote services; 2) empathic listening; 3) use of mobile telephony and telemedicine.

Articles focused on mental health emphasize: 1) strengthening of the health care system and primary prevention⁴⁸48 Carbone SR. Flattening the curve of mental ill-health: the importance of primary prevention in managing the men-tal health impacts of COVID-19. Ment Health Prevent 2020; 19:200185.; 2) the use of online/call center services²⁹29 Galea S, Merchant RM, Lurie N. The mental health consequences of COVID-19 and physical distancing: the need for prevention and early intervention. JAMA Intern Med 2020; 180(6):817-818.^,5050 Gunnell D, Appleby L, Arensman E, Hawton K, John A, Kapur N, Khan M, O'Connor RC, Pirkis J. Suicide risk and pre-vention during the COVID-19 pandemic. Lancet Psychiatry 2020; 7(6):468-471.

51 Talevi D. The COVID-19 outbreak: impact on mental health and intervention strategies. J Psychopathol 2020; 26(2):162-168.

52 Racine N, Hartwick C, Collin-Vézina D, Madigan S. Telemental health for child trauma treatment during and post-COVID-19: Limitations and considerations. Child Abuse and Neglect 2020; 104698.

53 Nicolini H. Depresión y ansiedad en los tiempos de la pandemia de COVID-19. Cir Cir 2020; 88(5):542-547.

54 De Luca R, Calabrò RS. How the COVID-19 pandemic is changing mental health disease management: The growing need of telecounseling in Italy. Innov Clin Neurosci 2020; 17(4-6):16-17.^-5555 Serlachius A, Badawy SM, Thabrew H. Psychosocial challenges and opportunities for youth with chronic health con-ditions during the COVID-19 pandemic. JMIR Pediatr Parent 2020; 3(2):e23057.; 3) interventions/psychosocial support⁵³53 Nicolini H. Depresión y ansiedad en los tiempos de la pandemia de COVID-19. Cir Cir 2020; 88(5):542-547.^,5656 Fatke B, Hölzle P, Frank A, Förstl H. COVID-19 crisis: early observations on a pandemic's psychiatric problems. Dtsch Med Wochenschr 2020; 145(10):675-681.; 4) training of professionals⁵³53 Nicolini H. Depresión y ansiedad en los tiempos de la pandemia de COVID-19. Cir Cir 2020; 88(5):542-547.; and 5) the non-discontinuity of mental health care for children and adolescents during the pandemic⁵³53 Nicolini H. Depresión y ansiedad en los tiempos de la pandemia de COVID-19. Cir Cir 2020; 88(5):542-547..

Caring for the mental health of victims, especially post-traumatic stress, is a cause for concern among Ghosh et al.²⁵25 Ghosh R, Dubey MJ, Chatterjee S, Dubey S. Impact of COVID-19 on children: Special focus on the psychosocial as-pect. Minerva Pediatr 2020; 72(3):226-235.; Calleja-Agius et al.⁵⁷57 Calleja-Agius J, Calleja N. Domestic violence among the elderly during the COVID-19 pandemic. Rev Esp Geriatr Gerontol 2021; 56(1):64., and others, since it is often associated with comorbidities such as depression, anxiety, and gastrointestinal and respiratory problems. Two papers address suicides during the pandemic. Gunnell et al.⁵⁰50 Gunnell D, Appleby L, Arensman E, Hawton K, John A, Kapur N, Khan M, O'Connor RC, Pirkis J. Suicide risk and pre-vention during the COVID-19 pandemic. Lancet Psychiatry 2020; 7(6):468-471. propose different strategies for mental health services, such as: assessment of care pathways, monitoring of those with suicidal ideation, dissemination of the importance of restricting access to means and places commonly used for suicide, responsible role of the media in publishing reports on suicides and monitoring alcohol consumption by health care services, a point also highlighted by Ramalho⁵⁸58 Ramalho R. Alcohol consumption and alcohol-related problems during the COVID-19 pandemic: a narrative review. Australasian Psychiatry 2020; 28(5):524-526.. Joiner et al.⁵⁹59 Joiner TE, Lieberman A, Stanley IH, Reger MA. Might the COVID-19 pandemic spur increased murder-suicide? J Ag-gress Confl Peace Res 2020; 12(3):177-182., on the other hand, encourage efforts to prevent the occurrence of homicides and suicides.

Hegarty⁶⁰60 Hegarty K. How can general practitioners help all members of the family in the context of domestic violence and COVID-19? Aust J Gen Pract 2020; 49. lists steps general practitioners can take to engage and support patients who use violence in their relationships, such as accessing anti-violence helplines and online tools for establishing healthy relationships; taking a break when feeling stressed or anxious; exercising or contacting a friend or relative; identifying triggers that lead to violence and seeking help as soon as possible; avoiding drugs and alcohol; negotiating a “time-out” place at home - a place where family members know that aggressors should be left alone. Questions about how things are going at home and whether they want help with any unhealthy or negative behavior in their family relationships are welcome. In this regard, it encourages the use of motivational interviewing techniques, especially in patients who wish to voluntarily seek help. According to the author, researches show that male aggressors also see the health care professional as someone reliable to listen and advise them.

Informal and virtual social support networks should be encouraged²2 Vieira PR, Garcia LP, Maciel ELN. The increase in domestic violence during the social isolation: what does it re-veals? Rev Bras Epidemiol 2020; 23:e200033., as they help women feel connected and supported, as well as alerting perpetrators that women are not completely isolated. Given that victims tend to report domestic violence first to neighbors, witnesses and community members, it is important that it be widely publicized by the media and even that government agencies train people online on how to recognize and act in those cases²⁷27 Sharma A, Borah SB. COVID-19 and domestic violence: an indirect path to social and economic crisis. J Fam Vio-lence 2020; 37(5):759-765.^,3838 Slakoff DC, Aujla W, Penzeymoog E. The role of service providers, technology, and mass media when home isn't safe for intimate partner violence victims: best practices and recommendations in the Era of COVID-19 and beyond. Arch Sex Behav 2020; 49(8):2779-2788..

The importance of raising public awareness by mobilizing the mass media on the various types of violence against women, ways to seek help, and repudiation of any act of violence, is emphasized by Dahal et al.¹²12 Dahal M, Khanal P, Maharjan S, Panthi B, Nepal S. Mitigating violence against women and young girls during COVID-19 induced lockdown in Nepal: a wake-up call. Global Health 2020; 16(1):84. and Ghoshal³³33 Ghoshal R. Twin public health emergencies: COVID-19 and domestic violence. Indian J Med Ethics 2020; 5(3):195-199.. Walters³⁰30 Walters J. COVID-19 shelter-at-home orders: impacts and policy responses in the context of intimate partner vio-lence. World Med Health Policy 2020; 12(4):533-539., on the other hand, reinforces the importance of directing these efforts also towards men and boys. In addition to its role of disseminating and educating, the political pressure exerted by the media on governments, aiming at public accountability for facing domestic violence, is highlighted by Slakoff et al.³⁸38 Slakoff DC, Aujla W, Penzeymoog E. The role of service providers, technology, and mass media when home isn't safe for intimate partner violence victims: best practices and recommendations in the Era of COVID-19 and beyond. Arch Sex Behav 2020; 49(8):2779-2788.

Children and youth care and protection

In children’s lives, the repercussions of the COVID-19 pandemic are perceived in several dimensions, such as food, formal education, mental health and immunization schedule⁶¹61 Sociedade Brasileira de Imunizações (SBIM). Vacinação de rotina durante a pandemia de COVID-19 [Internet]. 2020. [acessado 2020 mar 30]. Disponível em: https://sbim.org.br/images/files/notas-tecnicas/nota-tecnica-sbim-vacinacao-rotina-pandemia.pdf
https://sbim.org.br/images/files/notas-t... . Therefore, the recommendations aimed at the child and youth population, presented in this section, cover the aspects just mentioned above, in addition to other situations that may cause violence. Such recommendations indicate that different realities in the world reveal values and what matters to countries when it comes to children and young people. In this sense, we consider that the recommendations disclose specificities about different national and international realities.

School closures raised serious concerns. Fegert et al.⁶²62 Fegert JM, Schulze UME. COVID-19 and its impact on child and adolescent psychiatry - A German and personal per-spective. Ir J Psychol Med 2020; 37(3):243-245. point to the need to protect children in this context, emphasizing, above all, the repercussions for the mental health of this population. Based on the experiences of “open-door” schools, Roca et al.⁶³63 Roca E, Melgar P, Gairal-Casadó R, Pulido-Rodríguez MA. Schools that "open doors" to prevent child abuse in con-finement by COVID-19. Sustainability 2020; 12(11):10.3390/su12114685.
https://doi.org/10.3390/su12114685.... argue that many teachers, families and communities are agents of social change who create supportive relationships and safe environments that protect childhood. Donagh⁶⁴64 Donagh B. From unnoticed to invisible: the impact of COVID-19 on children and young people experiencing do-mestic violence and abuse. Child Abuse Rev 2020; 29(4):387-391. comments that schools are often the only place where children and adolescents feel safe and that they are also the main place where reports are received. Suspension of their activities had intensified effects on children from families in unfavorable social and economic situations, with family members who lost their jobs and whose Internet access is precarious, not to mention the lack of electronic devices to serve all school-age family members⁶⁵65 Morais AC, Miranda JOF. Repercussões da pandemia na saúde das crianças brasileiras para além da COVID-19. Physis 2021; 31(1):e310102.^,6666 Anjos CI, Francisco DJ. Educação infantil e tecnologias digitais: reflexões em tempos de pandemia. Zero-a-Seis 2021; 23(Esp.):125-146..

It is interesting to note that the indiscriminate access to screens by children during the pandemic was abruptly triggered and few articles discuss the negative and positive repercussions of such devices for children’s lives. Ghosh et al.²⁵25 Ghosh R, Dubey MJ, Chatterjee S, Dubey S. Impact of COVID-19 on children: Special focus on the psychosocial as-pect. Minerva Pediatr 2020; 72(3):226-235. mention the topic and recommend proactive and targeted interventions to ensure that all children return to schools, by any means, when the pandemic subsides. Parents, pediatricians, psychologists, social workers, hospital authorities, including governmental and non-governmental organizations, must guarantee “zero dropouts” and advocate financial support for families. These authors also point out that parents need to respect the child’s identity, clear space, and special needs, in addition to monitoring online activities, behavior and self-discipline.

The same association between social and economic losses and a likely increase in maltreatment is mentioned by Cohen et al.⁶⁷67 Cohen RIS, Bosk EA. Vulnerable youth and the COVID-19 pandemic. Pediatrics 2020; 146(1): e20201306., who recommend using telemedicine when assisting LGBTI+ young people, young people with substance use disorders and those at risk of child maltreatment, although they recognize difficulties in maintaining privacy during appointments. They also emphasize the need to create child protection services, such as shelters. The importance of reporting and safe and effective ways of notifying and handling cases is emphasized by Platt et al.⁶⁸68 Platt VB, Guedert JM, Coelho EBS. Violence against children and adolescents: notification and alert in times of pandemic. Rev Paul Pediatr 2021; 39:e2020267.. Donagh⁶⁴64 Donagh B. From unnoticed to invisible: the impact of COVID-19 on children and young people experiencing do-mestic violence and abuse. Child Abuse Rev 2020; 29(4):387-391. comments that, despite social isolation and closure of institutions, adaptations were made by specialized services, which include telephone support, videoconferencing and support through relatives/safe caregivers⁶⁴64 Donagh B. From unnoticed to invisible: the impact of COVID-19 on children and young people experiencing do-mestic violence and abuse. Child Abuse Rev 2020; 29(4):387-391. (p. 388).

Ramaswamy et al.⁶⁹69 Ramaswamy S, Seshadri S. Children on the brink: Risks for child protection, sexual abuse, and related mental health problems in the COVID-19 pandemic. Indian J Soc Psychiatry 2020; 62(9):S404-S413. suggest government interventions focused on emerging concerns about child protection, psychosocial and mental health, which must be addressed universally, as the COVID-19 pandemic has affected children all over the world. In the same vein, Clark et al.⁷⁰70 WHO-UNICEF - Lancet Commissioners. After COVID-19, a future for the world's children? Lancet 2020; 396(10247):298-300. recommend coordinating across sectors and communities to implement a child-centered agenda. Dapic et al.⁷¹71 Ðapic MR, Flander GB, Prijatelj K. Children behind closed doors due to COVID-19 isolation: abuse, neglect and do-mestic violence. Arch Psychiatry Res 2020; 56(2):181-192. point out the importance of professional attention to vulnerable and at-risk children.

Several authors⁷²72 Sacco MA, Caputo F, Ricci P, Sicilia F, De Aloe L, Bonetta CF, Cordasco F, Scalise C, Cacciatore G, Zibetti A, Gratteri S, Aquila I. The impact of the COVID-19 pandemic on domestic violence: The dark side of home isolation during quarantine. Med Leg J 2020; 88(2):71-73.^,7373 Pereda N, Díaz-Faes DA. Family violence against children in the wake of COVID-19 pandemic: a review of current perspectives and risk factors. Child Adolesc Psychiatry Ment Health 2020; 14:40. demand greater attention from the authorities to families where there have already been reports of violence, in order to avoid further events. In this sense, Dahal et al.¹²12 Dahal M, Khanal P, Maharjan S, Panthi B, Nepal S. Mitigating violence against women and young girls during COVID-19 induced lockdown in Nepal: a wake-up call. Global Health 2020; 16(1):84. suggest that groups of mothers be guided and mobilized during that period to assess women and children at risk of violence and act as a support system.

Discussion

Some remarks must be made about the results found. The first concerns the fact that the data collection took place in 2020.

Despite a large number of publications dealing with violence against women and girls, the articles accessed were intended to warn about the possibility of increasing violence against these social groups, not constituting, for the most part, articles based on empirical research. This fact is quite understandable, since the pandemic hit the world quickly and suddenly, obviously not reducing the merit of the effort undertaken. Another important aspect concerns the inaccuracy of the recommendations resulting from those papers and which are the focus of our study, due to their clarity and applicability. Likewise, it does not always show which population it is intended for: the use of very broad categories such as “women” was recurrent.

By thinking about the category of women in a broad, all-encompassing way, several studies made the plurality of the experience of being a woman in different cultures around the world invisible, also erasing their needs to face the COVID-19 pandemic. Black and transgender Latina women are, for instance, not represented in those studies. In this framework, it should be noted that black women were the most penalized during the health crisis for several reasons, among which we highlight two: the vast majority are from the poorest classes and are part of the informal job market. They were afflicted both with the increased workload related to caring, not only for children, but also for the elderly and the sick, in addition to housework, as Moreira et al.¹⁴14 Moreira LE, Alves JS, Oliveira RG, Natividade C. Women in a pandemic context: a theoretical-political essay about house and warfare. Psicol Soc 2020; 32:e0200144. pointed out, and the impossibility of carrying out paid work.

We understand that the importance given to gender in the recommendations is due to the fact that it is a category structuring social relations, guided by a socio-symbolic hierarchy between genders, establishing inequalities that have repercussions for all spheres of social life. During the pandemic, these inequalities intensified, making the authors insist on including gender in the preparation of public policies considered universal, said to be neutral in terms of gender, race and class differences.

We know that these social markers intersect, defining the place that each person holds in the social structure and promoting inequities, which will be experienced in specific ways, depending on the social group to which they belong⁷⁴74 Collins PH. Pensamento feminista negro: conhecimento, consciência e a política do empoderamento. São Paulo: Bo-itempo; 2019.. An important point reiterated by several authors was the need to involve the whole of society and, particularly, neighbors in reporting domestic violence against women, children and adolescents, advocating the need to expand digital channels, telephone lines, codes to call for help and teleassistance that facilitate quick access to shelter and protection services. The maxim that “in a husband and wife’s fight, nobody steps in” needs, in fact, to be abolished. The report should be seen not as interference, but rather as protection of life. On the other hand, attention is drawn to the scarcity of recommendations aimed at actions with aggressors and other initiatives focused on primary prevention. As pointed out by Ruxton et al.⁷⁵75 Ruxton S, Burrell SR. Masculinities and COVID-19: making the connections. Washington, DC: Promundo-US; 2020., policies need to involve men through campaigns stimulating the interruption of gender-based violence at its source.

As for the recommendations aimed at the care and protection of children and adolescents, there is, on the one hand, the proximity of family members to children in the domestic environment, experienced by some in a positive way, translating into greater knowledge between children and guardians and a healthy coexistence, and, on the other hand, family coexistence may have been marked by tensions generated by the work overload of guardians in different spheres. Parents or guardians found themselves divided among different roles, formerly played by the school, by day-to-day sociability, by sharing tasks with the children previously lived among grandparents, relatives or a friendship network. Consequently, the confinement of families in cramped spaces, together with the experience of an unpredictable, insecure, uncertain scenario, was expressed, in some situations, in an increase in domestic violence³3 Marques ES, Moraes CL, Hasselmann MH, Deslandes SF, Reichenheim ME. Violence against women, children, and adolescents during the COVID-19 pandemic: Overview, contributing factors, and mitigating measures. Cad Saude Publica 2020; 36(4):e00074420.. In this sense, Overlien⁷⁶76 Øverlien C. The COVID-19 pandemic and its impact on children in domestic violence refuges. Child Abuse Rev 2020; 29(4):379-386. also confirms this configuration of the aggravation of domestic violence and highlights the importance of shelters and services aimed at children and adolescents at the time of the pandemic. Children lost their day-to-day play activities and contact with their friends - fundamental practices to form the child’s subjectivity and for their mental health. Such changes caused emotional tensions, feelings of insecurity, fear of losing parents, changes in behavior⁷⁷77 Marin A, organizador. Saúde mental e atenção psicossocial na pandemia COVID-19: crianças na pandemia COVID-19. Rio de Janeiro: Fiocruz/CEPEDES; 2020., among many other emotional expressions experienced by children during the pandemic.

Final considerations

The recommendations systematized and discussed throughout this text are promising as they expand discussions about strategies to deal with the scenario of violence against women and girls in the COVID-19 pandemic. Facing this pandemic, , as well as other future health crises, involves paying attention to the singularities of women and girls, especially those who live in vulnerable situations. Such carelessness in the policies adopted during the pandemic reveals how much progress is still needed to reduce social and gender inequalities.

The need for further studies on gender-based violence against women and girls in contexts of health emergencies remains evident. Traditional approaches to gender-based violence reified during the pandemic did not take into account the complexity of the issue, which involved not only acting to assist women in situations of violence, but also dealing with the health demands resulting from COVID-19. However, we emphasize that creative strategies were also designed and disseminated by some countries, including Brazil, in order to cover this multifaceted crisis, which intensified cases of gender-based violence. Therefore, this set of exhortations pointed out by the literature demonstrates the need to act proactively to prevent violence, protect and assist women in situations of violence. This pandemic has taught us that increasing investments in policies to prevent violence on a continuous basis is as essential as facing the pandemic itself.

References

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