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 Table of Contents  
INVITED VIEWPOINT
Year : 2020  |  Volume : 36  |  Issue : 5  |  Page : 120-125

Domestic violence during the COVID-19 pandemic: Lessons to be learned


1 Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
2 Department of Psychiatry, Hospital Putrajaya, Kuala Lumpur, Malaysia
3 Department of Clinical Psychology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India

Date of Submission12-Aug-2020
Date of Acceptance12-Aug-2020
Date of Web Publication02-Oct-2020

Correspondence Address:
Dr. Prabha S Chandra
Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru - 560 029, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_264_20

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  Abstract 


Pandemics such as the ongoing SARS-CoV-2 (COVID-19) have a significant impact on individuals, families, and countries alike. People have to deal with the consequences of the infection as well as the precautionary measures taken to contain the infection such as isolation, social distancing, and restriction on movements. Domestic violence (DV) is a gender-based violence that happens at homes and usually involves the spouse or partner or other family members. Due to the current pandemic and the ensuing lockdown, DV has posed a major challenge for frontline mental health professionals. The UN Women has reported increased rates of violence against women and children during the COVID-19 pandemic. However, it is difficult to measure the point prevalence due to restrictions, both in accessing help and in reporting. Women have reported difficulty in help seeking, while professionals have reported difficulties in assessment, service delivery, and in linking women to appropriate services. This article explores the possible mechanisms behind DV during COVID-19, its manifestations, difficulties in providing help during this pandemic, and recommendations for health professionals and mental health service providers. It also discusses the challenges in data gathering and research and provides recommendations for various stakeholders to address DV in future pandemics.

Keywords: COVID-19, domestic violence, intimate partner violence, pandemic, women


How to cite this article:
Krishnan TR, Hassan SH, Satyanarayana VA, Chandra PS. Domestic violence during the COVID-19 pandemic: Lessons to be learned. Indian J Soc Psychiatry 2020;36, Suppl S1:120-5

How to cite this URL:
Krishnan TR, Hassan SH, Satyanarayana VA, Chandra PS. Domestic violence during the COVID-19 pandemic: Lessons to be learned. Indian J Soc Psychiatry [serial online] 2020 [cited 2020 Oct 28];36, Suppl S1:120-5. Available from: https://www.indjsp.org/text.asp?2020/36/5/120/297157




  Introduction Top


Susan Sontag in her book “Illness as metaphor and AIDS and its metaphors” wrote – “It is not suffering as such that is most feared, but suffering which degrades.”[1]

Domestic violence (DV) is one of the worst forms of violence because it is experienced at the hands of a partner or a loved one and it degrades. Pandemics have historically been associated with different forms of violence. Sometimes, communal, sometimes against health workers, and often in the domestic sphere. DV is a type of gender-based violence (GBV) that happens at homes and usually involves the spouse or partner or other family members. While the term “home” resonates with a place of safety, comfort, and warmth for many, victims of DV endure varying levels of suffering and pain at their homes. DV also includes intimate partner violence (IPV) which is defined as “the behavior of an intimate partner that causes physical, sexual, or psychological harm, including acts of physical aggression, sexual coercion, psychological abuse, and controlling behaviors.”[2]

Pandemics such as the ongoing SARS-CoV-2 (commonly referred to as COVID-19) have a significant impact on individuals, families, and countries. People have to deal with the consequences of infection as well as the precautionary measures taken to contain the infection such as isolation, social distancing, and restriction on movements. Individuals face difficulties pertaining to health care, monetary resources, and security measures, which can impact their mental health and interpersonal relationships. Restrictions on mobility further increase the risk of violence as persons in abusive relationships are trapped in their homes with the perpetrator and may have difficulties in acquiring appropriate help.

DV, particularly during this COVID-19 pandemic and the ensuing lockdown, has posed a major challenge for frontline mental health professionals. Women have reported difficulty in help seeking, while professionals have reported difficulties in assessment, service delivery, and in linking women to appropriate services.

About three out of four women tend to experience IPV globally.[3] The UN Women has reported increased rates of violence against women and children during the COVID-19 pandemic. However, it is difficult to measure the point prevalence due to restrictions both in accessing help and in reporting.[4]


  Indian Scenario – COVID-19 and Domestic Violence Challenges Top


According to the National Family Health Survey-4, spousal violence in ever-married women in India between 15 and 49 years of age was 31.1%, which is a reduction of 6% from the findings obtained 10 years before it.[5] The most common type of spousal violence was physical violence (30%) followed by emotional violence (14%). About 4% of women reported having experienced DV during their pregnancy. Most women seek help from informal sources and family rather than the police or women's organizations. Despite the Prevention of Domestic Violence Act being available, women often hesitate to use legal protections. This could be due to a lack of knowledge, mistrust of the police and justice systems, or poor access to legal help.

The lockdown issued for the current pandemic has worsened the situation for Indian women, and the National Commission for Women (NCW) has received an increased number of DV complaints in the first four phases of the lockdown announced by the government.[6] Such a spurt in complaints has never been documented by the NCW in the last decade. There have been suggestions that the increased number of complaints may not be due to new incidents but are rather from repeatedly abused victims. The reasons for the increase or decrease in the numbers reported have not been explored yet.

In the COVID-19 pandemic situation, the source of help is often not available as women are not able to leave for their maternal homes. Under the current restrictions and fear due to the COVID-19 pandemic, the family members may not be able to offer the help they would have offered otherwise. Medical and police personnel are many times the first point of contact for the victims of DV. COVID-19 has posed a major challenge to the health-care system of the country. A significant proportion of the resources have been diverted for tackling the pandemic – regular outpatient consultations have been decreased, elective surgeries have been limited, and many hospitals have been reorganized as COVID-19 care facilities. Unless the treating doctor is looking out for signs of DV, the chances of picking up the crucial information are less. The health-care policy differences in different states add to the complexity of addressing DV. The lockdown has also engaged more police personnel in patrols and in enforcing lockdown. The overworked medical and police personnel may not be able to devote the time and effort required to sensitively identify and help the sufferers of DV.


  Why Do Conflicts and Violence Increase during the Pandemic? Top


Violence in home situations is likely to increase for several reasons – living with families in close confined spaces during the lockdowns can lead to conflicts as people are denied other ways of overcoming stress or boredom.[7] Many people experience a variety of stress, but they do not respond to it with abusive behavior.[8] A psychological theory posits that childhood trauma, preexisting personality disturbance, or substance abuse may be an explanation for why some individuals resort to the perpetuation of violence.[9] Economic vulnerability during pandemics causes livelihood issues such as job losses, prolonged unemployment, reduced income, debts, and food insecurity.[8] The protracted course of pandemics can lead to chronic stress, which is well known to play a significant role in causing poor mental health and psychiatric disorders.[10] The drastically changed circumstances arising out of the pandemic could trigger or worsen the existing conflicts in the house. In case there was an already-ongoing DV due to the perpetrators' controlling behaviors, jealousy, and misogynistic attitudes, it may increase during lockdowns.[8] The perpetrators and victims are in close contact round the clock which when coupled with social isolation could reinforce violence. Before the pandemic, women and children might have already faced extensive barriers, challenges, and complex decisions that might have prevented them from escaping the perpetrators safely. Such challenges to escape are amplified during a pandemic because their mobility is constrained, especially due to the social-distancing measures, economic insecurities, and disrupted routines. Perpetrators may also be aware that help is not available at hand and their controlling behaviors may therefore increase.

Substance use, particularly alcohol use, has long been known to be a risk factor for partner violence. Economic uncertainty and poverty-related stress are associated with poor coping strategies, which may result in increased substance use. The pandemic outbreak by itself has been correlated with irritability, anxiety, fear, sadness, anger, or boredom in substance use individuals.[11] These negative emotions could trigger relapse even in abstainers or intensify the existing substance usage.[12],[13] Withdrawal symptoms of substance use and related mood changes coupled with the inability to go outside for alcohol or illicit substances can lead to increased DV.

During lockdowns, the social infrastructure is disrupted, travel restrictions are implemented, and access to technology is limited. This may lead to separation from family members or decreased contact with neighbors. In some countries, only one member is allowed to go out to buy groceries during the lockdown. As a result, women and children who are exposed to violence have lesser opportunities to go out and seek help. The perpetrators exercise their power of controlling the victims, which further reduces their access to any services.

In addition, there is also a lack of availability of health services. Frontline health-care workers are often the first point of contact for survivors and they offer short-term physical protection for women and children. Given the severity of the pandemic, frontline health workers may be called upon to do other COVID-19-related work. The only link which women and children may have for support may hence not be available. Women may also avoid seeking health services for their physical abuse and injuries, for fear of possible COVID-19 infection.

A major concern has been that of challenges in the accessibility of services for women facing violence during the pandemic such as shelters or “One-Stop Centers” and difficulty reaching them due to lockdowns. Even if helplines are available, women may have to wait for the perpetrator to go out for a short while, to make the call. During lockdowns, it is very difficult for women to speak on their phones without raising suspicion. The possibility of reductions in hotline services, crisis centers, shelters, legal aid, and protection services makes it harder for women to reach the few sources of support that are usually accessible. Furthermore, at the time of lockdown, the accessibility to sexual and reproductive health services is also likely to be disrupted.


  How Does Domestic Violence Manifest? Top


We know that violence manifests in different forms such as coercive control, physical abuse, emotional abuse, or sexual violence, but many a time, just the physical violence gets the sole focus. Psychological violence is among the most common form of violence, and it almost always co-occurs with physical and sexual violence.

Psychological violence may occur in the form of controlling behaviors such as holding back financial support; denying permission to participate in health-seeking behaviors; making them vulnerable for contracting the infection by restricting soap and hand sanitizer; or not allowing the persons to use telephones or mobiles. The perpetrators may restrict women's access to services and reduce their opportunity to ask for help and get psychological support from both formal and informal sources. They may threaten to withhold insurance cards, cancel insurance, insist on knowing where the woman is at all times, spread misinformation about the COVID-19 to control or frighten them, and prevent them from seeking medical assistance.[14]

While physical violence is more apparent, sexual violence during a pandemic includes coercive sex, nonconsented sexual intercourse, harming during sex, and not using or not allowing to use contraception, thereby increasing unwanted pregnancy as well as sexually transmitted infections. Women in abusive relationships may be coerced or forced to get pregnant. Their freedom to decide on contraception and family planning may be compromised, and they may be scared to negotiate condom use by their partners.[15] Their lack of control over their sexual health leads onto unplanned and unwanted pregnancies. The control exerted by the offender and the increased proximity inside the homes during lockdown may diminish the chances for the woman to seek help. The restriction on elective surgical procedures may forbid family planning in that period, further adding to the pressure/fear of pregnancy.


  What Can Health Professionals Do? Top


Health professionals usually suspect violence when they see women with inexplicable injuries; unexplained physical symptoms; or mental health outcomes such as anxiety, psychological distress, and deliberate self-harm attempts. However, during pandemics, health professionals may have several other preoccupations such as resource scarcity, lack of personal protection, and focus on emergency medical care and hence may ignore the signs of possible violence.

Often, health professionals feel overwhelmed and have a sense of nihilism about intervening even though they suspect partner or DV. The tendency is to think of it as a social or family problem. However, in situations like pandemics, the health professional may be the only link to the outside world, and lack of recognition or not addressing the violence may be a missed opportunity for saving a woman's life.

It is, therefore, crucial for health-care providers to find out information on local services for survivors, including on hotlines, shelters, rape crisis centers, and counseling. They also need to identify these service timings, contact details, and whether these services can be offered from distance or if any referral is needed. The information regarding violence and local services must be available in health-care settings through booklets or pamphlets and should be easily accessible to clients. These may even be placed in women's restrooms and hospitals declared as safe spaces to discuss violence. If a survivor with suspected or confirmed COVID-19 seeks help because of violence, the response should be the same as for other survivors.

Health professionals may need training because many of them may not have had any education regarding a first-level response to DV. The World Health Organization (WHO) LIVES approach is an empathic and responsive method which can be used by health workers at all levels.

LIVES is a psychosocial approach formulated by the WHO that can be used as a first aid for women who are facing IPV or any other forms of DV.[16],[17]


  What is the Role of Mental Health Services? Top


Globally, DV is picked up less frequently at mental health and primary care services, covering only 10%–30% of recent violence.[18] However, the rates improve when a routine inquiry about violence is made part of mental health care. It has been found that women are more likely to open up to a health-care professional than to the police. Some of the hindrances in disclosing are fear of the consequences, fear of not being believed, fear of further violence, and feeling ashamed and discomfort with the health-care environment.

Women or even men with mental health problems are even more vulnerable to DV, especially during lockdowns. They are more likely to be in unsafe situations, entangled in exploitative relationships, and are more susceptible for violent victimization. Exposure to violence in the past increases the risk of developing mental illnesses, and there is evidence to show a bidirectional causal relationship.[18] They may not have access to treatment which may worsen symptoms, which, in turn, may increase abuse. All mental health providers need to be sensitive to the symptoms of anxiety, feelings of insecurity, and somatic symptoms as a cry for help. Ensuring that you have some “alone time” with the woman during a consultation is important, and every woman seen should be asked sensitively about DV and helped to access services. The questions need to be framed and asked in a sensitive manner, ensuring that you are in a safe place and no friend or relative is within earshot. Women also need to know that this information will be kept confidential and you will always keep their best interest in mind.

Mental health professionals often struggle with opening statements about DV. Some ways this conversation can be started would be by saying, “We generally ask about family life and relationships as they affect an individual's health. Have you been having facing any trouble in your close relationships? Do you have any arguments/conflicts at home? How are they generally resolved? Has anyone in your close relationships subjected you to any form of ridicule or humiliation that has made you feel upset? Have you been subjected by anyone in your close relationships to any form of threat, or harm, hitting, slapping, or kicking that has made you feel upset?” If “yes” to any of the above two questions you can then ask, “Can you talk more about it?”

Some general dictums to follow include allowing the woman to express her feelings, not interrupting, validating her feelings, and being nonjudgmental. The World Psychiatric Association Curriculum on IPV is a good resource that describes various ways in which mental health professionals can approach the problem.[19]


  Children Witnessing Domestic Violence during a Lockdown Top


Children who witness intraparental violence are more likely to be victims of abuse and are at more risk for adjustment problems in young adulthood. Some of them may even go on to perpetrate violence themselves.[20] During lockdown situations, children may be in the same room when interpersonal conflict is happening. Children also lose their confiding support systems, for example, extended family members, teachers, neighbors, and friends, who visit and talk to them, and may not be able to discuss their distress with others.

It is very crucial for health-care professionals and social workers to know how to “reach out” to these children in health-care setting or via video call through WhatsApp, Skype, etc.[21] Every woman who reports IPV issue, should be asked about her children. Several methods have been used to get in touch with the child without increasing the further risk of violence from the perpetrator. Teachers who may be taking online classes can be trained to detect any distress and help the child to speak out about any interpersonal violence at home.[9]


  Issues in Discussing Intimate Partner Violence in Tele Sessions With Women Top


With the lockdown and other challenges during the COVID pandemic, telemedicine and tele-psychiatry has emerged as an option for ensuring continuity of care and providing services to patients. There are several concerns related to discussing DV during tele sessions. Ascertaining privacy is the biggest challenge because the perpetrator might be near them and there is the possibility of escalation of violence if the perpetrator feels that violence is being reported. In addition, health professionals may not be able to examine the client for injuries or provide resources. The COVID-19 pandemic has posed us a challenge – how do we ask about abuse and provide safety to our patients during the time of tele-psychiatry? While this is a new experience for many of us who are used to seeing women in private, guidelines need to be developed. It would be important to check with the woman if someone is nearby, asking her to respond only in “yes” or “no.” Using a pretext to get her out of the room if the perpetrator or someone else is around and then discussing safety issues is one way. The answers will probably come from the women themselves, and health professionals will need to find newer and innovative ways of identifying and responding to violence including the use of technology.


  Remote Data Gathering and Challenges in Research Related to Domestic Violence during Pandemics or Lockdown Top


Policymakers depend on data to provide services. In a situation like a pandemic where data are not available, we will have to rely on secondary data sources such as nongovernmental organizations (NGOs) and helplines. The WHO has recommended some methods of gathering data remotely on DV during pandemics and emphasized that at no cost should the women's safety or researcher's safety be compromised. Before the next pandemic or the next phase of lockdown, it will be essential to consult and collaborate with experienced experts in the field (including women survivors who are experts by experience) to reduce the anxiety of shifting to new methods of data collection, to increase survivor safety, and to safely carry out studies on DV.[22]

Finally, we need to reflect on the experience of the last 3 months and strategize ways by which we can be better prepared for the next pandemic or the next lockdown to ensure women's safety [Box 1].




  Conclusions Top


The risks of violence that women and their children have faced during the COVID-19 crisis have provided an opportunity to improve and put in place efficient systems to protect women from violence. Strengthening the health-care system and a systemic response should ensure that the intersectionality of race, geography, class and caste inequalities, gender, and sexuality is taken into account.[27],[28] It is important that specific needs of women are addressed and women who have faced violence (experts by experience) participate in the planning. Innovative methods need to be used such as that in Spain and Greece where pharmacy and supermarket workers could be trained as partners and the code word “Mask-19” was adopted for women seeking help for violence in a discreet manner.[25],[26]

In the protection of women, besides recognition of the structural nature of violence, the government should strengthen the existing laws on GBV and facilitate online filing of cases by women.[29],[30] DV services till now have been working in silos. An integrated response that involves a collaboration of policymakers, the police, justice system, shelters, mental health and social services, technology experts, researchers, NGOs, and women survivors is the way forward in creating a comprehensive and inclusive action plan for pandemic and lockdown response to DV.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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