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Recomendações inter(nacionais) para enfrentamento a violências contra mulheres e meninas na pandemia de Covid-19 Inter(national)
Inter(national) recommendations to face violence against women and girls in the inter(national) Covid-19 pandemic

Vera Lucia Marques da Silva - Escola Nacional de Saúde Pública/Fiocruz - vera.marques@fiocruz.br - https://orcid.org/0000-0002-2595-2679
Liane Maria Braga da Silveira - Escola Nacional de Saúde Pública/Fiocruz - liane@ensp.fiocruz.br - https://orcid.org/0000-0001-7402-7343
Fátima Regina Cecchetto - Instituto Oswaldo Cruz/Fiocruz - face.fiocruz@gmail.com - https://orcid.org/0000-0003-3080-5582
Kathie Njaine - Escola Nacional de Saúde Pública/Fiocruz - kathie@ensp.fiocruz.br - https://orcid.org/0000-0003-3250-2331
Adriano da Silva - Escola Nacional de Saúde Pública/Fiocruz - adriano.silva@fiocruz.br - https://orcid.org/0000-0002-1105-9046
Liana Wemersbach Pinto - Escola Nacional de Saúde Pública/Fiocruz - lianawep@gmail.com - https://orcid.org/0000-0003-1928-9265

RESUMO
Este artigo é parte da pesquisa As violências no contexto da Covid-19: desafios e vulnerabilidades globais, que propõe uma reflexão crítica acerca das situações de violências de gênero potencializadas pelos protocolos de distanciamento social, requeridas pela pandemia da Covid-19. A partir de levantamento bibliográfico do ano de 2020, analisamos recomendações de pesquisadores e instituições de diferentes partes do mundo, com o objetivo de sistematizar e disseminar estratégias para lidar com este cenário. O material está organizado em dois eixos temáticos, a saber: Políticas de gênero e ações intersetoriais; e Estratégias de enfrentamento às violências contra mulheres e crianças no campo da saúde e da assistência social. As recomendações estão centradas no desenvolvimento de ações pelos Estados/governos, redes de atendimento e sociedade em geral. Parte das recomendações sugere aumentar ou adequar as ações de vigilância já existentes e parte contribui com propostas criativas, norteando ações promotoras e preventivas em nível individual e coletivo. A adoção de teleatendimento, campanhas midiáticas de conscientização de que a violência é injustificável e desenvolvimento de estratégias de denúncia por meio de sinais e códigos foram reiteradas pela literatura.
Palavras-chave: Violência contra a Mulher; COVID-19; Maus-tratos infantis

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.
Keywords: 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 Development1 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 conflicts2,3,4.
Based on the increased requests for help in service channels, UN Women5 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 aggression6, which can lead to lethal violence, are added. The United Nations Office on Drugs and Crime7 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 inequalities8. It is estimated that more than a decade will be needed for poorer women to overcome the devastation generated by the Covid-19 pandemic9, 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 analysis10 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 (Table 1 attached). 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.
1. 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 pandemic11’12,13,14. For Dahal et al.12, 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.13 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.15 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.14 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.16, 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 authors17,18 propose that governments develop actions at different levels to face violence against women and girls, concomitantly with health policies. Yenilmez18 also advocates intersectoral and networked action, and Stoianova et al.19 highlight the importance of legislation amendments aimed at tackling the problem of domestic violence.
Farooq et al.20 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. Gopal21 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.22, 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.23 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.

2. 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.25 In this sense, Evans et al.26 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 essential2,12’13’24\'27,28’29’30. For Dahal et al.12, 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 paper33, 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.12 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 Ferreira34, 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 service35,36, in addition to enabling equitable access to such technology. Tener et al.37 also reinforce the benefits of using teleforensic services.
Regarding the provision of shelters/safe places, Ghosh et al.25 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 authors25,38 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 Emezue39, 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.40 and Cohen et al.41 Da Silva et al.41 suggest using digital technologies as possible tools to help with this task. In turn, Sharma et al.27 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, Farewell43 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.44 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.41 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.45 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.46 provide recommendations on safely implementing clinical care and forensic medical documentation of survivors of sexual and gender-based violence.
Coulthard et al.47 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.49 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 prevention48; 2) the use of online/call center services29’50’51’52’53’54’55; 3) interventions/psychosocial support53,56; 4) training of professionals53; and 5) the non-discontinuity of mental health care for children and adolescents during the pandemic53.
Caring for the mental health of victims, especially post-traumatic stress, is a cause for concern among Ghosh et al.25; Calleja-Agius et al.57, 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.50 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 Ramalho58. Joiner et al.59, on the other hand, encourage efforts to prevent the occurrence of homicides and suicides.
Hegarty60 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 encouraged2, 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 cases27,38.
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.12 and Ghoshal33. Walters30, 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.38.
3. 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 schedule61. 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.62 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.63 argue that many teachers, families and communities are agents of social change who create supportive relationships and safe environments that protect childhood. Donagh64 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 members65,66.
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.25 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.67, 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.68. Donagh64 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 caregivers64 (p.388).
Ramaswamy et al.69 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.70 recommend coordinating across sectors and communities to implement a child-centered agenda. Dapic et al.71 point out the importance of professional attention to vulnerable and at-risk children.
Several authors72,73 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.12 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.14 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 belong74. 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.75, 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 violence3. In this sense, Overlien76 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 behavior77, 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.
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