Violence against women during covid-19 pandemic restrictionsBMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1712 (Published 07 May 2020) Cite this as: BMJ 2020;369:m1712
All rapid responses
To The Editor
Intimate partner violence (IPV) is a major public health problem across the world, and is more commonly referred to as domestic violence. The World Health Organization (WHO) defines IPV as "any behavior within an intimate relationship that causes physical, psychological or sexual harm to those in the relationship". Globally, 30% of women experience some form of physical or sexual violence by an intimate partner in their lifetime. It is typically experienced by women but can also be experienced by men. (1) Globally, IPV is the leading cause of homicide death for women. There is also a growing evidence suggesting that IPV might increase the risk of cardiovascular disease. (2)
During the quarantine due to the COVID-19, homes might have become a dangerous place for victims of IPV, since they are required to stay the whole day with partners and away from people who can validate their experiences and give help. (3)
Intimate partner violence is considered to be also a problem in Muslim-majority cultures. (4,5)
In a study from Egypt, women reported experiencing physical, emotional, and sexual violence at 26.7%, 17.8%, and 4.6%, respectively. (4) During the COVID-19 pandemic, there is very scarce data emerging from the Islamic countries with sporadic social media reports about domestic violence. In the absence of solid data, it is difficult to speculate, however, IPV is probably less likely to surge during the quarantine in Islamic countries than in the West, since there is much less alcohol drinking in Islamic countries, particularly during the month of Ramadan, more family ties, and generally more religious adherence during the time of catastrophes. Adherence to religious traditions is still considered as a barrier against drinking among both Muslims and Jews. (6)
Violence against women is not an Islamic tradition. The Qur’anic principles protect the status of women and support family values. The Qur’an sees women as full partners in the devotional rights of Islam. The marriage in Qur’an involves intimacy, support, and equality, saying, “They are your garments, and you are their garments” (Quran 2:187). Aisha, the Prophet’s wife, said, “The Prophet never hit a servant or a woman” (Sahih Al-Bukhari). Moreover, the Prophet Muhammad (PBUH) never resorted to beating his wives, regardless of the circumstances. (7)
The Prophet instructed Muslims regarding women, "I command you to be kind to women." He also said: "The best of you is the best to his family (wife) (Sunan al-Tirmidhī). The Quran urges husbands to be kind and considerate to their wives, even if a wife falls out of favor with her husband. A translation of Quran says, "O you who believe! You are forbidden to inherit women against their will. Nor should you treat them with harshness. (Quran 4:19).
Dr. Jamal Badawi, author of “Gender Equity in Islam” indicates that "under no circumstances does the Quran encourage, allow, or condone family violence or physical abuse. In extreme cases, and in an effort to save the marriage it allows for a husband to administer a gentle pat with a miswak (a small natural toothbrush) to his wife that causes no sort of physical harm to the body nor leaves any sort of mark. It may bring to the wife's attention the seriousness of her continued unreasonable behavior, and may be resorted to only after exhausting other prerequisite steps". (8)
In several hadiths, the Prophet (PBUH) directly discouraged the practice of wife beating. He considered the men who beat their wives as lacking in character, as indiscriminate in their behavior, and as unethical. (9)
1. WHO Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence. World Health Organization, 2013.
2. El-Serag, R., Thurston, R.C., 2020. Matters of the Heart and Mind: Interpersonal Violence and Cardiovascular Disease in Women. J. Am. Heart Assoc. 9, e015479. https://doi.org/10.1161/JAHA.120.015479
3. Mazza M, Marano G, Lai C, Janiri L, Sani G. Danger in danger: Interpersonal violence during COVID-19 quarantine [published online ahead of print, 2020 Apr 30]. Psychiatry Res. 2020; 289:113046. doi:10.1016/j.psychres.2020.113046
4. Yaya S, Hudani A, Buh A, Bishwajit G. Prevalence and Predictors of Intimate Partner Violence Among Married Women in Egypt [published online ahead of print, 2019 Nov 13]. J Interpers Violence. 2019;886260519888196. doi:10.1177/0886260519888196
5. Alsaleh A. Violence Against Kuwaiti Women [published online ahead of print, 2020 May 13]. J Interpers Violence. 2020;886260520916280. doi:10.1177/0886260520916280
6. Neumark, Y. D., Rahav, G., Teichman, M., & Hasin, D. Alcohol drinking patterns among Jewish and Arab men and women in Israel. Journal of Studies on Alcohol, 2001. 62(4), 443–447.
7. Nadir.A. Domestic violence hurts Muslims too. https://www.soundvision.com/article/domestic-violence-hurts-muslims-too
8. Badawi J. Gender Equity in Islam: Basic Principles. American Trust Publications, 1995. ISBN-13: 978-1882837205
9. Ammar NH. Wife battery in Islam: a comprehensive understanding of interpretations. Violence Against Women. 2007;13(5):516‐526.
Hassan Chamsi-Pasha, FRCP, FACC. Cardiac department, King Fahd Armed Forces Hospital, Jeddah, Saudi-Arabia. (firstname.lastname@example.org)
Majed Chamsi-Pasha, MBBS, SBIM, Jeddah, Saudi-Arabia.
Mohammed Ali Albar, MD, FRCP. Medical Ethics department, International Medical Center, Jeddah, Saudi-Arabia.
Competing interests: No competing interests
The increased levels of violence during the covid-19 pandemic are alarming indeed. Not only because of the lasting consequences for the physical and mental health of the women and the (unborn) children affected by the violence, but also because of the risk of intergenerational transmission.
The environment in which an individual develops, from the very earliest stages of life into childhood, has a fundamental influence on its growth and development and affects its behavior and susceptibility to disease (1). International studies performed before the COVID pandemic have shown that domestic and family violence in pregnancy is widespread and that violence often begins during pregnancy, or, if domestic violence already exists, its severity increases during pregnancy (2). Women who experience violence during pregnancy are more likely to deliver prematurely and have a baby with poorer neonatal outcomes (3). After birth, these children more often have internalizing problems and infants exposed to violence show insecure attachments, increased agressive behavior, reduced prosocial behavior, and poorer health (4,5). Adverse childhood experiences such as child maltreatment or domestic violence increase the risk of future disease, but also increase the risk of mental illness, substance abuse and violence, perpetuating a vicious circle of stress and adversity (6). Consequently, the current outbreak of violence does not only harm the health and wellbeing of those affected now, but also affects their future health and wellbeing, as well as the health of their future children.
Therefore, in addition to the authors call for more attention, protection and care for the women and children affected by the outbreak of violence during the COVID pandemic, I call for more upstream approaches to prevent violence. Although violence is a multifacetted and complex problem that cannot easily be solved, there are effective interventions that can help prevent domestic or intimate partner violence, such as the Grameen Bank project in Bangladesh, and the Nurse Family Partnership. If we do no take action now to seriously try to prevent any further escalation of violence, we will not only witness doubling numbers of traumatised individuals but also doubled numbers of individuals at risk of becoming future perpetrators of domestic violence.
There is a triple dividend of preventing further escalation of violence; it will have the potential to improve the current health and wellbeing of women and children, their future health as well as that of their future children. This is a promising way to break the intergenerational cycle of violence and improve the lives of generations to come. I believe preventing violence will address the sustainable development goal of reducing inequalities and I believe we have no time to waste and should start investing more in preventing violence.
Tessa Roseboom, professor of Early Development and Health, University of Amsterdam
1. Fleming TP, Watkins AJ, Velazquez MA, et al. Origins of lifetime health around the time of conception: causes and consequences. Lancet. 2018; 391(10132), 1842–1852.
2. Violence against women, UNICEF 2015. Retrieved from https://unstats.un.org/unsd/gender/downloads/WorldsWomen2015_chapter6_t.pdf
3. Shah PS, Shah J. Maternal exposure to domestic violence and pregnancy and birth outcomes: a systematic review and meta-analyses. J Womens Health. 2010; 19(11), 2017–2031.
4. Martinez-Torteya C, Bogat GA, Levendosky AA, von Eye A. The influence of prenatal intimate partner violence exposure on hypothalamic-pituitaryadrenal axis reactivity and childhood internalizing and externalizing symptoms. Dev Psychopathol. 2016; 28(1), 55–72.
5. Cameranesi M, Lix LM, Piotrowski CC. Linking a history of childhood abuse to adult health among Canadians: a structural equation modelling analysis. Int J Environ Res Public Health. 2019; 16(11). doi: 10.3390/ijerph16111942
6. Hughes K, Bellis MA, Hardcastle KA, Butchart A, Mikton C, Jones L, Dunne MP. The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis. Lancet Global Health 2017:2:e356-66.
Competing interests: No competing interests
Home should typically be a place of refuge during the COVID-19 pandemic.
Roesch E. et al. successfully demonstrates how self-isolation can lead to female victims of abuse having little escape from their abusers. Whilst we accept the rubric that ‘protection for women and girls’ is mandatory to future response plans, we ask: why is the issue of male domestic abuse not being considered?
Domestic abuse is typically experienced by women, but is frequently experienced by men. Figures from the Office of National Statistics, confirm that of every three domestic abuse cases in the United Kingdom (UK), two victims are female and one is male.
The national lockdown which took effect on the 23rd March 2020, effectively trapped male and female victims of violence with their abusers. The Mankind Initiative, a well-established charity in Britain offering support to male victims, reported a 35% increase in call volumes compared to the pre-lockdown period. In addition, visitors to the Mankind Initiative website in the week of 27th April 2020 were three times higher than before the lockdown. The most popular pages visited on the website concerned signs of domestic abuse in men and statistics on male victims.
The UK government has responded to concerns regarding the safety of domestic abuse victims during this pandemic, stressing that self-isolation rules do not apply under such circumstances. While the level of dissemination of this message may be arguably lacking, the government clearly encourages reporting of domestic violence by both genders, either to the police or local charities.
Men often find it more difficult to seek help; and social prejudice, embarrassment and shame have been proposed as potential reasons for this.[5, 6] Reluctance in reaching out is reflected in published figures of domestic violence victims, with 51% of men versus 81% of women sharing their concerns about potential abuse with another person. Mankind Initiative identifies a lack of reference to male victims of domestic violence in both the media and in politics to be a key issue.
We propose that any future response regarding protection of individuals who experience domestic violence should reference both male and female victims. This will help prevent the further isolation of male victims and potentially increase the likelihood they will report the abuse.
1. Domestic Abuse Prevalence and Victim Characteristics - Appendix Tables. In: Statistics ONS, editor.: Office for National Statistics; 2019.
2. PM address to the nation on coronavirus: 23 March 2020. 2020 23rd March.
3. Media and Policy Briefing: Male Victims of Domestic Abuse and Covid-19 Briefing (3): 27th April to 3rd May 2020. Mankind Initiative; 2020.
4. Coronavirus (COVID-19): support for victims of domestic abuse. In: Office H, editor.: www.gov.uk; 2020.
5. Shelter S. Domestic violence and abuse against men: Shelter 2020 [Available from:https://scotland.shelter.org.uk/get_advice/advice_topics/families_and_ho....
6. Ross J. Male domestic abuse victims 'suffering in silence'2019. Available from: https://www.bbc.co.uk/news/uk-wales-47252756.
7. Brooks M. Male victims of domestic abuse and partner abuse: 50 key facts. Mankind Initiative; March 2020.
Competing interests: No competing interests
That the gendered effects of a pandemic gather attention is representative of a further, deeper, and acutely prolonged, crisis, namely, the suffered narratives of women experiencing violence are buried beneath concepts of honour and shame or silenced through marginalisation and delineation of understanding the phenomenological alterations of the violations of violence throughout existential, spiritual, physical, and mental well-being.
It should not take a global disaster to create fractures and ruptures within existing health systems and strategies to elevate the suffering of women enduring violence with a view to alleviating such suffering.
Yet, the confines of a lockdown magnify the contexts of violence and thereby present significant burdens and hurdles for approaching research, preventative measures and health-based interventions for violence against women during covid-19 pandemic restrictions. As the editorial by Roesch et al (2020) rightly point out, the pandemic presents various ‘pathways of risk’.
Whilst it is proposed that the health sector plays an integral role in the mediation of the risks and consequences of violence against women during the pandemic restrictions, this also presupposes the universality of health systems as a global force, which act to eliminate violence against women. However, from current research that I am undertaking in Afghanistan, this is far from the case. Health professionals are not immune to harmful socio-cultural processes and attitudes towards violence against women.
Furthermore, and this is most significant for considerations when responding to and treating women experiencing violence, the ways that suffering are experienced and why violence is harmful lack conceptualisation – and a conceptualisation that encompasses the lived experience and first person narrative of violence, as opposed with or juxtaposed to a pathologized criteria of psychiatric disorders that are correlated with a history of violence. The connection between violence and suffering is often lost, or rather, there is a chasm that exists between a woman bearing the experiences of violence and the legacies that the violence leaves within, and in most part, this is related to the silenced suffering that even health sectors yield expression of.
As researchers and clinicians, it is of course vital to ensure service provision exists and correct procedures for signposting and reaching marginalised women are evident in long-term community outreach strategies for preventing and responding to violence. However, a missing link is the voice of the sufferer; to hear and be heard by another requires a view that perceives the pandemic restrictions are actually a mirrored replica of the everyday confinement of a narrative that remains within. Thus, of course, let it be known that women experiencing violence is a crucial feature of the covid-19 pandemics as has also been evidenced with other epidemics in the past, but the ways that the pandemic restrictions emphasise the silencing of suffering must also be overt. Only then, can the imprisonment of suffering find a freedom.
Competing interests: No competing interests