“The Cries behind the Closed Rooms”: Domestic Violence against Women during COVID-19, A Crisis Call

1 Department of Psychiatric Social Work, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India

2 Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India

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Author of Correspondence: Dr. Debanjan Banerjee, Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India
E-mail: dr.Djan88@gmail.com

ABSTRACT
The Coronavirus disease 2019 (COVID-19) has emerged as a global health threat. Beyond just the public health perspective, such pandemics can cause immense psycho-social implications, that long outlast the infection itself. The stress as well as lockdown and social distancing as measures to control the outbreak, has led to change in living structures and behavioral responses. The already prevalent ‘social evil’ of domestic violence has increased globally, more so in India, a country already burdened with gender inequality. This can range from physical violence to sexual, psychological and financial abuse which gets further compounded by under-reporting, lack of awareness, stigma, societal apathy and patriarchal belief systems. Victims of abuse, especially under the present pandemic crisis can have both acute and chronic harmful psycho-social consequences. Keeping this in background, this commentary glances at the problem statement of domestic violence during COVID-19 crisis, the social contributors
to the same and role of mental health education as a unique tool to prevent and mitigate this ‘social evil’.
Keywords: Coronavirus, COVID-19, pandemic, domestic violence, abuse, women
Introduction
“Injustice anywhere is a threat to justice everywhere”
(Martin Luther King, 1958)

The Coronavirus disease 2019 (COVID-19) has been a global health problem. Beyond just the purview of public health, it has affected the daily lives of billions, either segregating them in isolation or stranding them with their families for long periods like never before.[1] The negative social consequences are gradually becoming apparent as ‘human behavior’ can change markedly under crisis and ‘within closed walls’. One of the offshoots, the global ‘evil’ of domestic violence has increased markedly. It includes gender-based violence, child and elder abuse, and intimate partner violence (IPV). The contributing factors during this pandemic are increased stress, travel restrictions imposed by lockdown, increased marital discord, unprecedented staying periods with the partners, overcrowding, stress, anxiety, financial crisis and substance abuse.[2] Further compounding the problem statement are the factors of under-reporting, lack of access to social and health care, domestic threats and lack of awareness and sensitivity even amongst health care professionals. Families with pre- existing abuse make it an increased ‘norm’, justified by the isolation and lockdown. With the increase number of days in the lockdown, reports in the increased number of cases of intimate-partner violence were understood across the globe. The United Nations (U.N.) defines IPV as any behavior by an intimate partner or ex-partner that causes physical, sexual or psychological harm, including physical aggression, sexual coercion, psychological abuse and controlling attitudes. It is often considered synonymous with domestic violence or abuse. Specifically, when directed against women, it can be threats or acts of coercion, aggression or arbitrary deprivation of autonomy, all of which have detrimental effects on their wellbeing and quality of life.[3]The United Nations (U.N.) Secretary General Antonio Guterres called out for a “ceasefire” on April 6, 2020 in order to address the “horrific global surge in intimate partner violence”.[3]

Violence and disasters are known to have an old correlation. Eruption of Mount St. Helens in 1980, Hurricane Katrina in 2005, Black Saturday bushfire, 2009 and the Earthquake in Haiti, 2017 are classical examples of IPV that followed in the background of family stressors, reported aggression, unemployment and other associated stressors [4]. Even previous outbreaks like Ebola, cholera, Zika and recently Nipah have led to disruptions in inter- personal relationships, and increase in domestic violence.[5] Though globally, data is yet to

emerge in a systematized manner, the gender based violence trends are increasing in United Kingdom National Domestic Abuse Helpline.[6] Similar rise has also been seen in other countries heavily affected like Spain, Italy and China.[7] It is vital to remember that persistent domestic abuse can have detrimental psycho-social and physical consequences and it has already been deemed as a ‘social evil’ that is tough to identify and tackle. This commentary thus plans to draw attention to this concerning aspect of the pandemic and highlights some of the psycho-social factors that might lead to this issue. The role of mental health education and its integration into public health as a measure of mitigation are eventually discussed.

Domestic violence in women: The Problem Statement during COVID-19

“I was tired of explaining that I too have to work from home. No one was willing to look after my children. I had to do every single detail while managing my office work. It was getting at me. I have never experienced such times. I am spending sleepless nights, with no one to listen to me….”
(A techie from Bangalore, on working from home during the lockdown)

“The alcohol use of my husband has increased so much. I cannot even go to my own house due to lack of transport. If I deny or protest, I will get beaten up, what’s the point! I am more scared of being at home for longer than the infection!”
(A crisis call to our helpline, from a lady staying with husband in rural Karnataka) (** Both excerpts altered to some extent and taken with consent for anonymity)
The above excerpts might be from different poles of social class, but essentially reflect a common theme: the lack of understanding my proximal family, altered perceptions about women’s autonomy and substance abuse, all eventually contributing to domestic violence.

Globally, one in every three women experience physical or sexual violence during their lifetime. At least 35 to 40 percent of relationships are marked by some form of violence by partners.[8] The authors do not intend to stress that domestic abuse is directed exclusively against women, however in most of the cases they are the victims and similar perspective will be maintained throughout this article. The violence against women is in fact increasing, especially in developing and populous country like India. India has been infamous for

gender-based violence, ranked the fourth country in world for gender-inequality, according to public perceptions.[9] As per National Crime Research Bureau (NCRB) data, nearly 90,000 cases related to crimes against women were registered against women in 2018, higher than 86,000 in the previous year.[10] Nearly one-third of these were some form of domestic abuse. The National Family Health Survey (NFHS-4) 2015-16 reported that more than 30 percent of Indian women between 15-49 years have experienced physical violence in relationships, with 85 percent cases the perpetrators being their male partners.[11] These definitely represent the tip of the iceberg, as social stigma, fear and legal hassles prevent reporting of most cases. As billions have been stranded at their homes for ‘social distancing’ in an attempt to control the outbreak, domestic violence has been rising. The National Commission of Women in India received 239 complaints between March 23 and April 16, as compared to the previous lockdown phase having 123 cases [12]. Many of these were domestic in nature, related to bigamy, polygamy, dowry related issues, substance abuse and marital disharmony. It is also important to understand that not all forms of domestic abuse are physical violence: restriction of rights, mobility, autonomy and sexual harassment are also equally traumatic. Psychological and financial abuse might be chronic and subtle, but eventually normalized though having a greater impact in the long run.

It is important to understand that every decision of the government for the betterment of the communities comes with the aspect of co-morbid psychological and psychosocial difficulties which then have a direct correlation with the quality of life and mental health of the individuals. The hotline services working across the country have received close to hundred calls reporting “physical, emotional and verbal of abuse” [13]. Urgent measures of awareness, mass sensitization, community-based approaches and active inclusion of women and child safety measures during this crisis are needed to fight this ‘social evil’.

The Vicious cycle of Domestic Abuse: Delay or hesitation to report?

It is important to understand that violence occurs irrespective of gender, class, caste, creed, time or place. Family, considered as the primary support system, becomes the primary site of exploitation and violence. Sociologically, role allocation being sexist in nature has resulted in the demarcation of household work as “women’s work”. The change in the daily home routine and structure due to the increased amount of time spent by other members altogether increases the role strain and affects the ambience of the house. Family in this context has

been often termed by individuals as a “primary site of exploitation” and the trend of the same has been seen to rise with the increasing number of days in lockdown. Women across the helplines in the country have stated restriction in terms of access, food, non-provision of masks thereby making them use “dupattas and pallus” for respiratory hygiene, non-access in the ration card, LPG and clinics. Most of the women in the country do not even have an access to phones for communication as they have to depend upon their husbands, fathers or brothers. The ineffectiveness of law wherein marital rape is still not considered as a criminal act, adds to the insult. All these factors have a holistic effect on the affected person’s health and rights [14]. Evidently at times of financial and economic recession, human behaviour tends to be impulsive, reckless, controlling and aggressive and the brunt usually goes down the patriarchal power-hierarchy, so relevant for India. Here are few factors contributing to the vicious cycle of domestic abuse, especially during the pandemics.

Psychosocial Concerns:

  1. Lack of awareness on the availability of hotlines: Most of the individuals, who undergo violence, cannot report it or bring it to the notice of the authorities due to the lack of awareness about the hotlines. Increase in the awareness and promotion will increase the help-seeking behaviour and reporting among them. The penetration of these helplines in rural areas is really a
  2. Misinformation and role of social media: For all practical purposes, COVID-19 has turned into a digital ‘infodemic’ with information overload adding to the stress burden. Various rumour-mongering and fake news over social media appear as obstacles in the way of autonomy for women, increasing fear of infection and transmission.[15] Misunderstanding the precautions of pandemic might alter social perceptions leading to faulty attitudes among
  3. Lack of health care access: Many cases that are already registered at various social centres or hospitals might be lost to follow-up and review during COVID-19 due to non-availability of many health services, travel restrictions and strict imposition of lockdown. These cuts off the vulnerable from social care and can perpetuate the already existing
  4. Lack of sexual and reproductive health services: In the current condition, it has been difficult for them to get in touch with the healthcare professionals who provide sexual and reproductive health services in person and at the same time, the same has not been provided currently over helpline services either making it difficult for them, thereby increasing the rate of unprotected sex, forced sex, pregnancy and marital rape.[16] The lack of idea about healthy sexuality and intimacy practices are prevalent during this pandemic, which often lead to sexual frustration, coercive and risky sexual interactions.
  1. Fear of the police/legal hassles and stigma: Most of women stay away or refrain from reporting to police out of the fear, lack of cooperation or if the fear of exploitation by the police. They tend to not got ahead and come and seek help thereby increasing the difficulty. Definitely, it cannot be generalized as many are willing to help. But some unfortunate experiences usually taint the larger scenario. The social and self-stigma related to disclosure and normalization by the families further lead to under-reporting.
  2. Difficulty in managing family: With many members living under the same roof, women tend to manage the chores of not just the household but also of the aspects of childcare, but due to the traditional structures, role strain and role allocation may not adequately managed thereby causing difficulty in the form of aggression and
  3. Objectification of women: Objectification theory states that women are treated as an object to be valued for its use by others and she is viewed as a physical object of a male desire. This behaviour in the Indian tradition is found as a “normalized heteronormative tradition”, thereby increasing the concerns of name calling, self- objectification, several risks, and stressors thereby affecting the physical and mental health of women [17]. Movies and media often add to this, exacerbating this belief- system.
  4. Cycle of Violence: Alcohol as a mood enhancer has a direct correlation with feelings of anger, frustration and irritation. A man’s perception of the need to comply to the gender norms could be exacerbated by substance abuse thereby shifting the focus on women. This then results in violence. Due to the vulnerabilities of women, the vicious cycle might continue from the women to off springs, further force from the family of origin, the expected normalcy from the family of procreation and difficulty in the accessibility and availability of the legal aid services add to the problems [18].
  5. Lack of livelihood: Women who are unable to go for work during this crisis, have to critically balance ‘work from home’ and ‘work for home’. Perceptions of family might interfere with their work patterns with added domestic responsibilities, the clash of which leads to discord. Many might be in financial crisis, worsening their autonomy in their respective familial circles.
  1. Knowledge-Attitude-Practice (KAP) gap: This is perhaps the most important contributing factor.[19] For decades, domestic violence has been normalized by social strata across all classes, so much so that the awareness and need for prevention are undermined grossly. The impact of mental and physical health is also largely

Role of Mental Health Education: A Uniquely Powered Tool

Mental Health Education (MHE) is specially equipped at times of such crisis with strategies ranging from individual to systemic and community level in promoting mental and social wellbeing.[20] Domestic abuse being an integral component of both, MHE can be fundamental to enable awareness and understanding in the communities and aid in the larger reach with the help of media and community health workers. It can also use technology for training and advocacy programs. Here are few ways in which that can be brought about.

  1. Increasing awareness: Information-Education-Communication (IEC) materials can be prepared to ensure the understanding of the people on the intimate partner violence and the help-seeking behaviour through helplines. Socio-culturally appropriate and multi-lingual infographics can be simple aids to put out the message to the
  2. Boosting the manpower: Though crisis management and psychosocial first aid is structured as a package by the mental health care professionals, the aspect of networking, collaborating and to ensure capacity building among them could be done through the training of the police personnel and other individuals who volunteer and are ready to provide protective
  3. Provision of Legal Aid work: Statistics once generated could be shared with the police authorities, women cells and legal aid cells wherein the immediate details could be planned and also in case of urgency 24×7 legal aid courts, ambulance services could be set
  4. Community outreach: Local, state and national government could be provided with sensitive and comprehensive messages in the form of audio, video and written methods such that maximum message can be circulated and processed for the beneficiary.
  5. Social stigma campaigns: Involving all levels of stakeholders in various social campaigns which incorporate awareness about domestic violence, the helplines involved and the legal provisions can be helpful. The Mental Health Education (MHE) department of our institute has already been doing novel work in the field of COVID-19 awareness using social media campaigns.[21] Social media, in fact, is uniquely equipped to support this cause due to its high penetration and consumption. In certain countries like France and Spain, pharmacies are being involved through media awareness, where asking for ‘Mask-19’ is a code for domestic violence alert.[22]
  1. Integration of social and public health systems: Mental health promotion needs to be integrated into health communication at all levels of care. The grass-root community workers, general physicians and nurses face the maximum case load and thus need to be trained to deliver awareness about domestic violence.[23] Tele- medicine facilities are probably an asset in these situations for digital training and communication.
  2. Media-Physician collaboration: Mental health and public health experts need to be collaborating actively with all forms of print and digital media to debunk misinformation and help them educate the community about abuse
  3. Victim care: Various forms of adjustment disorders, stress reactions and post- traumatic stress disorders are prevalent in abuse victims. Depression, anxiety and suicidality are frequent accompaniments. MHE measures can be critical in helping them avail counselling and treatment facilities, fight the stigma and preserving their autonomy and self-esteem. Gatekeeper training can help suicide

Conclusion: The Way Forward

In the dark times, it is a shoulder, a hand or an emotional response that one needs to feel heard and catered to. In the current scenario where one cannot have the face to face individual session, these services need to be provided to the vulnerable and needy populations through telephone, online or other virtual methods for which the necessary pamphlets or leaflets could be prepared and circulated through social media methods as promotion of mental health and protection of human rights. Besides, civil society and non- governmental organizations will play critical role in providing assistance. It is a collective responsibility and all of us irrespective of educational or socio-economic background can aid in prevention of this social evil. The Government can promote ‘domestic abuse prevention’ as an ‘essential service’ which raises the bar of importance. The Indian Pandemic Act of 1897 definitely needs modification; incorporating the needs related to domestic violence

might be worthy. Citizens need sensitization to identify the earliest signs of abuse and report them to the necessary authorities. Legal and administrative provisions should be hassle-free to enable more reporting and assurance to the victims. The National helplines by Ministry of Health and Family Welfare, Government of India (MoHFw, GOI) can integrate child and women safety services to make it more comprehensive. Importantly, the marked gaps in research and data related to monitoring and implementing the interventions in domestic abuse need to be filled with systematic studies. India is a fertile ground for the same, considering the increased prevalence of this social evil. An integrated public-mental health approach is the key and mental health education is an essential tool. The COVID-19 pandemic might be yet another opportunity for us to relook and evaluate the gaps in our prevention and care of domestic violence, before it is too late.
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