Mental Health Impact of Gender-Based Violence Amid COVID-19 Pandemic: A Review

Gender-based violence (GBV) and poor mental health have received particular attention among healthcare professionals, policymakers, and researchers amid the COVID-19 pandemic. This paper presents a review of available literature to understand the dynamics of GBV and its mental health impact in the context of COVID-19. Confinement and control by abusive partners, social and economic disruption, and restricted access to healthcare services were identified as the main contributing factors of GBV. The paper elaborates on the contribution of broader socioeconomic determinants of health as well as cultural and societal factors of victimization in shaping GBV by placing specific populations or individuals in a more vulnerable position within the society based on their gender. Socioeconomic determinants included socioeconomic status, education, migration and racial, ethnic, or gender-based minoritisation. Cultural and societal factors of victimization are mostly related to gender-based structural power discrepancies and communication patterns. Evidence suggests a complex relationship between COVID-19 specific stressors, such as health anxiety and intolerance of uncertainty, GBV, and mental health issues. COVID-19 stressors might directly trigger the mechanism of aggression and cause physical or psychological violence and associated mental health implications in victims, or it might be mediated by pre-existing mental health issues experienced by perpetrators.


Introduction
Gender-based violence (GBV) is a lamentably widespread phenomenon that affects most countries, regardless of their economic and social development stage. Bouta, Frerks, and Bannon 1 define GBV as the "physical, sexual, and psychological violence against both men and women that occurs within the family and the community and is perpetrated or condoned by the state." Therefore, GBV should be a broad universal term, not restricted to a particular setting or type of violence, and used to discuss various issues. Many instances of GBV inherently violate fundamental human rights and present a serious public health threat. The consequences of these violent acts, be it corporeal violence or various manifestations of psychological and sexual violence, entail deplorable consequences on the victims' mental health, including but not limited to anxiety, depression, various substance abuse, post-traumatic stress disorder (PTSD), sleep disorders, suicidal tendencies, and self-harm 2 .
Nevertheless, while GBV is a commonly used term, delving into the problem in-depth requires a thorough understanding of other terminology around this issue. Numerous terms are often used interchangeably to discuss the different GBV-associated problems; however, it is imperative to draw distinctions between them to understand the implications of each issue. Since GBV disproportionately affects women, another critical term is violence against women (VAW) 3 . Globally, one in every three women has suffered beatings, has been pressured into sex without consent, or has become a victim of some form of abuse in their lives 4 . Therefore, VAW encompasses all types of violence mentioned above, but only when targeted at individuals who identify as women.
Moreover, another frequent term is domestic violence, which can also be called family violence. It is the broadest term, as it does not imply violence against any particular gender and applies to any person residing in the same household as the perpetrator, be it a child, a partner, or another relative 3 . On the contrary, intimate partner violence (IPV) exclusively applies to partners in long-term relationships, both heterosexual and same-sex couples. Therefore, domestic violence and IPV are not based on the victim's and the perpetrator's gender identity. We will use GBV as an umbrella term for this review while also using more specific terminology explicated above to narrow down specific issues.
All the aforementioned forms of abuse have adverse consequences to the victim's mental health, thereby contributing to a severe public health issue. Mental health is defined as "a state of well-being," including emotional, psychological, and social components. It helps determine an individual's ability to cope with everyday stresses of life, work productively, and contribute to the community 5 . Sexual and physical violence are also known risks to mental health. During the COVID-19 pandemic, "shutting down" businesses and the "stay home" order can aggravate GBV and domestic violence and exacerbate mental health conditions. Depression and anxiety are the most common mental health issues and are among the most critical public health concerns 5 .
This narrative review of past literature aims to explore the dynamics of GBV during the COVID-19 pandemic. The paper addresses the contributing factors and mental health impacts of GBV globally while considering how broader socioeconomic and cultural factors may place specific individuals at a higher risk of violence.

Prevalence and Trends of Gender-Based Violence During the COVID-19 Pandemic
Preliminary data indicate that the ongoing COVID-19 pandemic may significantly impact GBV and associated public health implications. In addition to the unfortunate incidents covered by media, the number of domestic violence incidents has been documented in all regions worldwide during the COVID-19 pandemic [6][7][8][9][10] . VAW reportedly increased significantly from 4-5% before to up to 50% during the lockdown based on online surveys in different settings [11][12][13] . The most common form of violence was psychological abuse 11 . Interestingly, this type of violence had been the most frequent even before the COVID-19 pandemic 14 . Alongside the common forms of abuse, IPV offenders weaponized the anxiety and fear caused by COVID-19, thereby indirectly using it against their partners; for instance, prohibiting medical aid in case of emergency or prohibiting their victims from carrying out routine hygienic practices, such as handwashing, in order to increase the partner's dread of becoming infected with COVID-19 15 . Before lockdown, women who had suffered from IPV were more likely to be abused in isolation with their partners 11 .
Broader socioeconomic determinants of health were salient before the pandemic but have been amplified by the ongoing unprecedented public health crisis. Countries on the lower socioeconomic development spectrum have seen particularly severe cases of women's self-isolation in unsafe domestic environments brought about by violent and abusive relationships 16 . In a time-series study in rural Bangladesh, among women experiencing emotional violence (being insulted, humiliated, intimidated, or threatened) or moderate physical violence (being slapped or having something thrown at them, being pushed, or having their hair pulled), over half reported that it had increased since the lockdown 12 . According to a preliminary gender analysis of the COVID-19 crisis, persons who identify as women may be disproportionately affected due to their socioeconomic and humanitarian circumstances in various ways, such as facing adverse consequences for their education, safety, health, income, nutrition, and food security 17 .
Additionally, women who come from minority groups are at an increased chance of suffering from the adverse effects of GBV. For example, when it comes to reproductive and sexual health support, marginalized communities are disproportionately in danger of not gaining access to the appropriate services 18 . Moreover, the critical situation caused by COVID-19 specifically affects people identifying as lesbian, gay, bisexual, transgender, intersexual, queer, and others (LGBTIQ+), who already suffer from the lack of adequate access to genderaffirmative healthcare and rampant discrimination as a marginalized community. For instance, a recent study in Argentina carried out among transgender and non-binary persons demonstrated that the most common GBV perpetrators were family members of the victims, especially those who identify as nonbinary 19 .
Cultural and societal perceptions of victimization include gender-based structural power discrepancies and communication patterns. It was noted that although IPV is often conceptualized as occurring in the context of VAW by their male partners, reciprocal violence is a common form of IPV 20 . Several gender differences may serve as risk factors of IPV, such as men's emotion regulation abilities and women's social support. The study by Glowacz 21 found that the majority reported being victims of violence among the perpetrators. However, the findings were limited to minor violence as perpetrators of terrorismtype intimate violence would be unlikely to report their violent actions. Furthermore, victims would be restrained from responding by their controlling partners. Currently, as long as the COVID-19 pandemic aggravates the situation, the 'silent' cases of severe IPV against women will possibly remain more widespread.

Confinement and Control by Abusive Partners
Numerous risk factors that lead to IPV are being aggravated by various aspects of the COVID-19 pandemic. Lockdown measures, in particular, contributed to the growing number of domestic violence cases, developing what the United Nations has named "shadow pandemic within the pandemic" 22 . "Shelter-in-place" restriction policies, implemented by governments globally as a preventative measure against COVID-19 spread, obligate victims to endure abuse within the confines of their homes 22 . Various data demonstrate that GBV has grown globally during the lockdown, as victims, most frequently women, have little to no opportunities to get away from their abusive partners. Reports from numerous countries indicate that various public health measures aimed at slowing down the transmission of COVID-19, such as lockdowns and social distancing, entailed inadvertent negative consequences for the victims of domestic violence 18 . The controlling and stalking tendencies of GBV perpetrators have grown during lockdown when they are constantly forced to remain in a domestic setting.
Moreover, some studies have shown that the number of calls to helplines from IPV victims has gone up 23 . Nevertheless, a contrary trend has been observed, whereby a significant decline in the IPV victims who sought aid from various support services, such as emergency departments and assault referral centers, has been reported 24 . Unfortunately, this could be because women are constantly controlled by their abusive partners in the confined spaces during the lockdown, and the opportunities for a disclosure of the maltreatment are reduced 23 .
According to sociological and gender research, the more time families spend in direct contact, the higher the possibility that groundless violence may occur -a tendency which literature ascribes to human psychology [25][26] . Nevertheless, aside from the adverse consequences on people (domestic violence), it would also be interesting to consider the positive effects of constantly being nearby during lockdowns due to the unprecedented nature of the COVID-19 crisis. Some of the recent studies have already provided insight into this matter. For example, a cross-sectional study among Nigerian couples found a decreased prevalence of IPV in the early phase of the pandemic, suggesting that couples can experience less partner violence during periods of confinement. Nevertheless, it is crucial to consider that the study respondents mainly were working women whose minimum level of education was a college degree 14 . Therefore, it is possible to suggest a link between the positive impact of couples' confinement and the level of their education and employment status.

Social and Economic Disruption
Considering that the frequency of domestic violence is disproportionately higher in regions struggling with the economic repercussions of the COVID-19 pandemic, it is likely that economic problems are major contributing factors to the sharp rise in domestic violence cases. A survey carried out among Spanish women indicated that the impact of economic consequences was twice as significant as forced cohabitation due to the lockdown 27 . Despite having no prior reported abuse in a family, anxiety brought about by financial hardship during the crisis and little aid from society may have incited violence. Pandemic has caused economic insecurity due to loss of jobs and livelihoods, closure of businesses, and household members living in increased stress and tension 28 . Economic insecurity resulted in worsened economic dependence of women on their spouses or intimate partners 29 . For instance, sudden unemployment on the husband's side may render him unstable and temperamental, leading him to take his anger out on his spouse. As a result of domestic violence, more separations and divorces are likely, meaning government resources will be employed, placing additional strain on the economy 30 . The adverse effects of domestic violence on physical and mental health are well documented in the literature, ranging from depression, risky sexual behavior, and substance abuse to more long-term challenges like chronic diseases [31][32][33] . More importantly, because of domestic violence, countries face the possibility of losing a productive workforce that may otherwise contribute to the economy but is instead taken away by the mental and physical effects of domestic violence. An unprecedented phenomenon regarding the pandemic and domestic violence is that economic complications simultaneously present causes and consequences, creating a vicious cycle. Essentially, domestic violence cases aggravated by the pandemicrelated economic hardships entail deplorable mental and physical consequences, which, in turn, lead to a loss of a valuable workforce that could have alternatively made a significant contribution to the country's economy. Although this unfortunate issue may take a longer time to develop, it is inescapable, nonetheless 28 .
Another factor associated with the pandemic is the disruption of social protective networks and the inability of the victims to seek help and access protective community support or leave the relationship 34 . Before the pandemic, domestic violence victims had an opportunity to seek various forms of help, such as support in the face of family and friends, shelters, and even protective orders and other forms of legal aid. Lockdown measures take many of such options away 28 . Moreover, seeking help from colleagues in the workplace is another essential remedy for the victims, which became unavailable during COVID-19, as many companies and establishments implemented remote working conditions on a large scale. These work-from-home policies have significantly diminished people's overall opportunities for socializing, and more importantly, they have prevented abuse victims from seeking or maintaining support from their co-workers [35][36][37] . Besides, women's limited access to different sources of housing, such as shelters and hotels that have reduced their capacity to host, and travel restrictions have prevented women's access to safer places 29 . As women have been forcibly cloistered in their homes, it is likely that the frequency and magnitude of violence they are subjected to will only grow. In humanitarian settings, insecurity and instability during COVID-19 may lead to increased exposure of women and children to unsafe and risky environments, including sexual violence and harassment during the procurement of essential goods 16 .
Also, the closure of school and childcare facilities is a considerable loss for domestic violence victims as it creates more stress and responsibility for both victims and their children. In addition, we must also consider the notion that areas under containment might not have available childcare support, which only aggravates the children's hardships; for instance, there may be negative consequences to their food security, adequate education, and general development. Moreover, children may also be mentally affected by witnessing increased domestic violence in their households [38][39] . Besides, school closures have led to thousands of adolescent girls staying at home, placing them at heightened risk of violence, especially in humanitarian settings 16 .

Restricted Access to Health Services
As the pandemic grows, all health resources are directed towards responding to the COVID-19 situation, leaving other essential services such as GBV support understaffed and under-resourced. Medication shortages have been reported worldwide, with some countries already experiencing stockouts of sexual and reproductive health (SRH) supplies. Many clinics have closed or reduced their hours, while others have had to redirect human resources and clinic space to the COVID-19 response. In addition to possible supply-side issues, lockdown might have restricted women's access to health care services. Moreover, fear of exposure to the coronavirus might discourage women from attending clinic appointments and seeking other relevant services. Reduced transport options during lockdown also disproportionately impact women, for whom walking carries a greater risk of assault. Women who experience IPV and do not ask for help could have otherwise been identified in the emergency departments by the trained healthcare workers, but now emergency departments are overwhelmed by COVID patients 23 . Notably, an American largescale online survey demonstrated that people still visited emergency departments during the lockdown for violence outcomes. For the most part, visits for these outcomes decreased to a lesser extent than overall emergency department visits, confirming that violence remains a concern during the COVID-19 pandemic 40 . The COVID-19 crisis has aggravated pre-existing injustices and discrepancies in social and healthcare systems. In a recent large-scale web survey in the UK, people who identify as women, ethnic minorities, and those with chronic illnesses experienced significantly more cancellations of medical or surgical appointments and needed longer care hours during the lockdown 41 . Healthcare systems are generally not easy to utilize, and they are also unable to adequately assist immigrants, considering their background and SRH needs 42 . Under non-pandemic circumstances, immigrants in the United States do not have sufficient access to public health insurance programs, generally due to regulations that do not allow registration because of legal and immigration status or several years living on the United States territory 43 . Given the current high-risk epidemiological situation with many economic and social stressors, the access to appropriate healthcare services may only continue to decrease for immigrants and communities found in similar situations of social and economic depravity.

Impact of Gender-Based Violence on Mental Health Amid COVID-19 Pandemic
The literature provides compelling evidence of the detrimental consequences of domestic violence on people's mental health. Such consequences include but are not limited to high-risk sexual behavior, depression, substance abuse, and even problems such as chronic mental afflictions [31][32][33] . Both GBV and mental health issues are complex and multifaceted concepts 44 . The adverse effects of the COVID-19-related lockdown on women's mental health and GBV have been reported in low-and middleincome countries 11,16 . A recent German survey reported alarming IPV levels and demonstrated that the COVID-19 Pandemic Leads to a mental health burden even in highly developed Western countries 45 . Another cross-sectional study in the United States showed that during the lockdown, IPV and sexual violence were significantly associated with greater symptom severity of depression and anxiety in the two weeks following the stay-at-home state order 46 . The study also demonstrated that those with more outstanding social support appear to have a better capacity to withstand the mental health impacts of the pandemic.
Notably, there is a complex relationship between COVID-19 stressors, IPV victimization, and mental health (or health risk behaviors). Gresham et al. 47 found that COVID-19 stressors, such as social disconnection, financial insecurity, and health anxiety, were positively associated with IPV victimization, and IPV victimization was positively associated with substance abuse. On the other hand, mental health issues may mediate between COVID-19 specific stressors and IPV. For example, uncertainty caused by the pandemic plays a vital role in triggering the mechanism of aggression, and mental health issues experienced by perpetrators could mediate this relationship. Glowacz, Schmits, and Dziewa 21 showed that anxiety and depression mediated the relationship between intolerance of uncertainty and physical or psychological abuse regardless of gender in a multinational sample from Belgium, France, and Canada. The study also found that physical assault was significantly higher in men, whereas psychological aggression, anxiety, and intolerance of uncertainty were significantly higher in women.
In addition, concerns have been raised regarding mental health and its relationship with family violence among healthcare practitioners. Being a woman was one of the most common risk factors associated with increased risk of depression and anxiety [48][49][50][51] , exposure to COVID-19 patients 49, 52-54, and fear of being infected 50,53,55 . In a study among family and mental health practitioners in Australia, increased proportions of caseloads, changed work practices during COVID-19 restrictions, and associated incidents of family violence resulted in higher workplace stress which was related to sleep disturbances, headaches, more significant negative affect and an overall worsening of mental health of the participants 56 .
GBV victims face unique challenges amid the COVID-19 pandemic. Through the analysis of available literature, we found that the factors contributing to GBV were related to confinement and control by abusive partners, social and economic disruption, and restricted access to health services. Moreover, we identified the role of socioeconomic determinants and cultural perceptions of victimization in shaping SBV issues, as well as complex relationships between COVID-19 stress factors, violence, and mental health (Figure 1).

Conclusion and Recommendations
Globally, GBV is a public health crisis. The COVID-19 pandemic amplified the mental health implications of GBV, primarily due to the effect of lockdowns imposed by the governments to curb the infection spread, financial insecurity, and social disconnection faced by the communities, and diminished health services overstretched by the necessity to address challenges caused by the pandemic. In this study, we identified the main contributing factors of GBV during the pandemic, outlined the broader structural and systemic factors shaping GBV, and elaborated on the complex relationship between COVID-19 specific stressors, GBV victimization, and mental health issues. Future research is needed to explore how the dynamics of GBV and its mental health impact within the COVID-19 pandemic should be addressed by public health policymakers and healthcare professionals to provide more resources and help to GBV victims.

Funding
No funding sources

Acknowledgment
The authors thank Professor Dr. Mainul Haque of the National Defence University of Malaysia for his helpful comments that improved the manuscript.