key: cord-0905810-71nws8w8
authors: Nordhues, Hannah C.; Bhagra, Anjali; Stroud, Natya N.; Vencill, Jennifer A.; Kuhle, Carol L.
title: COVID-19 Gender Disparities and Mitigation Recommendations: A Narrative Review
date: 2021-04-20
journal: Mayo Clin Proc
DOI: 10.1016/j.mayocp.2021.04.009
sha: 4d78bb8358a08c7b2acdc9c4e74a3ed2706f902f
doc_id: 905810
cord_uid: 71nws8w8

The coronavirus disease 2019 (COVID-19) pandemic has rapidly created widespread impacts on global health and the economy. Data suggest that women are less prone to severe illness; however, sex-disaggregated data are incomplete, leaving room for misinterpretation. Additionally, focusing on only biologic sex underestimates the gendered impact of the pandemic on women. The present narrative review summarizes what is known about gender disparities during the COVID-19 pandemic and the economic, domestic, and health burdens along with overlapping vulnerabilities related to the pandemic. Additionally, this review outlines recommended strategies that advocacy groups, community leaders, and policy makers should implement to mitigate the widening gender disparities related to COVID-19.

The coronavirus disease 2019 pandemic, caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has rapidly evolved since the initial identification of the virus in Wuhan, China, in December 2019. Over 112 million confirmed cases of COVID-19 have been reported with over 2 million deaths worldwide. 1 The enormity of the situation has created widespread impacts on global health and the global economy.

Global data suggest that there are sex differences in mortality from COVID-19. 2, 3 Biologic differences in hospitalization and mortality rates between cisgender men and women are the subject of many epidemiologic and biomedical studies. [4] [5] [6] [7] [8] Beyond biologic sex, other gendered behavioral differences may alter the risk profiles of men and women, with prior studies suggesting that women more effectively follow hand hygiene and mask-wearing practices. 9, 10 In light of these emerging data, some have suggested that women are less affected by the COVID-19 pandemic. This stance risks greatly underestimating the gendered impact the pandemic has on women beyond biologic sex variation. [11] [12] [13] Past health crises have demonstrated that people with unprotected human rights at baseline are more likely to experience health, social, and economic consequences of a crisis. 13 14 In the US, the pandemic is exacerbating preexisting inequities; low-income, Black, Latinx, immigrant, and Native American communities have seen a high burden of the disease. 15, 16 Often underestimated are the roles of women in the pandemic and the exacerbation of gender J o u r n a l P r e -p r o o f inequities that leave them vulnerable. 16, 17 Understanding the impact of sex and gender on disease processes is essential for understanding the impact of health inequities and adequate public health responses; however, approximately two-thirds of the global data are not sex disaggregated, masking gendered issues surrounding COVID-19. 2, 18, 19 We review the nonbiologic impact of COVID-19 on women and highlight recommended steps to ensure that gender disparities remain at the forefront of resource allocation and policy creation during the pandemic.

We performed an initial literature search of Embase and MEDLINE databases through May 7, 2020, to find the most pertinent evidence in English-language articles relating to the COVID-19 pandemic and sex or gender with modifier terms that included female, women, mother, pregnancy, gynecologic disease, breast disease, breastfeeding, domestic violence, and disparities and appropriate synonyms. All article types were included in the initial search to allow for a complete view of the available evidence. Citations from reviews and perspective articles were evaluated for inclusion when appropriate. After initial literature review, authors identified categories of impact for inclusion, and subsequent publications were identified and included as they became available.

Articles were chosen for inclusion on the basis of clinical judgment and interpretation of findings at the time of publication and were not evaluated systematically. Because the literature and context of COVID-19 are evolving, we specifically chose not to review the biologic mechanisms of COVID-19 during pregnancy. We chose to include articles with concepts of nonbiologic mechanisms of gender disparities and collated common mitigating recommendations from national and international societies.

In a multiyear analysis of US census data, women composed 52% of all "essential workers" who do not have the luxury of staying home and social distancing for safety during the pandemic. 20 Health care personnel and primary caregivers, whether paid or unpaid, have an increased potential for exposure to patients and infectious materials and therefore an increased risk for COVID-19. Women compose 70% of the global workers in the health care sector, with 80% of nurses and midwives identifying as women. 21 The State Council Information Office in China reported that over 90% of health care workers in Hubei province are women. 21 In 1 analysis, 60% of health care workers in China who were hospitalized with COVID-19 were women. 22 The Centers for Disease Control and Prevention (CDC) also reported that US health care providers composed 11% of all COVID-19 cases, and 73% of those cases were in women. 23 J o u r n a l P r e -p r o o f Within the paid health care workforce, gender disparities exist by occupation. In most countries, male workers have the majority of the highest paid positions (eg, physicians, dentists, and pharmacists). 21 In addition to the large proportion of female nurses and midwives, women have the majority of the lowest paying positions (eg, personal care workers). 21 Within these positions, women are more likely than men to be employed by the private sector, which offers less job security, lower pay, and more barriers to full-time employment and health benefits. 21 Importantly, the pandemic's economic burden on women is further exacerbated in the health care sector because an 11% pay gap exists, with women earning less than men for doing similar work. 21 Outside the health care workforce, women are heavily affected by the economic impact of the pandemic. In the US, unemployment during the pandemic has disproportionately affected women because women make up a large proportion of workers in the retail, dining, and entertainment sectors, where business has been significantly impacted by the pandemic. 24 These jobs often are in the front line with few employee protections. 25 In April 2019, the US Bureau of Labor Statistics reported similar unemployment rates for women (3.4%) and men (3.8%) aged 16 years or older. 26 However, in April 2020, the unemployment rate was 16.2% for women and 13.5% for men. 26 Furthermore, women more frequently serve as primary caregivers within a household and are more likely to perform unpaid work not captured by these statistics. 21 In the US, an estimated 65% of unpaid family caregivers are women and 80% of them provide care for at J o u r n a l P r e -p r o o f least 1 person older than 50 years. 27, 28 During outbreaks of cholera and Ebola disease, women had a 3-fold higher caregiver burden, placing them at increased risk for disease exposure and illness. 29, 30 Working women spend more time performing household tasks and caring for their children and parents compared to their male colleagues. Among heterosexual cohabitating couples where both are employed full-time, women have more household and child care duties than men. [31] [32] [33] These responsibilities are further exacerbated with work-from-home situations, closures of child care facilities, and distance learning. 19 Additionally, compared to men, women in the US are more than 4 times as likely to live as a single parent with fewer resources and safety nets; women who are primary breadwinners have lost jobs at some of the highest rates. 19 These unrecognized factors compound the impact of the workforce burden of COVID-19 on women.

Recommendations for mitigating occupational and economic gender disparities include the following (Figure 1 

While the CDC, World Health Organization (WHO), and other organizations recommend that people stay home to be safe from COVID-19, home is often not safe. 35, 37 Global data suggest that 1 in 3 women have experienced physical and/or sexual violence by an intimate partner. 38, 39 During global health crises, women and girls are at increased risk for intimate partner and domestic violence. 14 This likely results from a combination of heightened tension in the household and increased time at home isolated with an abuser during quarantine. During the 2014-2016 Ebola disease epidemic, with school closures, quarantines, and restricted community activities, reports of sexual violence increased 27%. 39 The global economic impact of violence against women has an estimated cost of $1.5 trillion (approximately 2% of the global gross domestic product). 38 In China's Hubei province, domestic violence reports tripled in February 2020 during quarantine. 39 Since the outbreak of COVID-19, the United Nations (UN) reported that domestic violence intensified 25% to 33% in France, Argentina, Cyprus, and Singapore. 38 Increased J o u r n a l P r e -p r o o f numbers of cases of domestic violence and demand for emergency shelter have also been reported in Canada, Germany, Spain, New Zealand, Brazil, Australia, the United Kingdom, and the US. 38, [40] [41] [42] In some of these countries, the number of domestic violence reports has increased by up to 50%. 40 Coercion, control, and social isolation are hallmarks of domestic abuse, and stay-athome orders may have major implications for power struggles within abusive households. 40, 41 Increased time at home increases the risk of violence, and abusers often target children and pets to further their control over the household. 42 Some reports have indicated that abusers use fear of infection with COVID-19 as an emotional abuse tactic, restrict hand washing, or forbid medical treatment. 42 As a result, women may be less likely to seek health services. 39 While stay-at-home or shelter-in-place orders are necessary to quell the spread of the virus, stringent restrictions on movement close escape routes for those seeking help. Women may be less likely to report domestic violence during telehealth visits if they are home with abusers during the appointment. Known risk factors for domestic violence include economic strain, unemployment, reduced income, and limited community resources, 39, 41, 42 and financial concerns decrease women's chances of leaving an abusive relationship. 39, 41 Alcohol abuse is another known risk factor for domestic violence, and in-home alcohol consumption has increased during the COVID-19 outbreak. 38, 42 J o u r n a l P r e -p r o o f

The vulnerability of women and girls during crises is exacerbated by lack of access to their usual social networks and by less access to health care. 38, 41 In addition to school closures, other community resources and shelters for women and children have reduced funding or capacity. 39 Some domestic violence shelters are being repurposed as housing shelters for patients with COVID-19 and are reaching capacity. 38 UN Women raised concerns that genderbased violence (GBV) and reproductive health services resources may be increasingly diverted as the pandemic progresses. 14, 38 Challenges in identifying and mitigating domestic violence issues have also contributed to increased trafficking in human beings (THB) during the pandemic. Domestic violence, decreased access to support services and shelter, and financial stress due to job loss may push women to take risks leading to trafficking, 43 and closed borders and travel restrictions leave asylum seekers vulnerable to THB. 44 To compound matters, convicted traffickers are released prematurely from incarceration (without notification sent to victims), and traffickers use online recruitment techniques, offering sexual services that can be shared without consent. 44 (Table 1) :

-Allocate additional resources to combat increases in GBV o Governmental and private organizations should increase resource allocation to meet the increasing need for response to GBV and THB. 19, 38 o Information should be widely available on how to access safety or immediate security. 35 -Develop culturally sensitive, country-specific plans o Geographic and cultural differences should be recognized for development of country-specific strategic plans for preparedness and response. 29 o Local and national first responders must be trained to respond to GBV in a compassionate and nonjudgmental manner, to know about community resources, and to be prepared to refer survivors immediately. 29 o Health care facilities and systems should proactively build referral pathways to ensure safe relocation for survivors of GBV and THB when they present for assistance. 29 -Develop innovative solutions to combat GBV o Use social media to build advocacy and awareness about increased violence against women and proactively engage with media outlets to increase visibility of resources. 38 J o u r n a l P r e -p r o o f o Mitigate economic impact as a barrier to leaving abusive relationships by targeting economic empowerment strategies, including providing support to women to recover or build resilience for the future. 29 o Build strategic public-private partnerships to develop innovative resources for survivors of domestic violence and ensure that regional authorities are prepared to support this population of women. 38 o Strengthen antitrafficking frameworks and capacity and update existing strategies to address trends in THB and consequences of the COVID-19 pandemic. 45

Fear, stress, and anxiety have increased considerably within the general population as COVID-19 has spread. Quarantine has increased loneliness and isolation, potentially exacerbating mental illness, substance abuse, and self-harm or suicidal behaviors. 35 Depressive disorders are twice as common in women compared to men, and depression and anxiety are interconnected to gender-based roles, stressors, and life experiences. 48 Multiple studies have shown that in the general population, women are more likely than men to experience symptoms of anxiety and posttraumatic stress during the COVID-19

pandemic. [49] [50] [51] A large population study from Iran reported that women experience higher J o u r n a l P r e -p r o o f levels of anxiety than men, whether or not they live in a high-prevalence area. 50 In a study from China, the odds of experiencing anxiety symptoms as a female were 3.01 times that of males during the initial months of the COVID-19 pandemic. 51 Women are experiencing considerably greater posttraumatic stress symptoms than men and are more likely than men to develop symptoms of re-experiencing, avoidance, poor sleep, and negative cognition or mood and arousal symptoms. 49 According to a recent analysis in the US, depressive symptoms during the pandemic have increased 3 times from baseline, although having more resources was associated with less depression. 52 This suggests that there may be a compounding effect of the increased financial, work, and domestic burdens of COVID-19 on women's mental health.

Additionally, multiple studies have shown that the mental health of workers in health care may be more impacted than that of other workers, and women are overrepresented in the health care field. 21, 49, 53, 54 A study from China, which assessed multiple mental health variables in medical and nonmedical workers, found that medical workers had a higher prevalence of insomnia, anxiety, depression, somatization symptoms, and obsessive-compulsive symptoms compared to nonmedical workers, and being female was an independent risk factor for anxiety o Health care leaders and employers should try to ensure that workers have adequate time off between shifts, that workers are rotated between higherstress and lower-stress functions, that scheduling is flexible, that buddy system support mechanisms are developed, and that workers have knowledge of adequate access to MHPSS. 56 o Individuals should take time for themselves, when possible, and use coping strategies such as rest, healthy eating, physical activity, and social connectedness between work shifts. 56

As illustrated during previous infectious outbreaks, including outbreaks of Ebola and Zika viruses, women's sexual and reproductive health (SRH) rights are frequently limited during times of difficulty. 29, 57 The COVID-19 outbreak strains the health system and further limits the system that provides SRH services, especially in resource-limited, low-income, and middleincome countries. 57, 58 Disruptions in normal clinic operations may cause interruptions in usual SRH services, including contraception, safe abortion, and care for HIV infections and sexually transmitted infections (STIs). 59 Prior crises have shown that reduced access to SRH care J o u r n a l P r e -p r o o f increases rates of unintended pregnancies, unsafe abortions, STIs, pregnancy complications, mental health complications, and maternal and infant mortality. 14, 60, 61 The American College of Obstetricians and Gynecologists (ACOG) and the American Medical Association (AMA) have published guidelines and statements ensuring access to safe abortion care during the COVID-19 pandemic to the full extent the law allows. 62, 63 Despite this, multiple US state governors have supported cessation or delay of medical and/or surgical abortions during the pandemic, citing them as elective or nonessential. 12, 19, 63 Delaying these procedures and denying timely access increases the rates of unsafe abortions. 62, 64 An analysis of global supply chains raised concerns about access to contraceptives (many of which are manufactured in Asia) during the outbreak. 65 Shortages of contraceptives have been reported in Myanmar and Mozambique, and India's government stopped exporting progesterone for contraception; supply chain concerns for packaging materials were also included in analyses that predicted these potential shortages and delays for contraceptives. 66 Pregnant and lactating people are frequently excluded from clinical trials with the explanation that the safety of a treatment in pregnancy is unknown. [67] [68] [69] This protection-byexclusion fallacy, however, leaves cisgender women at risk. For pregnant and lactating people, though, exposure to the virus is similar to that for the general population, so pregnancy and lactation alone should not exclude participation in studies. Under the Common Rule, pregnancy J o u r n a l P r e -p r o o f is no longer classified as a vulnerability, so that pregnant people no longer need special protection for inclusion in research; with safety regulations, individuals should be able to determine their eligibility and entry into research studies on the basis of informed consent. 67 Despite this change, a search of 588 active studies evaluating COVID-19 found that only 4 were designed for pregnant people and were not designed to evaluate therapeutics. 67 Of the 376 trials evaluating therapeutic interventions, none were designed for pregnant or lactating people and more than two-thirds specifically listed pregnancy as an exclusion criterion. 67 It is essential to consider the safety of treatment in pregnancy and lactation; however, the risk of inadequate treatment or treatment with incomplete data is of equal concern.

While there are many reports of difficult access to SRH services and poor outcomes after prior pandemics, little has been published about the effect of COVID-19 on SRH so far. The full impacts of this pandemic on SRH remain to be seen. Multinational cooperation and scientific study of SRH outcomes in response to COVID-19 should be a public health priority. 58 Medical and humanitarian organizations worldwide agree that contraception, family planning, abortion, prenatal and postpartum care, and breastfeeding support services are core components of essential health services, and access to this fundamental human right should not be disrupted because of COVID-19. 19, 63, 70, 71 

Recommendations for mitigating SRH impacts include the following: J o u r n a l P r e -p r o o f -Health care providers and organizations should prioritize innovative solutions to ensure equitable access to essential SRH services through both private and civil society channels 19, 29, 71 o Recognize that SRH services are essential and must remain available at all times, particularly during times of crisis. 14, 19, 34, 58, 59, 70, 71 o Provide counseling and information regarding fertility awareness and correct condom use in case of disruption of other contraceptive supplies. 70 -Minimize barriers to accessing SRH services for current contraceptive users 29, 71 o Women already using combined hormonal contraceptives (CHCs) and progesterone-only pills (POPs) should continue for an additional 6 to 12 months without the need for office visits or monitoring during the pandemic. 63 Prescribers should provide and dispense refills for multiple months to minimize patients' trips to the pharmacy. Health insurance plans and medical office policies should waive timeline limitations on refills. 70 o Depot medroxyprogesterone acetate (DMPA) users can switch to available POPs, or patients can be trained on self-injectable contraception to avoid face-to-face contact and minimize office visits. 63, 70 o Long-acting reversible contraceptive (LARC) users should extend use to avoid face-to-face contact during the pandemic, as evidence suggests efficacy for 2 years beyond the US Food and Drug Administration (FDA)-approved timeline. 63 -Minimize barriers for women seeking initial SRH services while relieving the burden on J o u r n a l P r e -p r o o f primary health care structures 29, 71 o Use telemedicine with remote assessment for new contraceptive users to provide prescriptions for CHCs, POPs, or self-injectable contraception for 6 to 12 months. 63, 70 o Continue to offer appropriate use and provision of LARCs with initial remote assessment, minimal face-to-face contact, and adequate safety protocols. 63, 70 o Postpartum counseling about contraception provided before hospital discharge should include LARCs (immediately post partum), permanent contraception (at delivery), and the lactational amenorrhea method. 29, 70 -Continue to provide access to emergency contraception and safe abortion services while minimizing exposure risk to COVID-19 19, 63, 70 o Provide education on available over-the-counter and prescription emergency contraceptive (EC) options. 70 Use remote assessment to determine choice of ECs and provide appropriate ECs with minimal face-to-face contact. 63, 70 o All practice recommendations and position papers recommend continuing to provide safe abortion services without requiring face-to-face contact after remote assessment. Ensure that no-touch/no-test early medication protocols are in place to minimize risk of COVID-19 exposure while providing essential services. 63 -Collect, analyze, and report data regarding women's SRH outcomes during COVID-19 to understand the full impact and target future mitigation strategies J o u r n a l P r e -p r o o f o Generate timely research and surveillance of key clinical, epidemiologic, and psychosocial links between COVID-19 and SRH to assess the immediate-,mid-, and long-term impacts on women and girls. 59 These data will allow strengthening of health system capabilities and community engagement to sustain accessibility and quality of SRH services for vulnerable populations during future health emergencies 58 o Study the efficacy of innovative solutions and barriers to access to develop databased evidence regarding best practice standards and to ensure that innovations do not further marginalize those at greatest risk. 71 o Include pregnant and lactating people in research efforts. As private companies and governments rapidly attempt to develop treatment and prevention therapeutics, they must commit to studying therapeutic options for pregnant and lactating individuals. There should be open exchange of information and data from maternity hospitals globally to ensure the best possible management of infected pregnant and lactating people. 68

Just as inadequate sex-disaggregated data mask complete understanding of the pandemic, so do inadequate ethnicity-and race-disaggregated data. However, the available J o u r n a l P r e -p r o o f data show that the categories previously described are disproportionately affecting Black and indigenous women and women of color (WOC). 3, 16, 17, 19 Gender inequality, structural racism, and poverty are interconnected, and convergence of these challenges exacerbates system weaknesses that put these marginalized groups at increased risk 19 (Figure 2 ).

WOC are overrepresented as frontline workers. Many of them have incomes that are less than the federal poverty level, so they cannot afford to lose any income and they are less likely to have employee protections such as sick days. 25, 72 In the US, 76% of health care jobs are held by women, nearly half of whom are WOC, so they have increased exposure to WOC are overrepresented in low-paying jobs, and pay inequality for women further exacerbates the economic impact of COVID-19. 24 34 While 20% of families in the US identity as single-parent families, 66% of these identify as Black and 41% as Latina, exacerbating the household and financial burdens. 19 Women who are primary breadwinners have lost jobs at higher rates than married women, and WOC are overrepresented in this group. 19 Assessment of increased gender-based violence in the US requires recognition that rates of societal violence against WOC are higher than the national average. 19 On some American Indian reservations, nearly 50% of women have reported experiencing sexual violence. 19 WOC also face systemic racism and barriers to accessing SRH services (leading to poorer reproductive health outcomes) compared to White women. 38, 73 Native American women have some of the J o u r n a l P r e -p r o o f highest suicide rates in the US, and Black women experience the highest levels of anxiety. 19 As mental health concerns increase during the pandemic, WOC are particularly vulnerable.

The terms sex and gender are routinely conflated in medical research, with COVID-19 studies thus far focused on cisgender women. Most studies do not specifically discuss the gendered impact on transgender women or the risk based on sexual orientation, although the lesbian, gay, bisexual, transgender, queer, and other marginalized sexual orientations (LGBTQ+) population has frequently been marginalized and has a high risk for disparities. The pandemic has exacerbated barriers to health care in the LGBTQ+ community. Higher rates of cancer, HIV infection, smoking, and health care discrimination place these individuals at higher risk for the effects of COVID-19. 74 The worsening shortage of specialized health care professionals, postponed gender-affirming procedures, and decreased access to hormone therapy are associated with heightened anxiety and depression in the transgender population. 75, 76 Additionally, transgender women may face other physical and mental health needs related to receiving gender-affirming care, such as vaginoplasty. 77 Transgender people of color have significantly lower life expectancy because of discrimination and underlying disparities in economic opportunities, GBV, affordable housing, and mental health. 19, 30 In addition, LGBTQ+ youth are more likely to experience homelessness, violence, food insecurity, and suicide. 19 The UN has recognized the international health concerns and unprecedented difficulties with mental, physical, and social well-being and health care access among LGBTQ+ individuals and has called for "States and other stakeholders to urgently take into account the impact of J o u r n a l P r e -p r o o f COVID-19 on [LGBTQ+] persons when designing, implementing and evaluating the measures to combat the pandemic," which may disproportionately affect LGBTQ+ communities around the world. 78 Sex-disaggregated data do not identify the specific gendered impact on gender-diverse individuals, and gender-disaggregated data (and data on sexual orientation) are essentially nonexistent. Collecting gender and sexual orientation data is critical for identifying and mitigating the wider impacts of COVID-19 on these marginalized populations.

Recommendations for mitigating the impact of overlapping vulnerabilities -The compounding risks of gender, race, and sexual orientation on vulnerabilities from COVID-19 must be specifically acknowledged.

-Policy changes during the COVID-19 pandemic need to be transformative for WOC and LGBTQ+ individuals rather than exacerbating current inequalities. 34 -All mitigating measures must ensure not only gender representation but also racial and cultural representation. 19

While we attempted to perform asynchronous identification of pertinent data for inclusion, the available data are constantly evolving. This review is not comprehensive and does not include all important areas of impact or all mitigation strategies. The terms sex and gender were identified by the individual study designs but primarily focused on cisgender women; J o u r n a l P r e -p r o o f gender-diverse individuals are underrepresented in the available data. Categorization of data by anatomical sex and not by gender is an inherent limitation to the existing data; these populations are likely underrepresented in our analysis. We attempted to use gender-inclusive language when possible, but for accuracy we used gendered terms of individual studies when referencing specific data.

Currently the incomplete sex-and race-disaggregated data limit our understanding of the impact of the pandemic. 2, 19 Governmental and private organizations must commit to collecting, reporting, and analyzing complete sex, gender, sexual orientation, race, and ethnicity disaggregated data to best understand the impact of the pandemic on diverse women and to prioritize areas of impact for study and intervention. 2, 19 Conclusion While data suggest that men are more likely to have severe COVID-19 infections, women are impacted by the pandemic in multiple ways that are not recognized in the traditional data sets. Worldwide, women have experienced an increased burden in the areas of occupation, economics, domestic violence, GBV, mental health, and sexual and reproductive health. Furthermore vulnerabilities related to poverty, race, ethnicity, and LGBTQ+ status combine to exacerbate the impact on vulnerable populations. 13, 17, 19, 34 J o u r n a l P r e -p r o o f Multiple national and international societies have recommended strategies for mitigating widening disparities for women during the COVID-19 pandemic. We recommend that policymakers, leaders, innovators, investors, and advocacy groups consider these categories of impact and mitigation strategies when implementing programs and policies in response to COVID-19. #EndTrafficking, #FreedomFirst and tag @UNICEFUSA (US) Allocation of additional financial resources Allocation of resources for shelters and provision of alternative accommodations when shelters fill (Canada, France, Caribbean countries) Accelerated community-level service delivery for survivors of GBV a (South Africa, Australia, France, United Kingdom) Governmental and legal policy changes Instead of GBV survivor leaving home, abuser must leave family home (Italy) Develop virtual justice system to provide legal services and provide extended protection orders in case of court delays (Kazakhstan, Argentina, Colombia) Strategic partnerships Mobile service partnerships with telecommunication firms to provide free calls to helplines (Antigua, Barbuda) Instant messaging service with geolocation for immediate support for survivors (Spain) Secure mobile phone applications and code messaging at pharmacies for domestic violence survivors to bring in additional support without raising attention of abusers (United Kingdom, Spain)

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Editing was provided by Scientific Publications, Mayo Clinic.