The implementation of infectious disease control measures, absent of critical gender considerations, has situated GBV as an afterthought of public health response [13]. Consequently, women and girls living in humanitarian settings have faced bi-directional syndemic vulnerabilities between GBV and at least three major infectious diseases in recent history: Ebola (2013-present), Zika (2015–2016), and COVID-19 (2020-present).
Linking infectious disease outbreaks with GBV: consequences for women and girls
Negative consequences of gender insensitive pandemic control policies with respect to GBV include increasing the proximity of survivors/victims to abusers, magnifying household socio-economic strain, reinforcing household gender roles, exacerbating inadequate access to sexual/reproductive health services, and limiting gender-specific data collection and analyses; all these consequences compound in humanitarian settings and are exacerbated for women and girls.
As illustrated by the COVID-19 pandemic, in the absence of widespread vaccination and effective pharmacological treatment, governments have implemented ad-hoc stay-at-home orders and regional lockdowns. In humanitarian settings, the breakdown of health and social services combined with lockdowns have culminated in inadequate protections for women and girls, as well as elevated levels of domestic and intimate partner violence [7, 14]. Prolonged stay-at-home orders and regional lockdowns during COVID-19 raise household economic precarity and stress which are known risk factors for domestic and intimate partner violence [15]. These stay-at-home orders and regional lockdowns also disproportionately hinder girls’ educational attainment which is a risk factor for child marriage [7, 16].
During the Ebola epidemics in the Democratic Republic of the Congo (DRC) and West Africa, public health policies failed to adequately consider the gendered division of household labor. Adherence to handwashing and sanitation measures elevated the demand for household water supplies and thus increased the frequency with which women and girls left the home to collect water [17]. Traveling long distances to gather sufficient water supplies during periods of increased demand elevated the risk of experiencing sexual violence and harassment from opportunistic perpetrators, especially when conflict and civil unrest were present [13, 17, 18].
Moreover, infectious disease control policies rarely consider GBV and sexual/reproductive health services as essential, thereby resulting in a consistent erosion of services in humanitarian settings [19,20,21]. The challenges faced by pregnant survivors of sexual violence with respect to accessing psycho-social support, healthcare, and abortion are magnified by pandemics and epidemics. The lack of sexual and reproductive health services during COVID-19 is particularly concerning given the elevated rates of unintended pregnancies [19] and unsafe abortions [22]. The lack of sexual and reproductive healthcare combined with wide-spread fear of bodily fluids during the West Africa and Eastern DRC Ebola outbreaks resulted in young women being shamed during menstruation or childbirth and subsequently sent to Ebola Treatment Centers [23].
The Zika epidemic in South America also draws attention to the critical need for sexual/reproductive healthcare. A fetus developing during the mother’s period of Zika virus infectivity faced an increased risk of developing congenital defects such as microcephaly [23, 24]. Women who gave birth to children with microcephaly during the Zika epidemic experienced elevated paternal abandonment [25], resulting in single motherhood and the potential for socio-economic adversity. Moreover, campaigns encouraging women to postpone pregnancy fail to consider lack of reproductive autonomy, inadequate access to contraception, and in some contexts criminalized abortion, particularly with respect to Zika-affected pregnancies resulting from sexual violence. Thus, gender-insensitive infectious disease control measures deepen both individual and structural-level GBV, thereby further eroding progress on gender equity in humanitarian settings. Women and girls in humanitarian settings experience pandemics and epidemics within a context of heightened GBV and reduced service provision.
GBV and sustained community transmission: consequences for infectious disease control
The relationship between COVID-19 and GBV is not unidirectional: individual and structural-level GBV increase the risk for sustained community transmission. One pathway from GBV to increased community transmission is through the sexual transmission of infectious disease. Even in the absence of epidemics or pandemics, access to and negotiation of contraceptives is negatively impacted by the structural gender inequality present in humanitarian settings. Unprotected sexual intercourse may increase the risk of exposure to certain pathogens. Sexual transmission of infectious disease may be heightened when transactional sex is used as a means to alleviate socio-economic strain. For instance, given that Ebola virus RNA can persist in semen for prolonged periods, unprotected sexual intercourse through sexual violence, transactional sex, and sexual abuse and exploitation propagated community transmission [10, 26]. The sexual transmission of Ebola, including through sex work and sexualized violence, not only introduced the virus into households but also spread the virus between communities [13].
Within a wider context of limited sexual/reproductive health and rights [27], sexual-violence perpetrated by Zika-positive perpetrators could result in infection alongside pregnancy and fetal congenital defects. Further compounding vulnerabilities was the exclusion of pregnant and lactating women from the development and administration of Zika vaccine trials [24]. Thus, sexual violence rendered women and girls vulnerable to Zika infection while those who were pregnant and lactating were systematically excluded from vaccination.
In Brazil, men in urban areas who engaged in casual sexual encounters during the epidemic were more likely to be Zika positive, making them potential carriers of the virus given that Zika virus RNA can remain in semen for prolonged periods [28, 29]. Thus, victims of sexual violence, sex workers, and those who participated in transactional sex may contract Zika through sexual contact with positive men, particularly if knowledge about Zika’s sexual transmission is inadequate [30, 31].
Further, emerging evidence indicates that some abusers are leveraging the uncertainty and fear associated with the COVID-19 pandemic to further assert power and control by engaging in distinct forms of psychological intimate partner violence: threatening to infect the victim, reducing access to hygiene supplies, and limiting access to testing and vaccination [30, 31]. In the absence of GBV prevention and response services, psychological forms of intimate partner violence could increase exposure to COVID-19 through limiting access to needed hygiene supplies and healthcare [32, 33].
In the DRC and West Africa, Ebola’s chain of transmission intersected with household gender norms, as women and girls led caretaking responsibilities for family members who were Ebola positive [13, 17]. Due to widespread morbidity and mortality, such unpaid and often unrecognized gendered familial responsibilities were heightened during the Ebola epidemic and increased the risk of women and girls coming into contact with infected bodily fluids [13, 17]. To further magnify the gendered burden, even when made available, personal protective equipment may not adequately protect women or girls because sizes are designed according to the dimensions of men [34]. In the absence of household water, soaps, adequate personal protective equipment, and disinfectants, exposure to contaminated bodily fluids while caregiving contributes to gendered viral transmission.
Additionally, within households in humanitarian settings access to technology such as mobile phones, TV, radio, and internet connection, is limited. For example, one phone many be shared among members of the entire household. Due to gender discrimination, women and girls face reduced access to and familiarity with digital tools [35, 36]. The gender digital divide—referring to the disproportionate lack of digital skills, permitted use, and access to technology among women and girls—can inhibit access to lifesaving public health information pertaining to infectious disease testing, routes of transmission, and vaccination [3, 35].
The failure to recognize and act on direct and indirect pathways of community transmission associated with GBV leaves women and girls vulnerable to infectious disease exposure. In fact, the failure to act on previous evidence from infectious diseases to safeguard the rights and health of women and girls is a form of structural GBV.