Across the globe, the month of March became a turning point for the COVID-19 pandemic. Amidst daily clinical updates, dramatic increase in cases, and rapid policy changes, International Women’s Day – an observance that allows gender equality to take the spotlight – came and went. Since March, COVID-19 worsened existing health disparities, further exacerbated by unacceptable police brutality, virus outbreaks in immigration detention centers, and removal of sexual orientation and gender identity protections in access to health care, among others. Clinicians must recognize how these times of crisis exacerbate existing racial and gender health disparities. With International Women’s Day in mind, we call for a re-focus on immigrant women’s health as a means of reducing the health disparities that are magnified by crisis.

Occupational concerns

An elderly Latina woman is being seen for insomnia. She was recently let go of her health aide job and is now newly caring for several grandchildren.   

Immigrant women face unique occupational concerns, as the current pandemic changes the employment landscape and leaves them to be society’s primary caregivers – and essential workers. Women often find themselves employed in formal or informal caregiver professions. With cultural factors like filial piety, immigrant women often care for immediate and extended family. Providing care both in and out of the home, women are at higher risk for caregiver burden and worsening mental health. As many immigrant women are essential health care workers themselves, there is higher risk of exposure to COVID-19. The informal economy inhabited by many immigrant women is destabilized by COVID-19, with few such jobs amenable to shifting to work-from-home. This financial stress, added to caregiving stress at home, can lead to increases in physical and mental health issues. The risk women face from both greater exposure, and caregiving burden will be especially dynamic as stay-at-home orders are lifted, yet children remain home with schools closed.

Next steps

Clinicians can continue using Patient Health Questionnaire and Generalized Anxiety Disorder both in-person or virtually to identify who might benefit from mental health treatment. Screening tools focused on social determinants of health are increasingly available and being integrated to primary care. Clinicians can also educate patients around caregiver resources such as the Family Caregiver Alliance.

Reproductive health

A South Asian adolescent is having trouble accessing treatment for heavy periods due to family pressures against birth control, and she feels more isolated at home during the pandemic as she stays in separate quarters during her periods.  

Immigrant women face distinct sociocultural issues around reproductive health during the pandemic. Staying at home during the pandemic and subsequent reduced access to health care may cause changes in sexual activity and family planning. More than 214 million women worldwide want to prevent pregnancy but are not using contraception. This global trend is similarly present for many immigrant women in the US, when sociocultural barriers to reproductive autonomy persist, such as pressure to bear children, male child preference, and early marriage. During COVID-19, these factors are compounded by decreased access to reproductive health services and contraception supply disruption. Diversion of resources may worsen reproductive health, as seen during the Ebola crisis when maternal mortality rose. Clinicians should also be mindful of providing stigma-free access to treatment of menstrual disorders. For those who must hide use from family or partners due to stigma, the loss of privacy, and decreased access to routine care during COVID-19 may create a barrier. In many South Asian cultures, menstruating women may be seen as unclean; families may adapt this practice in various ways during the pandemic, such as sleeping in a separate room, ironically like quarantine.

Next steps

Clinicians might use COVID-19 as an opportunity for humble exploration using the “explanatory model” to understand the patient’s feeling, ideas, fears, and expectations about reproduction. Reproductive counseling can continue using tools such as PATH Questions. This may elicit needs during COVID-19 like mail-order contraception, self-administered depo, or long-acting contraception.

Gender-based violence

A middle-aged East African woman presents with pelvic pain. She is experiencing PTSD around female genital cutting, which she was forced to have as a teenager before marriage.   

The COVID-19 pandemic may worsen gender-based violence many immigrant women face. Gender-based violence can take various forms, including physical, sexual, emotional, and financial. In the U.S., 1 in 3 women experience intimate partner violence (the most common form of gender-based violence), and rates are higher among immigrants. During times of crisis, such as COVID-19, violence can worsen. Increased time at home with a potentially violent partner is compounded by COVID-19 related restrictions that limit access to schools, public transportation, courthouses, and public service agencies that are paths to escaping violent relationships. Women living with controlling perpetrators may already have limited access to personal use of technology, including telemedicine. Unique forms of gender-based violence that immigrant women and girls may face include female genital cutting seen in some traditions. Although criminalized in most countries, it is predicted that global rates of female genital cutting will rise during the COVID-19 crisis, due to early marriage to protect from economic insecurity. Immigrant women may also experience threats for deportation and be increasingly prone to exploitation like street-based sex work.

Next steps

All clinicians should be trained in screening for gender-based violence. Clinicians can use screening tools and trauma-informed care to advocate for immigrant women suffering from gender-based violence. For clinicians who find themselves without local gender-based violence services, the UN has helped develop a smart-phone based application called the GBV Pocket Guide that provides guidance on how to support survivors.

Conclusion

As health care and economic resources are diverted to what is deemed “essential” during the COVID-19 pandemic, clinicians must not forget the unique sociocultural challenges faced by immigrant women that contribute to health disparities. Occupational concerns, reproductive health, and gender-based violence are essential issues in immigrant women’s health, and clinicians have the sacred responsibility of advocating for immigrant women to reduce health disparities during this extended time of crisis.

The authors would like to acknowledge Shilpa Shankar, MD and Susan Frayne, MD for their review of this piece.

Megha Shankar is an internal medicine physician. Jonathan G. Shaw is a family physician.

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