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Sex and Gender Issues for Individuals With Acquired Brain Injury During COVID-19: A Commentary

Published:September 03, 2020DOI:https://doi.org/10.1016/j.apmr.2020.08.004

      Abstract

      Worldwide, the rehabilitation community has been affected by coronavirus disease 2019 (COVID-19). The effect of COVID-19 has been disproportionately devastating for individuals with disabilities, particularly those with acquired brain injury (ABI) owing to injury-related cognitive or sensory and physical difficulties. Many physical and psychological symptoms of COVID-19 are already well-known issues for individuals with ABI. Even in a fully functional social and health care system, post-ABI deficits can pose greater challenges to women and other marginalized groups, such as lesbian, gay, bisexual, transgender, gender-nonconforming, and queer or questioning-identified individuals. The restrictions and changes brought about by COVID-19 have the potential to broaden the existing disparities and limitations. This commentary highlights 3 key areas to attend to during this pandemic to help assuage such disparities and limitations.

      Keywords

      List of abbreviations:

      ABI (acquired brain injury), COVID-19 (coronavirus disease 2019), IPV (intimate partner violence), LGBTQ+ (lesbian, gay, bisexual, transgender, gender-nonconforming, and queer or questioning-identified)
      Acquired brain injury (ABI), which includes traumatic (eg, fall, motor vehicle collision, penetrating injury) and nontraumatic (eg, aneurysm, anoxia, stroke, tumor) injury, frequently results in persistent and debilitating physical, cognitive, and emotional deficits and long-term or permanent disability.
      • Azouvi P.
      • Arnould A.
      • Dromer E.
      • Vallat-Azouvi C.
      Neuropsychology of traumatic brain injury: An expert overview.
      • Bramley H.
      • Hong J.
      • Zacko C.
      • Royer C.
      • Silvis M.
      Mild traumatic brain injury and post-concussion syndrome: treatment and related sequela for persistent symptomatic disease.
      • Laxe S.
      • Cieza A.
      • Castaño-Monsalve B.
      Rehabilitation of traumatic brain injury in the light of the ICF.
      • Marshall S.
      • Bayley M.
      • McCullagh S.
      • et al.
      Updated clinical practice guidelines for concussion/mild traumatic brain injury and persistent symptoms.
      • May M.
      • Milders M.
      • Downey B.
      • et al.
      Social behavior and impairments in social cognition following traumatic brain injury.
      • Navratilova E.
      • Rau J.
      • Oyarzo J.
      • et al.
      CGRP-dependent and independent mechanisms of acute and persistent post-traumatic headache following mild traumatic brain injury in mice.
      • Spitz G.
      • Ponsford J.L.
      • Rudzki D.
      • Maller J.J.
      Association between cognitive performance and functional outcome following traumatic brain injury: a longitudinal multilevel examination.
      According to the Global Burden of Disease Study in 2016, the incidence of traumatic brain injury was 1,221,494 in North America and 27,082,033 across the globe.
      GBD 2016 Traumatic Brain Injury and Spinal Cord Injury Collaborators. Global, regional, and national burden of traumatic brain injury and spinal cord injury, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016.
      Similarly, the incidence of stroke, which is only one etiology of nontraumatic brain injury, was 812,285 in North American and 13,676,761 globally.
      GDB 2016 Stroke Collaborators. Global, regional, and national burden of stroke, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016.
      Combined, these numbers still underestimate of all types of ABI worldwide. This suggests that a notable proportion of the population are living with the effect of ABI-related disability.
      Even in a fully functional social and health care system, individuals with disabilities face greater challenges. For individuals with ABI, these challenges are directly or indirectly related to physical or cognitive deficits secondary to their injury. Within the ABI population, there are additional disparities, the most explored and notable among women (by sex or gender) as well as the less explored marginalized groups, such as lesbian, gay, bisexual, transgender, gender-nonconforming, and queer or questioning-identified (LGBTQ+) individuals. Although men have significantly higher rates of ABI, women and LGBTQ+ individuals have worse long-term outcomes and experience higher rates of social, financial, and structural barriers than men with ABI.
      • Haag H.L.
      • Caringal M.
      • Sokoloff S.
      • Kontos P.
      • Yoshida K.
      • Colantonio A.
      Being a woman with acquired brain injury: challenges and implications for practice.
      • Wiseman-Hakes C.
      • Saleem M.
      • Poulin V.
      • et al.
      The development of intimate relationships in adolescent girls and women with traumatic brain injury: a framework to guide gender specific rehabilitation and enhance positive social outcomes.
      • Moreno A.
      • Laoch A.
      • Zasler N.D.
      Changing the culture of neurodisability through language and sensitivity of providers: creating a safe place for LGBTQIA+ people.
      Worldwide, the rehabilitation community has been affected by coronavirus disease 2019 (COVID-19). The effect of COVID-19 has been disproportionately devastating for individuals with disabilities, particularly those with ABI owing to injury-related cognitive or sensory and physical difficulties. Between December 2019 and July 18, 2020, COVID-19 was confirmed in 14,280,571 cases, with 601,268 deaths and 8530,951 individuals who recovered, in 213 countries around the world.
      Worldometer
      Coronavirus Pandemic Updated 30-May-2020 2:09 GMT.
      This global threat, characterized by the World Health Organization as a pandemic,
      World Health Organization Regional Office for Europe
      WHO announces COVID-19 outbreak a pandemic.
      typically presents clinically with infections in the respiratory and gastrointestinal tracts and with symptoms similar to viral pneumonia such as severe acute respiratory syndrome and Middle East respiratory syndrome,
      • Xie M.
      • Chen Q.
      Insight into 2019 novel coronavirus – An updated interim review and lessons from SARS-CoV and MERS-CoV.
      with more extensive lung disease in men.
      • Dangis A.
      • De Brucker A.
      • Gillis M.
      • Frans J.
      • Demeyere A.
      • Symons R.
      Impact of gender on extent of lung injury in COVID-19.
      According to one meta-analysis of 16 clinical COVID-19 symptoms, fever, cough, and fatigue were the most common.
      • Fu L.
      • Wang B.
      • Yuan T.
      • et al.
      Clinical characteristics of coronavirus disease 2019 (COVID-19) in China: a systematic review and meta-analysis.
      Although women and men appear to contract COVID-19 at the same rate, more severe morbidity and overall mortality rates are much higher in men.
      • Cagnacci A.
      • Xholli A.
      Age-related difference in the rate of COVID-19 mortality in women versus men.
      ,
      • Rozenberg S.
      • Vandromme J.
      • Martin C.
      Are we equal in adversity? Does COVID-19 affect women and men differently?.
      However, in general, both men and women with COVID-19 have been shown to have higher rates of anxiety, depression, anger, loneliness, hazardous and harmful alcohol use, posttraumatic stress symptoms, and lower mental wellbeing than the general population.
      • Ahmed Z.
      • Ahmed O.
      • Aibao Z.
      • Hanbin S.
      • Siyu L.
      • Ahmed A.
      Epidemic of COVID-19 in China and associated psychological problems.
      ,
      • Guo Q.
      • Zheng Y.
      • Shi J.
      • et al.
      Immediate psychological distress in quarantined patients with COVID-19 and its association with peripheral inflammation: a mixed-method study.
      Furthermore, women around the world are at a greater risk for intimate partner violence (IPV) as a result of COVID-19,
      World Health Organization
      COVID-19 and violence against women What the health sector/system can do.
      with one police department reporting triple the incoming statements of IPV in February 2020 compared to February 2019. Similar to COVID-19 and ABI, IPV causes isolation as well as additional physical, psychological, and sexual reproductive health issues for women,
      World Health Organization
      Violence against women.
      including headaches, depression, posttraumatic stress disorder, anxiety, sleep difficulties, gastrointestinal symptoms, substance misuse, and poorer overall health.
      World Health Organization Regional Office for Europe
      WHO announces COVID-19 outbreak a pandemic.
      Unfortunately, most of these physical and psychological symptoms are already well-known issues for individuals with ABI.
      Previous experience with natural disasters suggests that marginalized groups experience substantially more negative consequences in times of natural disaster, which warrants enhanced support and advocacy. For example, LGBTQ+ individuals are at a disadvantage, both for greater risk of COVID-19 mortality
      • Rosa W.E.
      • Shook A.
      • Acquaviva K.D.
      LGBTQ+ inclusive palliative care in the context of COVID-19: pragmatic recommendations for clinicians.
      and poorer ABI related treatment,
      • Moreno A.
      • Laoch A.
      • Zasler N.D.
      Changing the culture of neurodisability through language and sensitivity of providers: creating a safe place for LGBTQIA+ people.
      such as “lack of specialized and knowledgeable screening, education, and treatment for reproductive health, sexuality, and sexual performance related issues.”
      • Moreno A.
      • Laoch A.
      • Zasler N.D.
      Changing the culture of neurodisability through language and sensitivity of providers: creating a safe place for LGBTQIA+ people.
      (p377) Although the current COVID-19 pandemic is certain to lead to many unknown and unanticipated outcomes in this and other groups, there are specific areas known to affect women and LGBTQ+ individuals with ABI, namely IPV, social and financial disparities, and technological accessibility. Disparities in these domains can be expected to be exacerbated by the current state of the world and lead to further marginalization, making them critical to highlight as potential intervention targets.
      Women and LGBTQ+ individuals in general, and especially those with ABI, are more likely to be victims of abuse and violence, including IPV, which almost always results in multiple repeat injuries, including traumatic brain injury.
      • Lutgendorf M.A.
      Intimate partner violence and women's health.
      ,
      • St Ivany A.
      • Schminkey D.
      Intimate partner violence and traumatic brain injury: state of the science and next steps.
      Unfortunately, COVID-19 has increased the likelihood of this occurrence. Because the perpetrator is most likely to be a romantic partner, caregiver, or another individual within the home, stay at home orders increase the exposure of the victim to the victimizer, increasing the probability of abuse. The social distancing guidelines and closing of many services, such as shelters and other social programs, minimize the opportunity for escape. Furthermore, the surge of COVID-19 in medical settings likely reduces the chances of the abused seeking medical care for their injuries.
      Women and LGBTQ+ individuals with ABI are faced with greater social and economic disparities, as well as general and technological accessibility issues, which are expected to be worsened by the current pandemic. Women and LGBTQ+ individuals with ABI are more likely to be affected by poverty, social isolation, lack of familial support, lack of transportation, and lack of community resources.
      • Moreno A.
      • Laoch A.
      • Zasler N.D.
      Changing the culture of neurodisability through language and sensitivity of providers: creating a safe place for LGBTQIA+ people.
      Furthermore, women report more symptoms of depression, anxiety, fatigue, and sleep disturbance than men with ABI.
      • Juengst S.B.
      • Nabasny A.
      • Terhorst L.
      Neurobehavioral symptoms in community-dwelling adults with and without chronic traumatic brain injury: differences by age, gender, education, and health condition.
      The restructuring of the social and health care system (eg, conversion of rehabilitation units into COVID-19 units
      • Rivera-Lillo G.
      • Torres-Castro R.
      • Fregonezi G.
      • Vilaro J.
      • Puppo H.
      Challenge for rehabilitation after hospitalization for COVID-19.
      and some therapy services being deemed nonessential
      • Mattei A.
      • Amy de la Breteque B.
      • Crestani S.
      • et al.
      Guidelines of clinical practice for the management of swallowing disorders and recent dysphonia in the context of the COVID-19 pandemic.
      ) are likely to magnify the inequities in the accessibility of necessary services among women with ABI. Although all individuals with ABI may experience greater challenges in accessing essential services in light of the shift in how these services can be accessed (eg, changes in business operations, social distancing guidelines, greater reliance on the internet, curbside pick-up may not be wheelchair accessible, limited public transportation may limit the ability to get to medical noncancelled appointments, medical transportation services may be extremely limited or also cancelled.), women with ABI are more likely to lack the resources (internet access or even a computer) and support (family member, caregiver) to help them navigate these increased challenges.
      Along these lines, with the majority of essential services and everyday activities, including shopping, health care, and even social interactions, transitioning to electronic online formats, individuals with cognitive and sensory deficits are faced with navigating these complex and unfamiliar environments that are rarely accommodating to their unique post-ABI challenges. In the setting of social distancing, they may be left without much-needed technical assistance. Even when individuals are able to access in-person health care services, the landscape of these services is significantly altered. Having an aide or family assistant attend appointments with the individual with ABI to offset their cognitive difficulties in the provision and gathering of critical information is limited or completely disallowed. Mental health services may be limited to telehealth (which has accessibility limitations noted above) or unavailable, which could further increase suicide rates.

      Reger MA, Stanley IH, Joiner TE. Suicide Mortality and Coronavirus Disease 2019—A Perfect Storm? JAMA Psychiatry. 10 Apr 2020. [Epub ahead of print].

      ABI leads to chronic debilitating physical, cognitive, and emotional difficulties that compromise daily function and contribute to long-term disability in a large proportion of individuals. Although more men are afflicted with ABI, women and LGBTQ+ individuals are disproportionately affected by poorer outcomes, many of which are systemic. The restrictions and changes brought about by COVID-19 have the potential to broaden the existing disparities and exhaust the limited functional resources of these individuals. Special attention and intervention is warranted in the areas of (1) IPV, especially in the current environment of greater social isolation and less accessible resources for physical escape and psychological support; (2) accessibility of basic goods and health care services, especially with regard to the use of technology and web-based forums that are not optimized for individuals with ABI-related cognitive and sensory deficits; and (3) availability and accessibility of financial, social, and emotional support.

      Acknowledgments

      We thank the American Congress of Rehabilitation Medicine staff for supporting the Task Force, particularly Ms Terri Compos.

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