Gender-related rights are a matter of public policy , which conversely plays a central role in gender equity. Government interventions have sought to mitigate the spread of COVID-19 but have not addressed the impacts on gender .
Recognizing the extent to which pandemics disproportionately affect gender is critical to understanding their primary and secondary effects . The conception of gender assumes different cultural forms and meanings and is traversed by political, social, historical, and cultural issues, as well as mechanisms of domination and power [3,4], making it crucial when designing and implementing effective and equitable policies and interventions .
Prior studies showed a limited gender scope with variations in the degree of its inclusion during the development of health policies . The forms of organizations of the health sector and these policies could be thought of as a form of “biopower”  where social phenomena are naturalized by being characterized as biological, contributing to and deepening gender inequalities.
An overlap between gender identity and the invisibility of work was observed at the domestic level , where care and domestic tasks are complemented by paid employment , especially during COVID-19 .
Lockdowns and school closures during the pandemic have had serious consequences on different gender-related dimensions of general well-being, with a significant increase in the burden of unpaid work, especially for women, who provide most of the informal care, limiting their work possibilities, their economic capabilities, and opportunities [2,9]. Intersectionality [9,10] plays a central role in the analysis of public policies. The intersections of various structures in places of power such as the public, the home, and the intimate space, make women ultra-vulnerable groups .
Patriarchal norms were amplified in the crisis, along with gender-blind policies, have made women “invisible” , as well as other diversity groups and populations exposed to multiple inequity factors .
As experience and literature to date have shown, the COVID-19 pandemic has generated multiple negative gender-related impacts in all areas, especially health and socio-economic conditions [12,13]. In this complex context, there is a need to establish urgent measures that incorporate a gender approach in preparedness and response , but also in recovery from the crisis.
We aimed to explore the following questions: 1) What is the scope of the gender approach in the literature analysing the health and social protection policies promoted during the COVID-19 pandemic? 2) What are the challenges and recommendations for gender-sensitive policies for the post-pandemic and future crises?
We designed a study with three stages: 1) A global synthesis of the evidence through a scoping review [14,15], where we presented an overview of a diverse body of literature on the inclusion of the gender approach [3,4,10,16] focused on inequities in the health and social protection policies promoted during the COVID-19 pandemic; 2) The generation of an emergent framework composed of socio-cultural markers of gender inequities by conducting a content analysis of the literature; and 3) The creation of a matrix with the main challenges found in the literature and recommendations to be considered during the post-pandemic and future health crises.
Outcomes and definitions
Scope of gender in the literature
Context: the COVID-19 pandemic was an inclusion criterion. The categories were: geographic location (country), temporality (year of publication and period of analysis), type of study design (or methodological approach, in the case of not reporting the design), objective, first author’s gender (categories were imputed: male/female, based on prefixes, pronouns, names, and online bibliographies), type of main policy addressed, main characteristics of the policy/ies, and main reported results related to gender.
Theoretical-methodological approach to gender: According to a global analysis of available documents, the predominant gender approach was imputed, with two categories – binary and inclusive.
Use of language: Language conveys cultural and social attitudes . Based on a global analysis of available documents, the following categories were imputed: female/male (terms included: female/male, woman/man, girl/boy, mother/father) or gender diverse (terms included: lesbian, gay, bisexual, transgender, travesty, intersex queer, other identities, and LGBTIQ+).
Socio-cultural markers of emerging gender inequalities
From the global content analysis of all documents, the following dimensions were defined from which the emerging socio-cultural markers (categories) emerged, from which an emergent framework was generated and challenges and recommendations identified.
Intersectionality: This is the recognition of the combined effects of the social categories of race, class, and gender . Macro, meso, and micro-social levels were considered.
Gender roles: A set of culturally defined expectations that are assumed, learned, and performed according to gender .
Asymmetries and inequalities: Societies and cultures reproduce hierarchical structures articulating relations of power, domination, and subordination that translate into inequalities [3,4]. These inequalities should also be explored in public policymaking .
During the review stage, all texts published at the international level that met the following inclusion criteria were included “post hoc”, based on familiarization with the literature: texts that referred to the explicit, central, and transversal inclusion of the gender approach, with a focus on inequities in the context of health or social protection policies promoted during the COVID-19 pandemic. All documents were included without temporal, language, or geographic restrictions, with different designs: systematic reviews, narrative reviews, experimental, observational, descriptive studies, essays, viewpoints, qualitative studies, and policy briefs.
We excluded publications on policies implemented before the COVID-19 pandemic, that were not promoted by governments, that did not have sufficient information on a specific case of public policy (for example, those studies that were only limited to enunciating the name of a policy without a specific description), that did not explicitly report the incorporation of the gender approach, that were preprints, abstracts, presentations at scientific meetings, editorials, or research guidelines, and those whose full text could not be accessed. Opinion pieces, written press, political ads, official notices, and public presentations were not included, and neither were papers focusing only on research or policy “gaps”, reflections, recommendations, future perspectives, framework development, or lessons learned from health crises prior to COVID-19. Documents that were not captured by the database search or reference screening were not included.
We did not include studies that only reported population outcomes or impacts (deaths, cases, hospitalizations, health spending, mental health or other chronic diseases, unemployment indicators, loss of income, lower school performance, mental health, crisis recovery, vaccination, mobility patterns, violence date, individual experiences, intimate arrangements, scholarly productivity of women, etc.) and did not focus on policies in specific countries, or that specifically analysed system-level interventions, health services and personnel, violence victim care services, business or school contexts, or reported policy characteristics in a grouped, synthetic, or global manner from various countries. We excluded specific publications on fiscal policies, macroeconomics, data, online education, remote work or school, or other educative institution closure or business policies, implemented during the COVID-19 pandemic, and that were not directly addressed to the communities. Studies analysing any social or health policies in the context of a pandemic related only to specific groups (such as schoolchildren, college students, children, adolescents/youth, elderly people, patients with chronic diseases, and pregnant persons, women in rehabilitation, risk behaviours, postnatal women, or people with HIV) were not included.
We did not include studies analysing only leadership, political discourses, press conferences, or social networks information and media.
We did not include technical documents from government, multilateral agencies, and other organizations that were not captured by the initial search strategies in the database, or studies with potential conflicts of interest.
The data collection was carried out from March 5 to April 4, 2022, and the search was updated on August 15 to 18, 2022 (only on some databases by a rapid review). Ten specialized scientific databases were reviewed from different areas (multidisciplinary, health sciences, public health, social sciences, humanities, and gender): ScienceDirect, MEDLINE (via PubMed), Google Scholar, Anthropological Index Online, JSTOR Journal Storage, SAGE Journals Online, Springer, Studies on Women & Gender Abstracts, Cochrane Library and Global Index Medicus (GIM) – which includes regional indexes (African Index Medicus (AIM), Latin America and the Caribbean Literature on Health Sciences (LILACS), Index Medicus for the Eastern Mediterranean Region (IMEMR), Index Medicus for South-East Asia Region (IMSEAR), Western Pacific Region Index Medicus (WPRO)), with an independent search in LILACS.
We generated specific search strategies for each database based on combined terms in English, Spanish and Portuguese. Before developing the strategies, we carried out an exhaustive analysis of the dimensions and scope of this study, making it possible to generate sensitive strategies that we tested and refined to capture the greatest number of documents of interest (Appendix S1 in the Online Supplementary Document).
We also used the Google search engine to manually retrieve the references of both included and excluded articles captured by the initial search strategy, for which we conducted a full-text review. We eliminated duplicates found in the different databases.
We first evaluated the study titles and abstracts, after which we analysed the full text. If the full text of potentially a relevant scientific article could not be located, we tried to contact the author. Citations were managed with Endnote.
We prepared a register form to systematize the information of each document, which contained the pre-established dimensions and categories of analysis, with an open field to record emerging information.
Data extraction and analysis
We conducted a content analysis on the information gathered from the documents . To improve internal validity and mitigate possible information bias, all the information collected was reviewed at least twice. Three independent reviewers (including DLM, MLM and LLM) assessed the included documents for relevance, detecting potential discrepancies and finally reaching a consensus on the final inclusion. We developed an emerging framework of socio-cultural markers and a matrix of challenges and recommendations.
The study was based on published documents. The manuscript was evaluated by the Institutional Health Research Ethics Committee (CIEIS) of the Hospital Nacional de Clínicas of the National University of Cordoba, Argentina (Number: PV-2022-00490734-UNC-CE#HNC).
Scope of gender in the literature
A total of 771 records were retrieved, 188 of which underwent a full text analysis. 208 records were screened through the additional manual search described above (Figure 1).
Figure 1. The scoping review flowchart.
A total of 67 articles were included (54 from the initial search strategy and screening and 13 from the citation screening (Figure 1)). Included articles written in other languages (Spanish = 3, German = 1, Vitimite = 1, Portugese = 5) were translated into English.
The included studies [19–85] either covered at least one country from the European region (n = 18), or countries from the Americas (n = 21, 13 from Latin America and 8 from North America), Africa (n = 10), Asia (n = 20), or Oceania (n = 4), while one had a global scope.
Fifty-four studies dealt with social distancing, restrictions, or lockdown policies, seven with employment, income, or social protection, and five with gender-based violence measures (Table 1 and Figure 1). Most studies were conducted during 2020 (the first year of the pandemic caused by COVID-19) and had a female first author (n = 52/67) (Table 1).
Table 1. Description of the studies selected in the global scoping review according to the dimensions of analysis
GBV – gender-based violence, SAGE – Strategic Advisory Group on Emergencies, LBGTIQ+ – lesbian, gay, bisexual, trans, intersex, and queer+, LGBTIQA+ – lesbian, gay, bisexual, trans, intersex, queer, asexual+
Most studies approached gender through the binary model (61/67) with a predominantly male/female use of language, while some recognized that gender encompasses more than the binary and included other gender identities (eg, van Daalen et al.  and Cook et al. ).
These studies also recognized that the crisis is possibly affecting diverse gender identities  and that there is a need for intersectional data collection beyond a binary view  (Table 1). We found a gender-diverse approach in only six papers whose analysis focused on people of different gender identities [36,49,56,61,67,70]. We also found studies that only superficially mentioned LGBTIQ+ groups [22,34,39,50,52,54,58,65].
Socio-cultural markers of emerging gender inequalities
Most studies highlighted the absence of a gender approach in the government policies promoted during the pandemic (Table 1) by pointing out its implications on multiple socio-cultural markers related to gender inequalities (Figure 2).
Figure 2. Emerging framework of socio-cultural markers of gender inequalities.
Within the dimension of intersectionality, all studies have stressed or enunciated in their analysis at least some category at the macro, meso, and micro-social level (Figure 2 and Table 2) [19–85]. From a micro-social sphere, markers related to mental health, sociodemographics, vulnerability conditions, food insecurity, loss and instability of employment, and loss of housing related to the pandemic, as well as policies taken by governments were observed. Employment and income policies had a central analysis in the works of Cook et al. , Foley et al. , Bariola et al. , Holder et al. , Fuller et al , Yaish et al. , and Hien et al. . although in all the analysed studies, these markers were stated in some way during lockdown (eg, increased workload – formal, informal, domestic, and/or community work, loss or modality change of employment and income, feminized front-line employment and in other critical areas, sex workers in vulnerable situations, female-headed households, paid work and domestic work division, etc.) [19–85].
Table 2. Socio-cultural markers of emerging gender inequalities, challenges detected during the COVID-19 pandemic, and recommendations
LBGTIQ+ – lesbian, gay, bisexual, trans, intersex, and queer+, NGO – non-governmental organizations
Cook et al.  showed how a short-time work scheme implemented in four European countries with different welfare regimes relied on a normative (male) worker without questioning the gender division of domestic work . Another study carried out in Vietnam also highlighted the limitations of the development and implementation of protection policies to support ethnic minority groups where there has been no gender analysis .
Other aspects related to the loss of employment and income were observed, especially for Indian migrant women; their physical presence at the job site was crucial, as their jobs cannot be done online . Moreover, it was observed that black women disproportionately lost jobs in United States .
A study in India found a greater loss of employment among women than among men during lockdown . A qualitative study in India, carried out in a group of women from the informal labour sector during the lockdown, revealed how the multiple intersecting forms of inequalities create a complex “matrix of domination” including gender, caste, class, occupational, and religious identities .
A study in Bangladesh revealed critical factors related to women’s continuing or closing down small businesses during the pandemic in a highly patriarchal context .
However, a study carried out in Canada from February to October 2020 showed that gender gaps which existed in employment in the parent group narrowed when restrictions were relaxed .
Other aspects at the meso-social level also emerged in the studies, such as reduction of access to services and infrastructure for protection and justice [30,32], or macro-social level markers, such as macroeconomic instability, reduction of public spending for social protection, and different problems on government data monitoring level. Omukuti et al.  indicate how financial dependency and austerity and reduced public spending on social services shaped COVID-19 responses in Latin American and Sub-Saharan African countries, showing the importance of recognizing macroeconomic factors as drivers of gender vulnerability in the COVID-19 pandemic.
Lockdown and social distancing policies were presented in the studies as strongly related to the dimension of social and cultural roles on reproductive and care tasks linked to women, which were widely present in most studies, though in different depth or scope, or just enunciated (Table 1) [19–85].
Reproductive tasks were exacerbated and increased during the pandemic and by the government’s lockdown measures. Additionally, during this period, a triple workload was generated: paid, domestic, and community work [35,47].
As Gordon-Bouvier postulated, there was a crisis of exhaustion and reduced resilience during the pandemic, particularly impacting those engaged in social reproduction, both inside and outside the home .
Moreover, a study in Australia found that the rise in “relative equity” during the lockdown did not compensate for the extra unpaid work burden the pandemic caused for women . These measures also had negative impacts on the scholarly productivity in the group of female academics [24,60].
A study in Panama also delved into gender-segregated distancing policies, indicating lower visits to all community location categories on female-mobility days. As the authors claim, women could have undertaken fewer tasks outside the home than men .
Asymmetries and inequalities
The implemented policies related to the dimension of asymmetries and inequalities; although they were stated in several texts, they took on a central role in studies specifically addressing gender-based violence (GBV) during the lockdown period (Table 1) [22,27,30,32,36,39,43,50,51,58,61,69,70,75,76]. Difficulties in accessing essential services by survivors of GBV, both because they were unable to travel or seek help and because services were reduced during this period, were also reported in these studies [22,27,30,32,43,58,76].
Survivors of GBV with marginalized identities have been at greater risk of being doubly victimized by the perpetration of violence and by the failure of protection systems .
Dias Corrêa et al.  highlight that structural violence worsened during the pandemic lack of care by of the State.
Also, as indicated by Srivatsa , communication and outreach by local governments is critical. John et al.  showed how the Kenya government turned its attention to GBV only after reports of rising GBV led to advocacy by activist.
A study conducted in Canada and Scotland by Soremi et al.  indicated that female political leaders do not need to base their legitimacy on gender, even more so in environments where these policies have already been institutionalized, adding that the emphasis should be on professional progress.
In their global study, van Daalen et al.  showed how women’s voices were excluded in expert working groups and decision-making during the pandemic, with very low gender parity. Furthermore, van Daalen et al. , Bacigalupe et al. (in Spain) , and Sell et al. (in Germany)  found a deficient level of transparency on the committees’ composition.
Wenham et al.  found that, although the average number of women in scientific advisory groups on emergencies increased during the crisis, this did not imply a greater awareness of gender issues in politics. Similar ideas were expressed in other studies [20,23].
Kim et al. (in South Korea)  indicate that COVID-19 mitigation policies were sustained through a masculinized discourse related to policies focused on minimizing the spread of the virus and alienation from other social problems.
Perez-Brume et al.  clearly show the presence of violence and marginalization generated during the pandemic, pointing out serious and unacceptable situations suffered by transgender groups in some Latin American countries, such as Peru, Panamá, and Colombia, where the physical distancing policy was based on binary interpretations of gender.
The Irons’ study analysing gender-segregated quarantine in Peru suggests that these events were more than just the results of the policy-makers’ missteps, but rather the persistence and exacerbation of long-existing of colonial and patriarchal structures .
Rieger et al.  enunciated elements related to gender diversity, indicating that most survivors of gender-based violence are women and gender-diverse people. Different studies in Brazil, India, and Indonesia indicated psychological distress or mental health problems in gender-diverse persons during the pandemic, social distancing, and lockdown periods [49,61,67,70].
The pandemic’s consequences for diversity groups are varied, with an increase in inequities and LGTBI-phobia presence . Studies in Brazil and India [49,61,70] have shown that it exacerbated stigmatization and marginalization in already marginalized groups  such as gender-diverse persons.
However, Rodriguez Fernandez  and Polischuk et al.  provide examples of violence prevention services or social programs during the pandemic that included members of the LGBTIQ+ communities, as was the case of Argentina and New Zealand.
Also, the negative consequences of the closure were also observed in other groups such as sex workers, exposing them to exploitation by both their clients and the police . It was also detected in India, where the patriarchal structure and social prejudices conditioned women’s experiences of the COVID-19 crisis . Studies have also pointed out the humiliation of migrant workers from India by state authorities during lockdown . Dias Corrêa et al.  and Camilo et al.  also pointed out the structural violence from the police force in Brazil.
A study analysing the case of India indicated how the state and social mechanisms of power, following the pandemic outbreak, pushed the populations into precarious living situations and conferred upon them the status of “living-dead” .
Using the content analysis of the included documents (Table 1) [19–85] and the emerging framework of socio-cultural markers (Figure 2), we developed a matrix to identify and adapt the main challenges and recommendations detected for consideration during the pandemic (Table 2).
The disease caused by COVID-19 was first reported in Wuhan, China in December 2019 . To date (May 11, 2022), the World Health Organization has reported 516 476 402 confirmed cases and 6 258 023 deaths globally .
The COVID-19 pandemic has triggered unprecedented governmental and political action worldwide . Strict health measures such as social distancing policies, isolation, and lockdown, have been implemented in many countries  and were the focus of many studies included in this review.
Although these measures are effective and imperative in curbing the spread of infectious diseases [89–91], they have also had negative effects on multiple spheres of wellness, and they are the subject of analysis due to their economic, social, and psychological repercussions [89–92].
The pandemic has amplified multiple existing inequalities , especially those related to gender as found in this study, but it also occurred at a time of demands for social change and greater equality with a growing feminist movement from before the onset of the COVID-19 pandemic . However, the public health policies promoted during the crisis have not addressed the gendered impacts ; this has occurred in previous disease outbreaks [2,31,93] and was amply demonstrated in this study.
This omission of gender in health policies during the pandemic, in part, can be explained by the “tyranny of the urgent” [93,94], marked by a dissociation between immediate biomedical needs and those not considered a priority, such as inequities and structural problems.
This study also highlighted the methodological and scope limitations of studies published during this stage. A predominantly binary approach to gender has been observed, similar to what Williams et al. suggest .
Gaps were also evident at the level of the policies analysed and their impacts, as proposed by Agarwal . The literature was largely focused on the immediate confinement measures and the consequences on care/domestic work and violence , while there was no in-depth and central analysis of other inequity markers related to medium and long-term impacts that will surely affect recovery, such as food and nutritional insecurity, loss of livelihood, indebtedness, low resilience, and rising poverty . Food and nutritional insecurity issues were considered by Chitando , Oladeinde , Arora et al. , Singh et al. , Bau et al. , and Pinchoff et al.  carried out in African countries and India. A part of the documents analysed the gender impacts globally and immediate employment consequences. The limitation in the scope of gender markers in the analysed studies was probably since most were conducted during the early stage of the pandemic, raising the need to generate new visionary and localized evidence.
Smith  postulated that, while health policy research may have incorporated gender analysis, few specific studies on gender issues are related to outbreaks. We found that gender gaps are still noticeable, as was reported in previous studies [93,95].
Another aspect to be highlighted was the presence of a smaller number of documents in some regions, such as Africa, despite the evidence of the COVID-19 pandemic’s substantial impact and the partial and inconsistent policy response with respect to gender in this continent, as in Latin America . Low- and middle-income countries show problems of gender inequity with fragile health systems; they should be more proactive in improving their evidence-based strategies to provide sustainable solutions and reduce the different gaps , requiring more studies in this territory.
Despite the limitations of the literature, a multiplicity of socio-cultural markers was found that translate into present and future gender-related challenges caused by the pandemic and the measures implemented by governments.
This study sought to address the policy measures generated during the crisis from an intersectional and located approach, not only considering individual conditions but a broader framework that recognizes the social and geopolitical forces that shape people’s lives , assuming that communities are not homogeneous and that there is a diversity of experiences [45,97], and that the impacts of COVID-19 and the implemented policies will also be differential.
As we have observed, people with one or more identities (such as marginalized people, disability people, undocumented people, ethnic minorities, people of colour, sexual and gender minorities, migrant women, and cisgender women) may be particularly and disproportionately affected by the COVID-19 pandemic [22,97,98].
The gender-blind planning and decision-making in public health during the response to the COVID-19 pandemic stem from a hegemonic and patriarchal system, generating differential needs in these groups .
As found in this study, the measures implemented during the COVID-19 pandemic, especially lockdowns and restrictions and have substantially increased the risk of gender-based violence [22,27,30,32,36,39,43,50,51,58,61,69,70,75,76]. Gender and sexual minorities have been severely affected [36,49,56,61,67,70].
Besides the challenges mentioned above, there are other gender-blind spots, which also deserve attention, such as the low opportunities for female decision-making during the crisis [23,25,29,48]. However, the gender analytical lens found focused on the increased risk of gender violence, the domestic and reproductive work, and social inequalities, especially in employment and income [19–85].
This study’s main strength is the comprehensive approach to the gender approach at both the policy and knowledge levels generated during the COVID-19 crisis.
Further research in this field will be necessary to reduce the current knowledge gap; to our knowledge, there are no published works similar to this study. The global evidence regarding the gender approach in public policies promoted during the COVID-19 pandemic in different countries and contexts until now has never been, to our knowledge, fully synthesized. Another strength lies in the potential of the emerging framework and policy recommendations generated from the data, which could serve, although duly adjusted and adapted, to post-pandemic contexts and future health, humanitarian, and environmental crises.
Limitations include those arising from the design itself and its descriptive and exploratory nature. However, the purpose of this work was not to systematically compare the studies, but rather to describe and comprehensively discuss the “state of the art” on the subject from a theoretical, methodological, and analytical point of view in order to generate policy recommendations and more specific future research.
Due to the nature of the study, we have not evaluated the quality of the evidence and there may have been information that was not captured and included by the search. For pragmatic and feasibility reasons, it was necessary to limit the search strategies in three languages (although the language was not an exclusion criterion) and during the initial screening stage, only one researcher reviewed the abstracts and titles. The review may have missed documents written in other languages.
However, we have made different efforts to achieve the revision of an important diversity of databases that allows us to capture the greatest possible number of experiences from different continents and countries.
A series of measures were taken to minimize inclusion biases: a researcher reviewed the titles and abstracts of all records and all full texts at least twice. A sample of studies excluded in the abstract and title review again underwent a full-text review, and three researchers independently reviewed the potentially included studies.
Publication bias could have existed, considering the emergency context (as much of the work was generated during the first months of the pandemic), making it less likely for studies with positive results or implementation of gender protection policies to be published. However, the focus of this work was based on inequities, although studies from countries where positive strategies were discussed.
Other limitations were the gender imputation of the first author through information collected from the web rather than from self-perception and that the historical, ideological, political, and normative differential context of each country with respect to gender advances was not considered. However, a certain consistency was found among the analysed studies regarding the approach and scope, which may indicate that, despite context-specific gender norms, the effects of the pandemic and the implemented policies could transcend geographical barriers, languages, social and cultural contexts, similar to those reported in a previous study .
This study highlighted the multiple gender gaps in both knowledge generation and policy implementation during the COVID-19 pandemic in different countries. The lockdown policies negatively affected multiple dimensions of wellness for women, socially vulnerable groups, and other diverse identities.
This should be considered a call to action for researchers, policy-makers, and other stakeholders to incorporate a gender-diverse perspective into the policy field in an intersectional sense to overcome current inequities and asymmetries and not perpetuate and deepen them.
The COVID-19 pandemic represents a unique opportunity to realign policy priorities from inclusive and gender-transformative approaches to recovery.
To María Olivera Mores for proofreading and English language review. To the librarian Daniela Rodríguez for her collaboration in the process of accessing the full texts. To the Distance University of Madrid, through the Postdoctoral Stay Program 2022, for institutional support.
Ethics statement: The study was based on published documents. The manuscript was evaluated by the Institutional Health Research Ethics Committee (CIEIS) of the Hospital Nacional de Clínicas of the National University of Cordoba, Argentina (Number: PV-2022-00490734-UNC-CE#HNC).