Expert Roundtable: Intimate Partner Violence and COVID-19

The COVID-19 pandemic led to an exacerbation of pre-existing hardships and disparities in many vulnerable populations, including individuals affected by intimate partner violence. Pre-pandemic statistics showed that 30% of women are victims of sexual or physical IPV in their lifetime, and numerous reports have shown that the incidence and severity of intimate partner and family violence increased substantially after the pandemic began.¹

In the first weeks after school closures and stay-at-home orders were implemented in March 2020, for example, municipal law enforcement agencies in Alabama, Oregon, and Texas reported significant increases (27%, 22%, and 18%, respectively) in arrests or calls related to domestic violence compared with the previous periods.² In addition, a study published in August 2020 in Radiology found that although fewer individuals reported IPV to health care providers during the initial months of the pandemic compared with previous periods, rates of IPV increased and more severe injuries were observed on radiologic images.³

We interviewed the following experts to learn more about this issue and how clinicians may best assist affected individuals: Maya Ragavan, MD, MPH, MS, assistant professor of pediatrics in the division of general academic pediatrics at the University of Pittsburgh School of Medicine and author of a recent paper⁴ on the topic; Bharti Khurana, MD, director of the Trauma Imaging Research and Innovation Center and associate professor of radiology at Harvard Medical School and Brigham and Women’s Hospital in Boston; Annie Lewis-O’Connor, PhD, NP-BC, MPH, FAAN, founder and director of the C.A.R.E. (Coordinated Approach to Resilience and Empowerment) Clinic at Brigham and Women’s Hospital; and Mardi Chadwick Balcom, JD, senior director of the Community Health Intervention and Prevention Programs at the Center for Community Health and Health Equity at Brigham and Women’s Hospital. Dr Khurana and Dr Lewis-O’Connor are 2 of the authors of the aforementioned Radiology study.³

What does the evidence suggest thus far about the impact of the pandemic on IPV risk, and incidence, and what are believed to be the reasons for these effects?

Dr Khurana: Our study evaluated and compared the incidence and severity of IPV in the early phase of the pandemic to the previous 3 years. While the number of patients reporting IPV almost halved, physical IPV cases nearly doubled with a 5-fold increase in severe and a 4-fold increase in very severe injuries.³

Potential reasons for the overall decrease in the number of patients reporting IPV include an unfounded fear of contracting COVID-19 in the ED during the early phase of pandemic; the likelihood that IPV victims were overlooked by health care providers as they were overwhelmed by the surge of COVID-19 patients, and the fact that many outpatient clinics were not seeing patients in-person and screening questions were skipped during virtual visits, with no visual cues to bruises.

Potential reasons for increase in physical violence and severity include various stressors such as isolation, socioeconomic instability, fear of infection, absence of community support, increased substance use, and increased time spent with partners at home.

However, things have changed with a year into the pandemic. We are now seeing a lot more patients reporting IPV, although we still need to compare the numbers and do the detailed analysis of the severity.

Dr Ragavan: The emerging literature has shown that the pandemic has increased violence frequency and severity globally.¹ In terms of why, there are so many reasons. I am currently a co-investigator on a Centers for Disease Control and Prevention (CDC) funded project, in collaboration with the American Academy of Pediatrics, the University of Pittsburgh, and Futures Without Violence in which we are interviewing IPV advocates from victim services agencies asking this question (manuscripts are in process or under review). Many advocates described how IPV survivors are more isolated and may not be able to access support services.

Additionally, the circumstances surrounding COVID-19 may be used as a way to perpetrate violence and control. For example, we have heard of abusive partners taking stimulus checks, not paying cell phone bills, and perpetrating other forms of economic abuse during the pandemic.

Additionally, harm reduction strategies that worked prior to the pandemic may not be as effective or accessible now. However, I also want to state that COVID-19 has compounded challenges faced by IPV survivors before the pandemic begun. IPV survivors have always faced challenges meeting basic needs, which the pandemic has worsened. As another example, monitoring technology is a commonly used controlling strategy and now may be used even more frequently when so much of our lives have shifted to virtual.

Furthermore, IPV survivors belonging to marginalized communities (ie, immigrants, racial and ethnic minorities, and gender and sexual minorities) may face compounding challenges due to deep-seated structural inequities such as racism, xenophobia, etc. It is so critical as providers that we understand this syndemic framework where IPV, COVID-19, and structural factors compound upon each other. Advocates have also been describing the incredible resilience of survivors and their families during this time. 

What are some key recommendations for clinicians about how to adequately screen for and address IPV risk and occurrence with patients?

Dr O’Connor: We ae promoting safety — for example, establish whether the patient is alone and signal if someone has arrived in the home during the telehealth visit. We are promoting universal education and broad inquiry, such as, “These are challenging times for everyone — how are you and your partner getting along?” Again, before asking any sensitive questions and providing universal education, recheck that there is privacy to ensure that the patient is still able to talk freely. 

Some providers have begun to text their patients, asking proactively if texting is safe. I texted my patients, “If you have any sensitive or private issues that you would like to discuss, please consider having a private space so we can talk freely.” Some patients join a telehealth visit from their car or work, or at other places where they know they have privacy. 

Dr Ragavan: My suggestion is for clinicians to not screen for IPV. but rather use a universal education and resource provision approach. This strategy was developed by Dr Elizabeth Miller⁵ and Futures Without Violence. It suggests that clinicians provide all patients with education around IPV rather than asking for disclosure.

I have been stating that we know this time is so challenging for families and we have heard that some families may be facing challenges accessing food or housing, or may be experiencing stress or violence. Then I say we provide a resource sheet to all families. This strategy prioritizes resource provision over disclosure. As we know, there are many reasons someone may not want to disclose IPV — and it also promotes knowledge translation, where patients can have access to resources to support their communities.

If someone discloses, I recommend validating their experiences and ensuring resource provision. It is critical to be survivor-centered, so recognize that there are many reasons an IPV survivor may not want to engage with us or other service providers and that’s okay — survivors know how to keep themselves safe. We are here to offer support but not force someone to do something. 

If someone wants to use a more traditional “screening” method, I recommend they be wary that many screening tools do not consider the multiple forms of controlling behaviors abusive partners may use. I also strongly discourage IPV screening through telemedicine as there is no real way to ensure confidentiality. 

What are additional needs in this area in terms of resources and provider competency?

Chadwick Balcom, JD: The pandemic exposed the inequities survivors of violence face, and how safety at home from the pandemic can exacerbate violence. We all have to recognize the shift in access to resources — courts, shelters, and other supports — to a virtual platform, and how the lack of access to privacy and technology play a role in decreased access for some.

There is also the upside that for some survivors, virtual care and support can increase connection because many barriers — transportation, child care, time, etc. — are removed. Many people working in the field of supporting survivors of violence have learned that adaptability and flexibility are key to providing survivor centered trauma-informed care, support, and advocacy.

Dr Ragavan: As a pediatrician, I think we need a lot more work focused on best practices in pediatric settings, which is a bit different than adult settings. 

I also think it’s important to continue developing collaborative relationships with victim services agencies who do life-saving work supporting survivors and their families. Having warm referral systems in place can be very helpful. Additionally, as clinicians, we need to advocate to ensure that victim services agency staff get vaccinated and have the PPE needed so they can continue to do their important work safely. 

There are a lot of great resources available through Futures Without Violence and I strongly recommend clinicians review those resources. They have great strategies for telehealth as well. 

We also need to keep working on dismantling structural inequities to better support IPV survivors and their families. 

References

1. Roesch E, Amin A, Gupta J, García-Moreno C. Violence against women during COVID-19 pandemic restrictions. BMJ. 2020;369:m1712. doi:10.1136/bmj.m1712
2. Boserup B, McKenney M, Elkbuli A. Alarming trends in US domestic violence during the COVID-19 pandemic. Am J Emerg Med. 2020;38(12):2753-2755. doi:10.1016/j.ajem.2020.04.077
3. Gosangi B, Park H, Thomas R, et al. Exacerbation of physical intimate partner violence during COVID-19 pandemic. Radiology. 2021;298(1):E38-E45. doi:10.1148/radiol.2020202866
4. Ragavan MI, Garcia R, Berger RP, Miller E. Supporting intimate partner violence survivors and their children during the COVID-19 pandemic. Pediatrics. 2020;146(3):e20201276. doi:10.1542/peds.2020-1276
5. Miller E, McCaw B, Humphreys BL, Mitchell C. Integrating intimate partner violence assessment and intervention into healthcare in the United States: A systems approach. J Womens Health (Larchmt). 2015;24(1):92-99. doi:10.1089/jwh.2014.4870