How Social Distancing Can Endanger Our Patients: Intimate Partner Violence during the COVID-19 Pandemic

Reports of Intimate Partner Violence (IPV) have significantly increased since mandated stay-at-home orders in response to the coronavirus pandemic. In this setting, how can you be attuned to patients at risk? How do you screen for IPV? How can you support a patient who discloses abuse?

Case 1
A 33-year-old Latinx, primarily Spanish speaking woman who works as a waitress presents with a complaint of pelvic discomfort and vaginal discharge. She has headaches regularly and feels "sad" though she denies any suicidal or homicidal ideation. Symptoms have been present for 1.5 weeks with intermittent pain that is worse with intercourse. She describes the discharge as thick, yellow, and foul smelling, similar to prior episodes. On chart review it is discovered she was treated with ceftriaxone 250 mg and azithromycin 1 g last week for chlamydia, and this is the fourth time she has been seen in the past 3 weeks for similar symptoms. She's previously been treated for gonorrhea, chlamydia, and trichomoniasis. Last year, she had her first herpes outbreak. She states that she is sexually monogamous with her partner.

Her gynecological history is significant for pelvic inflammatory disease, and she has a total of 4 pregnancies and 2 miscarriages. She has a 6-year-old son and 8-year-old daughter at home. No other medical problems. The restaurant she works in has contracted with a community kitchen which has allowed her to continue working. Her partner has been furloughed from their job as a construction worker and has been very stressed trying to deal with their children’s home schooling while she works in the restaurant. Her physical exam is normal with exception of cervicitis. No adnexal or uterine tenderness. ꞵ-hCG negative.

Patient seems withdrawn and uncomfortable. When you pursue this with her, she becomes tearful stating, "I just don't understand why this keeps happening." Further inquiry reveals her partner has a history of infidelity.

Case 2
A 22-year-old African American man was brought in by ambulance from home following a fall down the stairs with subsequent left shoulder pain. Paramedics splinted the patient out of concern for a dislocation. Of note, the patient is a firefighter and paramedic, and knows the crew who transported him. He is currently taking pre-exposure prophylaxis (PrEP), and has no medical problems. He does not smoke cigarettes or use drugs, but he does drink alcohol socially.

Primary survey reveals a deformity of the left shoulder. Secondary survey reveals dried blood at the corner of the oropharynx, tenderness along the lower lateral aspect of the mandible, and malalignment of the teeth. The patient is intoxicated.

When you follow up with him regarding these physical exam findings, he is initially avoidant, stating he and his friends were, "messing around." The patient also tells you that he is not "out" to his work colleagues and they believe his partner, with whom he lives, is his best friend.

Introduction
Domestic violence (DV) is a broad term which encompasses intimate partner violence (IPV), elder abuse, and child abuse.¹ IPV refers to stalking, psychological, sexual, and physical violence, usually between current or former intimate partners.¹ While stay-at-home orders on the backdrop of the COVID-19 pandemic limit transmission of the disease, there are some unintended consequences to these prophylactic measures. In the wake of stay-at-home orders, DV reports and arrests have increased on a global scale.^1,2,3

Although shelter-in-place policies promote public health in regards to the pandemic, we must also recognize the risks that quarantine invokes for victims of IPV. Vulnerable individuals may be forced to spend more time with their abuser in enclosed spaces while facing many other stressors associated with the pandemic. As data emerges about the rise of IPV in the United States, we consider what role we have on the front line, in identifying and caring for our patients suffering in abusive environments.

Case Discussion
These cases present a few concerning points that should raise your index of suspicion for IPV: multiple ED visits in a short period of time, multiple sexually transmitted infections (STIs) in the setting of a monogamous relationship, concern about concurrent sexual relationships, a queer patient that is not "out," substance use, and injuries that are not consistent with the described mechanism. While your suspicion may come from these points or a positive result from a screening tool, Choo and Houry recommend a series of steps to ensure the patient receives adequate help.⁴

1. Confirm the abuse: Ask the patient open-ended questions about the abuse they experienced. Mirror the patient’s language rather than labeling behavior or relationships. For example if you met our patient in Case 1, you might say, "You mentioned your partner has a history of infidelity. Please tell me more about that," or you could say, "How often have you felt obligated to have sex with your partner?" In the second encounter, to better elucidate the mechanism of injury, you could ask, "Please tell me more about what you mean by you and your friends 'messing around?'"

PEARL: Patients may not interpret sexually aggressive acts as IPV or rape. Nonconsensual sex with a partner is rape. Because of the stigma associated with IPV or a patient's perspective, they may not define their experience in this way. Physicians must be sensitive about the language used to enhance trust building with the patient.

2. Validate and legitimize the patient: Frequently, victims assume fault for the abuse, and have difficulty disclosing information about it. Reiterate to the patient that your goal is to ensure their safety and unveiling the maltreatment is important for their health and well-being. In Case 1, "I can see this is really hard for you. I appreciate you sharing this information with me. Please tell me more when you are ready." In Case 2, "It takes a lot of courage to tell me about this situation. I am here to listen and help you."

PEARL: It is essential to follow a difficult disclosure with acknowledgement of the patient's bravery in sharing their experience and articulating concern for their safety and well being as their treating physician.⁴

3. Encourage and empower the patient: Urge the patient to speak to their primary care provider and seek help. In addition, educate the patient about available resources they can refer to after leaving the ED. There are general domestic violence agencies and hotlines, but also networks that address specific needs such as the National Coalition of Anti-Violence Programs, an LGBTQ focused network. In Case 1, consider using interpreter services to avoid taking away her power of language. In Case 2, respect the patient’s desire to not disclose his sexual orientation to work colleagues. Be mindful of the language you use regarding the abuser while the patient’s coworkers are around.

PEARL: Patients who identify as LGBTQIA and are not "out" may potentially be at higher risk for IPV. If their abuser is aware that they are not open with their sexuality, this may enhance the abuser’s ability to isolate them, or the abuser may antagonize them by attempting to “out” them in public. Such behavior can lead to escalation and physical altercations in addition to the negative psychological impact.

4. Assist with the legal process: Offer to contact the police to make a report so that the incident is documented. If the patient does not wish to involve the authorities at the time, engage a social worker or case manager to deliver information regarding legal resources.
5. Address immediate safety concerns: It is essential to assess if the patient feels safe returning home with a brief but formal danger assessment tool that calculates risk of escalating future IPV. If the patient does not have a safe place for discharge, consult your department’s social work or case management services to assist the patient in finding alternative housing. This may be through domestic violence safe houses or shelters, or patients can be encouraged to ask a support person for short-term lodging. If no outpatient options are available and there is significant risk, physicians may consider admitting a patient in danger of escalation of violence. If a child or an elderly person are involved in the abuse, it is your responsibility to contact Child or Adult Protective Services in all states.
6. Document: Suspected or explicitly reported partner abuse should be clearly documented as it can prompt future providers to follow up on the concern. In addition, Health Insurance Portability and Accountability Act (HIPAA) compliant photographs of any injuries may be added to the patient’s chart. Consider also contacting primary care providers to enhance follow-up.

Screening
EDs play a crucial role in the healthcare system, providing care for patients of all ages, socioeconomic status and background. While some providers rely on gestalt to raise suspicion of IPV, there is evidence-based data which suggests a different approach. An article published in Annals of Emergency Medicine highlights the importance of assessing every patient for IPV in the ED due to the high prevalence in our practice setting.⁴ Further, we must consider IPV in all patients, regardless of sexuality or gender identity or expression. The common heteronormative framework that many people use to anticipate IPV involves a scenario in which a feminine-presenting person experiences violence by a masculine-presenting person. A more sensitive framework to detect IPV is to consider the power dynamic in a given relationship.^5,6 In a busy ED, this can be accomplished by establishing a standardized process within the system.⁴

In practice, this process is often completed by nurses and documented in the chart if positive.⁴ Physicians should carefully review nursing documentation and perform their own secondary evaluation with each patient. This should be completed in a private setting without any visitors present as it creates an environment which is conducive for patient disclosure of abuse.⁷ In order to comply with updated CDC guidelines due the COVID-19 pandemic, many hospitals are limiting in-person visitors.⁸ This provides a unique opportunity for healthcare workers to assess for IPV, but leaves the question: how can we have these conversations effectively?

One study that analyzed recordings of IPV screens in the ED between physicians and female patients found that patients were more likely to disclose their abuse if physicians used open-ended questions.⁷ Additionally, the use of empathy and response to psychosocial cues were found to be successful strategies enhancing disclosure of abuse.⁷ Physicians should also use respectful and non-judgemental tone of voice and body language, including being at eye level with the patient.⁴

Various screening tools are available with different sensitivities and specificities for IPV (CDC Violence Prevention Screening).⁹ When using these with patients, and conversing about possible IPV, you should also inform the patient about the limits of confidentiality.⁴ One exception to maintaining strict confidentiality relates to a patient who is at high risk for self harm, or situations in which there is high suspicion of child or elder abuse.⁴ These difficult encounters may necessitate psychiatric evaluation for the patient, or mandated reporting to local agencies for the child and elder abuse scenario. When making this disclosure, you should follow it with the use of a brief normalizing statement explaining the rationale for screening.⁹

It is critical for students and providers to be equipped to screen and deliver care for patients impacted by IPV. One study showed that practicing interviewing skills through role play can help students improve their ability to identify IPV.¹⁰ This is a challenging topic to discuss. Training programs must provide ample opportunities for learners to practice asking open-ended questions when evaluating patients. When physicians incorporate these strategies into every conversation, it may lead to a more fluid conversation, put patients at ease, and enhance their trust.

Conclusion
These clinical vignettes highlight only 2 of the many possible presentations of patients suffering IPV who may seek care in the ED. The need to effectively recognize sufferers of domestic violence has been amplified by the COVID-19 pandemic. Establishing a standardized practice for screening every single patient regardless of race, sexual orientation, gender identity or expression, and socioeconomic status will help providers recognize victims of IPV. Employing the aforementioned techniques promote patient disclosure of abuse. If a patient confirms abuse, empathize, validate, and empower them. This can include addressing safety concerns by providing resources for alternative housing. Enlisting the help of interdisciplinary team members is essential. Especially now, it is critical that front-line physicians are attuned to subtle presenting features of patients who may be victims. Using a standardized screening tool and being prepared to respond to a positive screen could help save lives.

Take-Home Points

• Reports of domestic violence have substantially increased during the time of COVID-19 stay-at home-orders.
• All ED patients should be screened for domestic violence by a physician.
• IPV as a disease process does not discriminate based on race, sexual orientation, gender identity or expression, or socioeconomic status.
• Use open-ended questions in a respectful and non-judgemental tone and body language, including but not limited to being at eye level with the patient.
• Mirror your patients’ language.
• If screening is positive, confirm by restating, validate their feelings, encourage reporting, address immediate safety risks, and provide resources for the legal process.

References

1. Boserup B, McKenney M, Elkbuli A. Alarming trends in US domestic violence during the COVID-19 pandemic. Am J Emerg Med. 2020. doi:10.1016/j.ajem.2020.04.077
2. Feng J. COVID-19 fuels domestic violence in China - SupChina. SupChina. https://supchina.com/2020/03/24/covid-19-fuels-domestic-violence-in-china/. Published 2020. Accessed June 4, 2020.
3. Godin M. French Government To House Victims Of Domestic Violence In Hotels, Amid Rising Number of Cases. Time. https://time.com/5812990/france-domestic-violence-hotel-coronavirus/. Published 2020. Accessed June 4, 2020.
4. Choo E, Houry D. Managing Intimate Partner Violence in the Emergency Department. Ann Emerg Med. 2015;65(4):447-451.e1. doi:10.1016/j.annemergmed.2014.11.004
5. Common Myths about LGBTQ Domestic Violence. Human Rights Campaign. 2017. https://www.hrc.org/blog/common-myths-about-lgbtq-domestic-violence. Accessed June 4, 2020.
6. Treating LGBTQ Patients Who Have Experienced Intimate Partner Violence. American Psychiatric Association; 2019. https://www.psychiatry.org/File%20Library/Psychiatrists/Cultural-Competency/IPV-Guide/APA-Guide-to-IPV-Among-LGTBQ-Communities.pdf. Accessed June 4, 2020.
7. Rhodes K, Frankel R, Levinthal N, Prenoveau E, Bailey J, Levinson W. “You're Not a Victim of Domestic Violence, Are You?” Provider–Patient Communication about Domestic Violence. Ann Intern Med. 2007;147(9):620. doi:10.7326/0003-4819-147-9-200711060-00006
8. Coronavirus Disease 2019 (COVID-19). Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#minimize. Published 2020. Accessed June 4, 2020.
9. Rabin R, Jennings J, Campbell J, Bair-Merritt M. Intimate Partner Violence Screening Tools. Am J Prev Med. 2009;36(5):439-445.e4. doi:10.1016/j.amepre.2009.01.024
10. Edwardsen E, Morse D, Frankel R. Structured Practice Opportunities With a Mnemonic Affect Medical Student Interviewing Skills for Intimate Partner Violence. Teach Learn Med. 2006;18(1):62-68. doi:10.1207/s15328015tlm1801_13