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Roger R, MD, a primary care physician from Philadelphia, set up a telemedicine appointment with a 24-year-old female patient who was experiencing headaches and was worried she might have COVID-19.
During the televisit, Dr R noticed that "Tonya" (not her real name) had a purplish bruise under her right eye. When asked how she got the bruise, Tonya said she had bumped into a dresser. The physician suspected abuse. He then heard a man's voice in the background and thought it might belong to the abuser. "Is this a good time for you to talk?" he asked Tonya.
"When might be a better time?"
Tonya suggested an alternate time, and the physician called her then. During the visit, she shared that her fiancé, a car salesman who was also sheltering at home, was punching her.
"He always had a bad temper. Once he shoved me, but he's never hit me before. And when he was upset, we used to go out to eat and he calmed down. Now, we're stuck inside, we can't even get away from each other to go to work, and he's getting scary," she told the doctor.
The physician asked if she would like to be connected with a domestic violence counselor. When Tonya agreed, he called Jessica DuBois Palardy, LSW, the program supervisor at STOP Intimate Partner Violence, a Philadelphia-based collaborative project of the Children's Hospital of Philadelphia and the Lutheran Settlement House's Bilingual Domestic Violence Program.
A "Horrifying" Trend
Tonya's story is not unique. A United Nations report shows that there has been a "horrifying global surge in domestic violence" linked to "lockdowns imposed by the governments responding to the COVID-19 pandemic." The United States is no exception ― 2345 calls were placed to the National Domestic Violence Hotline between March 16 and April 6, 2020.
Carole Warshaw, MD, director of the National Center on Domestic Violence, Trauma, and Mental Health in Chicago, said, "We know that intimate partner violence is increasing among people sheltering at home, and that abuse has become more severe."
Even in nonabusive situations, being confined together at close quarters, often amid family stress and financial hardship, can be wearing, and tempers can flare. In an abusive relationship, "the main contributor to violence during shelter-in-place restrictions is that the isolation gives abusers more opportunities for controlling their partners, who have fewer options for accessing safety and support," Warshaw said.
It is critical to "approach every clinical encounter knowing that domestic violence may be at play," she emphasized.
Physicians Might Be the Most Important Lifeline
Physicians are already facing myriad COVID-19–related challenges, and having another concern to keep in mind may be daunting.
"We're in uncharted territory and we're all trying to figure out how to navigate this time, how to practice medicine via phone and video conferences, and how to deal with the financial repercussions of the pandemic — not to mention concern for the health of our families," said Peter Cronholm, MD, MSCE, associate professor of family medicine and community health at the Hospital of the University of Pennsylvania. "So maintaining vigilance is often difficult. Nevertheless, it's important not to let this critical issue fall to the wayside."
Marcella Nyachogo, MSW, LSW, assistant director of the Bilingual Domestic Violence Program, noted that physicians and other healthcare providers "may be the only people the patient interacts with, since the abuser may cut the survivor off from family and friends. And because the survivor isn't leaving the house, he or she doesn't have an opportunity to interact with coworkers or others — which makes healthcare providers the most important lifeline."
COVID-19 as a Weapon of Abuse
Carey Watson, MD, regional medical director of the Family Violence Prevention Program at Kaiser Permanente in Northern California, points to a disturbing trend in COVID-19–related abuse.
"Unfortunately, I'm hearing more and more accounts of how the illness itself can be one more weapon in the abuser's arsenal," she said.
Experts say that increasingly, abusers are claiming that their partner, who is employed in an "essential" job outside the home, is carrying the virus, and they are using this as a means of control and manipulation.
This is especially true of abusive partners of healthcare providers, Watson noted. She recounted the story of a divorced nurse whose husband did not allow her to have contact with their children, allegedly out of concern that she might have COVID-19, and would threaten her with a gun when she protested.
""It is important to keep this abusive tactic in mind, not only when dealing with patients but also with fellow physicians and healthcare professionals, and check in to see if everything is okay — especially if they seem particularly stressed out or distant," Watson recommended.
Trust Your Clinical Gut
How can you tell if your patients might be experiencing abuse when you're not seeing them in person?
Pay attention to subtle signals and "trust your clinical gut when something doesn't feel right," Nyachogo advised.
If a patient's demeanor is jittery or anxious or if someone next to him or her is answering all the questions or interrupting the visit, these could be red flags.
Cronholm added that telemedicine visits offer a "rare window into a patient's home life that would not be available in an office visit." For example, a house in disarray, the presence of broken objects, or the presence of another person hovering in the background suggests the need for further exploration.
The starting point of screening and intervention is to recognize that any domestic violence situation is potentially explosive. "The main thing for all providers to keep in mind is 'first, do no harm,' " Nyachogo emphasized.
"Our agency has been working for years with medical professionals in how to screen and connect folks with help most effectively and safely, and — although the specific situations posed by COVID are new — the overall approach is the same, which is to proceed with caution in how you approach the subject and how you make referrals," she said.
Begin by asking if it is a convenient time to talk.
"This question takes the onus off the patient, who may not know how to communicate that she has no privacy or is in the middle of an argument," explained Elsa Swenson, program manager of Home Free Community Program, which serves individuals experiencing domestic violence. The program is part of Minnesota-based Missions Inc Programs, which serves those experiencing domestic abuse and chemical dependency.
If the patient indicates that it isn't a convenient time to talk, find out when would be a better time. "This might be difficult for busy physicians and may not be what they're accustomed to when calling a patient at home, but the patient's circumstances are unknown to you, so it's essential to organize around their ability to talk," Swenson noted.
"Are You Alone?"
Another important piece of information is whether the patient has privacy — which can be tricky if the abuser is standing right there.
"You don't want to tip the abuser off to your concerns, so you need to frame the question in a neutral way," Watson advised.
For example, you might say that HIPAA laws require that you conduct the consultation with no one else present, and find out if there is a location in the house where the patient can have privacy.
It might be easier to talk on the phone than via video, suggests Florence Remes, LCSW, a New Jersey–based social worker who specializes in domestic violence. Going into another room and playing music or turning on the television might make it less obvious that a call is taking place, and the abuser would be less likely to overhear the patient's conversation.
Watson suggested that questions about abuse might be included with other questions and asked in a simple yes/no format. "I'd like to ask you some standard questions I'm asking everyone during the pandemic. Do you have a cough or fever? Do you have any other physical symptoms? Do you have access to hand sanitizer? How is your sleep? Are you experiencing stress? Do you feel safe at home?"
The abuser, if present, will only hear the patient's "yes" or "no" without knowing the question. If the patient indicates that she is being abused but is unable to talk, a later time can be arranged to further explore the issue.
Technology Is a Double-Edged Sword
Modern technologies have been a great boon to patients and physicians during this time of social distancing, allowing ongoing contact and healthcare when it would not otherwise have been possible. On the other hand, technology is fraught with potential dangers that can jeopardize the patient's safety and compromise privacy.
Remes recounted the story of "Susan," a client with whom she had been conducting teletherapy visits using an approved HIPAA-compliant telemedicine forum. Susan was working from home because of shelter-in-place restrictions. Her husband had been abusive, and Susan was concerned he might be "sabotaging" the household's Wi-Fi to isolate her from outside sources of support.
At the recommendation of Remes, Susan continued sessions either via phone calls or by using the WhatsApp program on her cellphone. Many of the requirements governing HIPAA privacy regulations have been temporarily relaxed, and clinicians can use nonencrypted forms of transmission, such as FaceTime, WhatsApp, or Skype, if no other platform is available.
But even cellphones have risks, Warshaw noted. The patient's abuser might track texts or look at call logs — especially on unsecured platforms. It's advisable to ask patients about who has access to their phone and computer and discuss ways to increase security.
Follow the Patient's Lead
Proceed slowly and start with nonthreatening questions, Palardy advised. "I notice you have some injuries — can you tell me how you got them? Did someone hurt you? What does your relationship look like when you argue? Is there anything that makes you feel uncomfortable or unsafe?"
Emphasizing that you are asking these questions because of care and concern is reassuring and helps patients to feel they are not alone, Nyachogo pointed out.
"As your doctor, I'm worried about your health and (if relevant) your children's safety. I can help connect you with counseling and support, legal resources, and a shelter, and everything is free and confidential. Would you be interested?" she said.
If the client acknowledges abuse, "follow their lead, but don't push too hard," Nyachogo warned.
"It is the client's choice whether or not to take action," she noted. "I've met survivors who said that it wasn't until a doctor or nurse expressed concern about bruises that it even occurred to them that they were being abused. Some lied to the doctor about how they got hurt — but the question planted a seed, even though it might have taken years to follow up on the referral," she said.
What if the Patient Doesn't Want to Get Help?
If a patient is not ready to seek help, you can create a home safety plan. This might include setting follow-up times. If you don't hear from him or her, you should then call the police. Or you might create a "code word," such as "apple pie." If the patient uses that word during a session, you know her life is in danger, Remes suggested.
Providing written information about how to get help is important but can be problematic if the abuser finds it.
Nyachogo recommends e-mailing follow-up materials that cover a variety of topics, such as keeping safe during the COVID-19 pandemic, relaxation, healthy eating, getting exercise while homebound, activities for children, and suggestions for hotlines and other resources if one is feeling suicidal or unsafe.
"If you present these as your 'standard' follow-up materials, the abuser is less likely to become suspicious," Nyachogo noted.
Resources Are Available During COVID-19
All of the experts emphasize that resources for victims of domestic violence remain available during the COVID-19 pandemic, although some shelters may be operating at reduced capacity. Some agencies are finding alternatives to group shelters, such as hotels or Airbnb, which carry less risk of catching COVID-19.
Referring a patient to domestic violence resources is a delicate process. "You don't want referring the patient for help to further endanger their life," Nyachogo said.
The more you can take the burden off the patient, the better. If she is interested in getting help, you can call a domestic violence counselor or advocate while she is on the phone.
"This type of 'warm handoff' is what Tonya's physician did," Palardy recounted.
A warm handoff requires that physicians be familiar with domestic violence resources, Warshaw emphasized.
"Don't wait until you are working with someone who needs help to find out where to refer them. Take the time to proactively research local agencies specializing in domestic violence and have their phone numbers on hand, so you can offer resources immediately if the person is interested," she advised. The National Domestic Violence Hotline can also assist with safety planning and access to local resources.
"Thinking on Your Feet" Critical for Physicians
Addressing domestic violence during this unprecedented time requires "thinking on your feet" about novel forms of detection and intervention, Watson said. This involves a combination of clinical acumen, creativity, and finely honed intuition.
Nyachogo added, "Keeping an eye on domestic violence can feel like an extra burden, but don't forget that it is lifesaving work."
National Domestic Violence Hotline
The patient can also text LOVEIS to 22522.
National Center on Domestic Violence, Trauma, and Mental Health
Provides resources for healthcare, mental health, and substance use treatment and recovery support providers on responding to domestic violence and other trauma
Provides resources for professionals and patients regarding access to substance use and mental health care during the COVID-1 pandemic
Provides support for parents, caregivers, and children during the pandemic
Provides resources for advocates serving families affected by domestic violence
United States Department of Justice
A state-by-state guide to local resources.
Children's Hospital of Philadelphia Research Institute
STOP Intimate Partner Violence (IPV)
New Jersey Coalition for Domestic Violence
Text HOME to 741741.
National Network to End Domestic Violence (NNEDV)
Batya Swift Yasgur, MA, LSW, is a freelance writer based in Teaneck, New Jersey.
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Medscape Medical News © 2020
Cite this: Domestic Violence Amid COVID-19: Helping Your Patients From Afar - Medscape - May 26, 2020.