COMMENTARY

Grim Findings on Partner Violence During the Pandemic

Bharti Khurana, MD; Giles W. Boland, MD; Ali S. Raja, MD, MBA, MPH

Disclosures

October 16, 2020

Intimate partner violence (IPV) is a serious and widely prevalent public health crisis that is defined as physical, sexual, or emotional violence between partners. One out of 2 female and 1 out of 13 male murder victims in the United States are killed by intimate partners. Nearly 20 people per minute suffer physical abuse by a mate. These CDC statistics precede the COVID-19 pandemic, which has imposed a host of unique challenges for all segments of society and particularly for the most vulnerable among us.

Socioeconomic instability, fear of disease, absence of community support, more substance use, and increased time spent with partners at home are among the stressors that can fuel an escalation and/or breed new episodes of violence. As healthcare providers, we have always been aware of IPV. What's changed in the past few months is the worsening severity of the injuries.

We recently published a study that revealed a fivefold increase in severe injuries and a fourfold increase in very severe injuries during the pandemic. For example, one woman suffered injuries of the liver, spleen, and bowel. Another had several rib fractures and punctured lungs. Both women were stabbed by their intimate partners. The number of patients reporting high-risk mechanisms such as burns, strangulation, stabbing, and use of weapons such as knives, guns, or sharp objects doubled during the pandemic.

Isolation is one of the key enablers used by perpetrators to facilitate dominance and control in an abusive relationship. Thus, lockdown and movement restrictions, vital to combat the spread of infection, are giving power to offenders. The extent of COVID-19 pandemic lockdowns and stay-at-home orders has varied between and within countries, but an alarming increase in the number of calls to IPV helplines has been reported worldwide since the pandemic began.

The healthcare setting is often the safest place for victims of IPV to seek help. During the initial phase of the pandemic, when restraining orders were difficult to obtain and shelters restricted access to preserve social distancing, caregivers at Brigham and Women's Hospital in Boston expected to see a dramatic increase in the number of patients reporting IPV to our violence prevention and support program. To calculate the proportion of increased reporting, we compared IPV reports during our COVID-19 surge (March 11–May 3) with the same time period during the previous 3 years.

Contrary to our prediction, our study revealed a 50% decline in the number of patients seeking support for IPV during the surge, although cases of physical abuse almost doubled before the pandemic. Given this surprising finding, we dug deeper into the nature and scope of physical injuries that were reported.

We saw a total of 58 injuries in 26 patients (of which 25 were women) in 2020 compared with 71 injuries in 42 patients from 2017-2019. We also found more deep injuries involving internal organs and bones: 28 during the pandemic vs a combined total of 16 in the previous 3 years.

Superficial injuries restricted to skin and soft tissues were dominant in the pre-pandemic years, constituting almost three times the number of deep injuries (45 superficial, 16 deep). However, during the pandemic, the superficial and deep injuries were virtually equal in number (30 superficial, 28 deep).

More injuries involved the central body during the pandemic, with 31 chest and abdominal injuries in 2020 compared with 10 from 2017-2019. By contrast, injuries to the arms and legs were the most common type of injuries in the pre-pandemic era.

A decline in the number of patients reporting IPV during the pandemic is especially worrisome, for a number of reasons:

  • IPV victims lack access to traditional support services, such as finding refuge at friends' houses or at shelters.

  • An unfounded fear of contracting COVID-19 in emergency departments may have kept victims from receiving help, forcing them to endure IPV for a more extended period of time.

  • IPV victims who did seek help in emergency departments may have been overlooked, or their injuries may have been misinterpreted by frontline healthcare providers who were overwhelmed by the surge of COVID-19 patients.

  • Many outpatient clinics were not seeing patients in person and instead relied on virtual visits. Unfortunately, virtual visits prevent clinicians from seeing most bruises and greatly reduce opportunities for gathering nonverbal cues.

  • Typical IPV screening questions may have been skipped during virtual visits and thus, unless the patient self-reported IPV, healthcare providers would not have had the opportunity to address it earlier in the cycle of domestic violence.

Historically, three distinct phases have been described in the cycle of IPV: the tension-building phase, the acute or crisis phase, and the calm or honeymoon phase. Over time, the frequency and severity of abuse increases, escalating to physical injuries, with the honeymoon phases becoming shorter. We found that despite a decrease in the overall number of IPV victims presenting for care, the increase in physical IPV and the severity of injuries sustained indicate that victims reported IPV at the later stages of their abuse cycle.

Our results also probably indicate that victims of mild physical or emotional abuse were not seeking any help, unlike pre–COVID-19, when they would have come to our clinics. Sadly, the victims who reached out to the violence prevention program during the pandemic, despite all obstacles and barriers, probably represent the tip of the IPV iceberg.

More than half of all homicides of women in the United States are related to IPV, with the severity and high-risk mechanism of abuse being critical predictors of homicide. It is essential for healthcare providers, social service agencies, community-based organizations, and society as a whole to reach out to the most vulnerable and develop safe and robust solutions allowing for the reporting or identification of IPV as long as social distancing is considered necessary during this pandemic.

Bharti Khurana, MD, is the director of emergency musculoskeletal radiology and program director of the emergency radiology fellowship program at Brigham and Women's Hospital in Boston, Massachusetts.

Giles W. Boland, MD, is a professor of radiology at Harvard Medical School and the chair of radiology at Brigham and Women's Hospital. Dr Boland is also an associate editor for the Journal of the American College of Radiology (Practice Management) and the current president of the Society of Abdominal Radiology.

Ali S. Raja, MD, MBA, MPH, is associate professor of emergency medicine and executive vice chair at Massachusetts General Hospital in Boston.

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