As the coronavirus pandemic continues to surge through the nation, a concerning “shadow pandemic” is quietly growing as well. Many cities and states, including Chicago, are reinstituting stay-at-home advisories and orders to protect communities from COVID-19. Unfortunately, an unintended consequence has been the increase in intimate partner violence (IPV). With the tightening of stay-at-home regulations, the health care system cannot overlook those suffering behind closed doors.

IPV includes physical violence, sexual violence, emotional abuse, and stalking. IPV can affect anyone and is one of the leading causes of homicide in women. During the COVID-19 pandemic, homes have become an even more dangerous place for individuals experiencing IPV. They have to spend the whole day at home with little access to outside support or childcare services, and stressors in the home are exacerbated due to social isolation, compact living situations, economic hardships, and unemployment. The pandemic’s impact on IPV also differentially impacts vulnerable populations such as minority women, undocumented immigrants, and those with mental health conditions.

Early data from the COVID-19 pandemic related to IPV is difficult to assess due to under-reporting to law enforcement agencies, under-utilization of existing social services, and the challenge of collecting self-report data during a global pandemic. To interpret the pandemic’s impact on IPV, data has been gathered by looking at call traffic to various domestic violence hotlines globally. For instance, calls to a domestic violence hotline in the U.K. increased by 25 percent within the first week of stay-at-home measures, and similarly, a Vancouver crisis line experienced a 300 percent increase in calls during the pandemic.

In Chicago, the Chicago Police Department has seen a 13 percent increase in domestic violence-related service calls since the pandemic started, compared to the same time last year. From March 21 to April 22, 2019, the Illinois Domestic Violence Hotline received five text messages, while in 2020, during the same time frame, the number was 118, an increase of over 2,000-percent. This massive increase in text messages likely represents changes due to stay-at-home orders in which people were less able to safely make a phone call. Now, more than ever, it is essential to have effective and timely IPV screening and intervention.

Oftentimes, the doctor’s office serves as a first-line screening for IPV. The American Medical Association (AMA) recommends that all medical centers develop a clear IPV screening policy. Throughout training, physicians are taught to create a safe screening environment, identify physical signs of abuse, engage in sensitive, empathetic, and non-judgmental conversation, and provide additional resources for help. Patients are asked, “Do you feel safe at home?” at visits in hopes of identifying patients that might benefit from additional care, counseling, or referrals.

However, the transition to primarily telehealth visits during the pandemic has disturbed this process. It may be hard to evaluate physical signs of abuse through a webcam and nearly impossible through a phone. Additionally, it is difficult for a physician to ensure a safe space for screening in a telehealth environment. In the clinic, health care workers can ensure a completely private conversation, whereas via telehealth, the same cannot be said — while they may ask about privacy at the start of the encounter, the perpetrator may be nearby and simply out of frame.

Specific actions can be taken to mitigate the risks to potential IPV patients in telehealth settings. Hand signals or a “safe word” can be established ahead of time to indicate when it’s safe to talk or if resources and support are requested. Using yes or no questions on a phone call can help limit the amount of information a patient reveals and assess whether it is safe for the conversation to continue. An alternate approach is for physicians to provide universal domestic violence resources to every patient, whether they disclose IPV. In either case, it would be essential that the resources given to the patient are hidden, such as the phone number of a shelter being listed as a pharmacy.

Kaiser Permanente’s Family Violence Prevention Program, established in 1998, demonstrates an effective model for addressing IPV in the health care setting. This model stands on four pillars: 1) establish a supportive environment, 2) inquire and refer, 3) provide on-site resources, and 4) connect with community groups. Health care providers can reference Futures Without Violence’s comprehensive resource guide on the “CUES” intervention for the first two pillars – Confidentiality, Universal Education, and Support. On-site resources, like a telepsychiatry program, can provide a seamless transition from identifying IPV in telehealth screens to connecting survivors with licensed therapists. Finally, partnering with community groups or non-profits like the Family Justice Center Alliance provides people with legal advice, including virtual resources, and shelter arrangements. Health care practitioners should also be aware of universal safe words and hand signals, like tucking the thumb and wrapping the other fingers around it, as signs for help. All health care centers should establish similar programs and train their providers on IPV telehealth screening, especially those serving vulnerable patient populations.

While some may argue that these various measures place an extra burden on physicians, that is all the more reason for health care systems to establish a uniform set of guidelines for IPV screening via telehealth. The truth is that many of these measures are already in use, just not on a large enough scale for all patients and providers to know they exist. Therefore, it is critical that all health centers select an appropriate action plan and disseminate it to their health professionals and actively provide education and ensure implementation.

As the nation continues to stay at home to prevent the spread of COVID-19, we must not neglect the subsequent rise in IPV. Health centers should implement telehealth screening protocols for IPV to mitigate this rise. Telehealth visits will likely persist for the foreseeable future. Health care systems have the capacity to save lives from both the virus and IPV — the time to address the shadow pandemic is now.

Gabriele Ruzgas, Elsa Nico, Katherine Thompson, and Nicole Zolman are medical students. Shikha Jain is a hematology-oncology physician who blogs at her self-titled site, Dr. Shikha Jain.  She can be reached on Twitter @ShikhaJainMD.

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