Introduction

While the damage and incalculable losses of COVID-19 continue to be felt globally, many people have been left to struggle with an intimately related and urgent crisis: the soaring rates of domestic violence worldwide.1 Domestic Violence (DV) or Intimate Partner Violence (IPV) is defined as “physical, sexual, psychological, or economic violence that occurs between former or current intimate partners”.2 It is the most common cause of non-fatal injuries to women worldwide, with 1 in 3 women experiencing it in their lifetime. 2, 3 IRISi research states that for women attending general practice appointments in the UK, the rate of domestic violence can be as high as 41%.4 The United Nations Secretary General has previously identified violence against women as a global pandemic.5 Furthermore, a UN warning issued in March of 2020 cautioned that rates of domestic violence would increase drastically due to lockdown measures put in place to fight COVID-19, with member states urged to take steps in order to protect those affected and mitigate harm.5 Now more than ever, governments and medical professionals have a clear moral obligation to tackle domestic violence, which should ostensibly be framed as an issue of public health.5-7, 8

The Effect of COVID-19 on Domestic Violence

Rising domestic violence rates have been reported in countries worldwide including China, France, Spain, Italy, the United Kingdom, and the United States.1, 2 Women’s Aid, one of Ireland’s leading national charities working to stop domestic violence, reported a 43% increase of contacts with their service in 2020, which is an unprecedented annual rise since their formation in 1974.9 The measures put in place to address Covid-19 have contributed to significant increases in the rate of child abuse and domestic violence globally.10 Lockdowns and quarantine measures provide a perfect breeding ground for domestic violence risk factors, including increased relationship strain and stressors, social and geographical isolation, and an inability to access support services.2 

There has been a 60% increase in calls to domestic violence services reported in the World Health Organization’s EU member states during the Covid-19 pandemic, with online inquiries increasing fivefold in 2020.6 Common phrases in the literature of late pertaining to domestic violence are “hidden” or “shadow” pandemic, just the “tip of the iceberg”, and “paradox”: the latter referring to the oxymoron of instructing people to stay home in order to save lives, something which may be tantamount to requesting at-risk individuals take shelter in a burning building, endangering themselves to protect others.5 The United Nations Population Fund has warned that continued lockdowns could result in 31 million more cases of gender-based violence globally over the next decade due to the delayed and abortive rollouts of preventative and interventional programmes designed to tackle domestic violence.6 Regardless of future predictions, it is already evident that the Covid-19 pandemic will have reaching ramifications in the coming years for millions of men, women, and children whose health, well-being, and lives will continue to be endangered in their homes.

The Cost of Domestic Violence

Domestic violence carries a high cost in lives, in physical and mental ill health, and in impaired childhood development. It strongly correlates with increased morbidity and mortality.7, 8 “Women who experience domestic violence often suffer from chronic health problems including gynaecological issues, gastrointestinal disorders, neurological symptoms, chronic pain, cardiovascular conditions, and mental health difficulties”.11  Beyond this very salient human cost, intimate partner violence also carries a high economic price. Sonas, the leading Irish provider of refuge services for women in the greater Dublin area, estimates that domestic violence costs the Irish economy 2.2 billion euros annually. Despite this, less than 1% of the cost, approximately 20 million euros, is spent on responding to or preventing domestic abuse.12 IRISi estimates that the annual cost of healthcare provision to domestic violence survivors in the UK, not including mental health treatment, is 1.7 billion pounds.4

The Role of Healthcare Providers

Healthcare professionals and general practitioners specifically are uniquely well-positioned to identify and address domestic abuse, which is an imperative when one considers the following statistic: 45% of women murdered by their partner will have presented to a healthcare professional for the treatment of a domestic violence related injury in the 2 years prior to their death.3,8, 13 80% of women in violent relationships seek help from health services, which are often their first, or only, point of contact.4 In terms of clinical presentation, head, neck, and upper extremity injuries are the most common injuries in domestic violence survivors, however the responsibility of general practitioners and healthcare providers in identifying potential cases must go beyond critical appraisal of a patient’s presenting complaint for potential warning signs.3, 8 General practitioners must become comfortable asking about domestic violence and educating themselves continually about local resources.10, 11 

Beyond screening, general practitioners can provide support around immediate patient safety and the creation of a safety or escape plan for affected patients, as well as referrals to social workers and local support organisations.2, 3, 8 The cooperation of general practitioners with local and specialist services is vital for the success of interventions, and a multidisciplinary approach is preferred to ensure survivors are not lost along a referral pathway.4, 5, 8, 14 Psychiatrists, emergency medicine physicians, GPs, radiologists, dentists, maxillofacial surgery teams, gynaecologists, and professionals working in sexual health clinics are all likely to encounter survivors of domestic violence and should receive appropriate training.14 Indeed, sexual health and gynaecological problems are the most consistent and largest physical health differences between female abuse survivors and women in the general population.15 Barriers to healthcare professionals in identifying domestic violence include insufficient training, fear of breaking confidentiality, the prioritization of Covid-19, and “the perception that this topic is not their responsibility.”5, 17 For some, domestic violence is a “family issue” that is not routinely discussed as part of a healthcare appointment, especially given the lack of resources, lack of consultation time, and the perceived or actual lack of effective support that can be given to patients at risk.17 Despite this, women want healthcare professionals to have an active conscience, to be open-minded, to be unhurried, and to respect their confidentiality when it comes to issues around domestic abuse.18

The Need for Education 

There is an urgent need for education and dialogue around domestic violence among healthcare professionals, students, survivors, and the general public. Public media campaigns are vital for raising awareness and sensitizing the public as well as empowering survivors to come forward.2, 5 General practitioners and pharmacies can establish confidentiality codes or signals for survivors to indicate that they need help.5 “Safe words” can be used in telemedicine appointments where the patient may be in the same building, or even the same room, as their abuser.11 Midwives and clinic nurses in particular could receive training around the identification of domestic violence and the utilization of codes or safe words, as pregnancy is one of the most high-risk times for women who are being abused.13 Unfortunately, while interventions involving “safe words” seem promising and cost-effective, they still rely on the initial education of both the general population and the healthcare team via public campaigns, informative leaflets, handouts, and training sessions, without which these interventions are liable to lead to miscommunication and missed opportunities.5, 8 More costly interventions include standardized training programmes, such as those devised by IRISi, or the appointment of an Independent Domestic Violence Advisor (IDVA) within a hospital or general practice to provide support and education to staff and patients.4, 14 One study in which IDVAs were appointed to five hospitals in England allowed for significantly earlier identification of survivors, as well as the contacting of survivors who otherwise would have been “hidden from society” beyond the reach of community-based organizations.13 

With regards to medical education settings, one study demonstrated that medical students show poor clinical performance with simulated domestic violence patients, sometimes subjecting the domestic violence survivor to an “event orientated interview” more befitting of a law enforcement officer than the “patient centred communication” expected of a healthcare professional.19 Of 25 medical schools surveyed in the UK, both staff and students, 75% of respondents felt that the training they received around domestic violence was inadequate or insufficient.20 Similar to the barriers cited by physicians in clinical practice to addressing domestic violence with patients, the reasons cited in educational settings include a lack of time, a failure to consider domestic violence a medical problem, and an assumption that it will be covered elsewhere.20 Unfortunately, quality education around domestic violence in healthcare settings is far from a guarantee.13

Conclusion

Domestic violence is a shadow pandemic that will continue to affect millions in the wake of COVID-19. Healthcare does not respond adequately to violence against women in most settings. 8, 14 Multidisciplinary approaches and integration with community-based services to ensure direct referral pathways exist are vital for identifying and treating survivors of domestic violence in the healthcare environment. Healthcare providers are uniquely positioned to provide useful aid to survivors of domestic abuse.  General practitioners in particular occupy a trusted societal role and are frequently exposed to populations who could benefit from guidance, intervention, and referral. This is both a moral and professional obligation, as the soaring rates of domestic violence worldwide constitute a global health emergency.

References

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