Intimate Partner Violence and Sexual Assault During COVID: An Interview with Dr. Kari Sampsel
Interview with Kari Sampsel, MD, FRCPC
Interviewed by Miya Smith, MD
During my brief time in the emergency department (ED), I have already seen a significant number of patients coming in with complaints related to sexual assault (SA) and intimate partner violence (IPV), also known as domestic violence. With the rise of COVID-19, I believed that I anecdotally saw a rise in these types of visits. As someone interested in this work, I wondered if other areas noticed similar trends. I had the opportunity to discuss the topic of intimate partner violence (IPV), as well as sexual assault (SA) briefly, with Dr. Kari Sampsel. Dr. Sampsel is an expert in these fields and has done research and advocacy work surrounding these issues. She is an Assistant Professor in the Department of Emergency Medicine at the University of Ottawa in Ontario, Canada.
What is your specific area of interest within social emergency medicine?
My focus is sexual assault, IPV, a little bit of human trafficking. I do the intersection of medicine and law witness [testimonies] for court primarily in the realm of sexual assault and a little bit of domestic violence. I used to be a coroner. I stopped doing that when I had kids just because call plus babies did not work out all that well. I have been the Medical Director of our Sexual Assault and Partner Abuse Care Program since 2008. I also do research and policy work around sexual assault, domestic violence and human trafficking.
How has COVID-19 affected the way ED providers should be thinking about intimate partner violence and sexual assault in the ED?
With intimate partner violence in particular, we have to be mindful of the fact that not everybody is based at home. And while everybody was being advised to “shelter at home” and “it’s the safest place to be, for some people that was just sort of a death sentence. That was something that was very dangerous and very concerning for them, because the normal things they would use as opportunities to have some normalcy or to be able to escape and get help at an emergency department, in particular -- because we’re the only place that’s open 24 hours a day, 7 days a week -- no longer exist anymore. With IPV in particular, a lot of this has to do with control. The abuser is trying to isolate the person from the outside world -- from their friends, family, coworkers -- and now that’s way easier, when we’re supposed to be at home away from everybody else. For someone to use the normal mechanism, if you were in distress or injured, you would call 911, right? Well, not if someone is sitting in the room right next to you, or not if they’re listening on your phone calls, or smashed your SIM card. Those are very extremely common things that abusers do to keep that isolation and control over someone.
Same thing with text messaging; there's all kinds of spyware apps that [abusers] will install onto [someone’s] phone to basically get a running commentary of what they were looking at, who they were contacting, etc. So for someone to get out, it was a huge undertaking, even more so than it was for them at baseline, which was already incredibly difficult. If you have someone who got out and came to get help with you, you need to take that seriously. You need to do everything you can to keep that person safe. This is not the [situation to say] “oh, well you don’t need a head CT, you’ll be okay” or “here’s some phone numbers, call somebody and see if you can figure something out” or “we’ll have social work come see you in the morning.” You need a real follow-up safe plan for that person, because that was probably their only safe out. If they go back, that's it basically.
We’re in a process of putting together a manuscript looking at the level of injury that we’re seeing for people that are coming to us during the pandemic, and it is, as people suspect, higher. So you have to be way more hurt to risk getting out and coming to the hospital. These are the more severe and more sick versions of intimate partner violence than we would see on the average day. That's why I am a big proponent of universal screening. I think everybody should be asked at every visit, we don’t ask so therefore we don't know.
How has COVID-19 affected these patients’ interest or ability to seek care in the ED or elsewhere?
They can’t get out. It’s really hard to get out. And for a long time, people were terrified of COVID-19. At the beginning, our emergency department’s volumes dropped [tremendously] because everyone was terrified to come in. They didn’t want to potentially catch COVID-19 or burden the emergency department because they saw all of these reports out of Italy, New York, and other places with [overwhelmed] with extremely sick patients and thought “my head injury because I got slammed against the wall is really not that big of a deal in the grand scheme of things.” The psyche of someone who has been [abused long-term] is that they believe that they deserved it or did something wrong or that it’s just how things are. To convince someone that it’s not okay, and that you shouldn't be treated that way, takes a little bit of unlearning. They’re not going to see their ongoing abuse as something that is worthy of burdening an emergency department or other healthcare place, based on everybody saying, “stay away unless you are super sick.” They are never going to think of themselves as “super sick,” which is sad, because [IPV] is more lethal than a lot of the other things we look for.* All of them apologize for being there or for “wasting your time.” People are very downplaying, apologetic, and stoic about it. They feel embarrassed by it. But it’s the psychology of a person who is in the situation and basically has been mentally beat down, in addition to whatever physical things have happened. So, it’s hard to draw people out, especially in a pandemic.
The CDC estimates 35% of women and 11% of men experience physical injury as a result of intimate partner violence. About 1 in 5 homicides are estimated to be at the hands of an intimate partner (learn more here).
Are there unique questions that we should consider when making decisions about which patients impacted by intimate partner violence or sexual assault to test for COVID-19?
If they are COVID-19 positive, how will they be notified of that? If you have a public health facility that is calling people and giving them test results, that may be notification that this person has sought care for something. The abuser might [say] “how the hell did you get a COVID-19 test?” You need to make sure there are safe phone numbers or contact methods that [ensure] you can give results to the patient and the patient only, not to someone else in their household -- especially if it’s their substitute decision maker by the substitute decision maker tree. If you look at a [typical] partner, they’re the next legal person to give information to, but maybe you don’t want to do that in this circumstance. So it's something you have to consider, because it maybe implies that somebody went to get care, and that can open up a big [conversation] that may put the person at risk.
Are there unique questions that we should consider when making decisions about how to dispo patients impacted by intimate partner violence or sexual assault with COVID-19?
The major thing that I always think about is if they are [COVID-19] positive, you have to know what the downstream effects of a self-isolation or quarantine order are. If you're going to test somebody for COVID-19, and they need to isolate somewhere, are they going back to that abusive place to isolate and can’t go anywhere for 14 days? Or can they go somewhere else? And we need to think about where that somewhere else is, and whether they are able to shelter in place in a safe manner. If they’re going to go to a women’s shelter, do they have capacity? And what are their physical distancing measures? I know a lot of shelters here [in Ottawa] had to reduce their capacity because they’ve had to put in physical distancing measures to try to prevent [COVID-19 from] going like wildfire through the entire population of people there.
What do you think are the most important research questions that need to be answered with regard to intimate partner violence or sexual assault patients and COVID-19?
We have two things coming out, I wish they were under review right now, so I could tell you more about them. One is [looking at] provincial volume. Ontario is 12 million people, I’ve got pre-pandemic and during pandemic numbers for [cases] we are seeing in the database of all ambulatory care settings (walk-in clinics, emergency departments, family doctors), what happens [during this] time for IPV and sexual assault relative to other non-pandemic related [complaints], and what the patterns of IPV assaults look like. A couple of community partners actually implemented a couple of new crisis chat lines/text lines, and they're looking at what their volumes of call are and types of calls they’re getting. This is not healthcare based, but a crisis-service based community resource. Their [study] is a little trickier because it’s all anonymous, so somebody could call back 3 times for the same person, because they’re not collecting demographic data. Hopefully that will be out soon as well.
Are there any new policy measures, be they local or national, related to intimate partner violence or sexual assault and COVID-19 that you are excited about?
There’s a couple of things that COVID-19 has done in general, which is a good thing. I think it has given medicine a kick in the ass to be way more virtual. Why does somebody need to drive to a hospital, pay for parking, come in for you to say “your blood results were all okay, we’ll see you in 3 months,” drive home, etc? With COVID-19, we have been forced to push forward on even more virtual care. We have been able to do virtual visits with our sexual assault and IPV patients. We were implementing that prior to COVID-19, but this just gave us the extra support and kick to be able to do it for people who don’t need a physical, in-person assessment. If I don't need to reassess you for your head injury or your strangulation, being able to do a video visit where I can actually conference call in [all] of the people that we need -- so I’ll get the community resources that you’ll need to liaise with next and bring them all in at the same time. All of this has made that more simple. The good thing also is we have new crisis lines and text message chatting, abilities for people to be able reach out to us. Whether it’s us specifically as specialized care programs or community resource partners, COVID-19 made that a reality, and I really hope that it maintains it.
If you could implement one policy measure related to intimate partner violence/sexual assault and COVID-19, what would it be?
Look for it, take it seriously. Ask people and when they say yes, know what to do. Take that seriously and do something. [I want] continuing efforts to reach people. And when people come to us, I think this would be a perfect opportunity to implement universal screening. We’re asking people all of these screening questions, and everyone is getting masks -- let’s just throw one in there:” “Are you safe at home?” “Are you sheltering at home? Is it a safe place to be sheltering at home?” “Has somebody hurt you?” That’s all you need to do. But I fear that with everything else and the greater weight of cognitive loading is going to prevent that from happening.
Anything else we should be thinking about?
The overall statistics of IPV and SA are way more common than aortic dissections, posterior aneurysms and Zollinger-Ellison syndrome, and even COVID-19. Sexual assault is 1 in 3, IPV is 1 in 5 or 6*, and we don’t know this or pay attention to this. We treat it like it’s a separate thing that is not intrinsically linked to people’s health and wellness. The person that’s coming back with chronic pelvic pain or chronic headaches, there’s a significant overlap with that and a history of violence. So, we need to start looking at this as the public health emergency that it is.
My own little teaching point is that adult abuse is just like child abuse. As far as recognition is concerned, we are taught the signs of child abuse from day one in medical school. Adults are just big children in this case. You have a story that changes, a story that doesn’t make sense, injuries that don’t make sense with the mechanism of injury, injuries in different stages of healing, injuries in concealed areas, injuries that don’t match what they were capable of doing, because maybe they have a disability of some sort. All that stuff, which we all know forwards and backwards for child abuse is the same stuff in adults. And so, if you think about this and [say] “if this was a child, would I be concerned for abuse?” You should be concerned about abuse in the adult.
The CDC estimates that the lifetime prevalence of IPV among women is 1 in 5 and 1 in 7 in men (learn more here). The CDC also estimates 1 in 3 women and 1 in 4 men experience sexual assault for the first time between the ages of 11 and 17 years old. The lifetime prevalence for women is 1 in 5 and for men is 1 in 38 (learn more here).
Are there any resources that you would recommend if people are interested in learning more about this topic?
There are lots of good repositories for this information. Our network website in Ontario (Ontario Network of Sexual Assault and Domestic Violence) has a lot of really great information which is applicable in lots of different settings. The International Association of Forensic Nursing (IAFN) website has wonderful resources as well. [Sexual assault and IPV care] is very nursing driven, but I think this [information] can be extrapolated out to physician audiences too, if people are interested in that. There’s also a wonderful thing that was sent to me as well for if you're having a Zoom or virtual chat with someone. There’s a set of [phrases] on it, how somebody can signal if they're in trouble. [For example,] somebody says, “yes I’ve had an egg parfait for breakfast.” [Just] a particular catch phrase that is meant to be a signal for help without tipping off someone. There was a Superbowl ad a couple of years ago where a woman was phoning 911 and pretending to order a pizza, and the 911 operator asked, “this is 911, are you in trouble?” And the woman says, “Yes, yes I am. Yes, I would like some pepperoni on my pizza.” And then they realized that this was a domestic violence call. This was a great ad. That one is worth people seeing and understanding.
Links:
https://www.cdc.gov/violenceprevention/intimatepartnerviolence/fastfact.html
International Association of Forensic Nurses https://www.forensicnurses.org/
Ontario Network of Sexual Assault and Domestic Violence Treatment Centers https://www.sadvtreatmentcentres.ca
Super Bowl (2015) Ad https://www.youtube.com/watch?v=5Z_zWIVRIWk, also see: https://nomore.org