SEXUAL and domestic violence has wide-ranging impacts on health and wellbeing, resulting in high attendance of women survivors in health settings. The effects of the COVID-19 pandemic on movement restriction and finances appear to be exacerbating sexual and domestic violence incidence, nature and severity (here and here).
In July 2020, a national survey of 15 000 Australian women showed 4.6% experienced physical or sexual violence, 5.8% coercive control and 11.6% one form of emotionally abusive, harassing or controlling behaviour by a partner in the previous 3 months. For two-thirds of these women the violence started or got worse during the COVID-19 pandemic. Lockdowns enhance social isolation of women and their children, a common tactic that some men use as part of coercive control over partners, enabling more abuse to happen. Recent global updates about how to address domestic violence have highlighted how to respond generally and also in the context of the COVID-19 pandemic.
Safety concerns and barriers to accessing help for survivors have been affected by the closure of many face-to-face services. Health practitioners are the highest level of professional group told about sexual and domestic violence. To a great extent in Australia, health care during lockdowns has moved to remote consultations through electronic communication (phone or video), often known as telehealth. The Australian Government has supported this financially through Medicare, with the greatest uptake being GP and mental health consultations by telephone. An Australian Bureau of Statistics survey in 2020 showed that telehealth was being used by around one in five patients, with half saying they would use telehealth in the future.
But do we know if this mode of communication is of harm or benefit for women with trauma histories?
Much has been said about the harms and safety issues of using telehealth. The basic rule of asking about abuse and violence is that the patient is alone in a private setting. For example, all antenatal patients are screened for domestic violence in Victoria, but as most are now done through telehealth, the screening rate is likely to be less than before the COVID-19 pandemic.
On the telephone it is almost impossible to know if patients are alone, even if they are asked that question directly by the clinician. For women living with sophisticated perpetrators, for whom monitoring is a high level skill, it might be dangerous for women and children to discuss their experiences of sexual and domestic violence. However, there have been recent suggestions for how to get around this (Box).
|How to approach asking about sexual and domestic violence|
|Use closed questions initially that require a yes/no answer:
· “Are you alone? Can anybody overhear? Is this a safe time to talk?”
|If you hear or see somebody in the background:
· “This consultation requires by law that you are alone. Could I ask for the person in the background to leave please?”
Then once you are sure they have left:
· “I frequently ask patients how safe they are feeling at home because this can affect your health. Do you feel safe at home at the moment?”
|If you are very concerned about what you hear or see in the background:
· Make an excuse for the patient to be seen face-to-face so that they are allowed to come and see you.
|How to approach responding to sexual and domestic violence|
|Express your ability to help:
· “I can connect you with services that can help even during lockdown. Would you be interested? How can I send you the details safely?”
· “You know you can always phone the police if you feel more unsafe.”
|Organise a follow-up visit:
· “I would also like to see you again. Can we organise a code word now so that I know it might not be a good time when I ring again for the next consultation? Can you say an ordinary word now that would not alert anybody if they heard you?”
What might be the benefits of telehealth for survivors where current safety is less of an issue?
Some patients think telehealth is the same as face-to-face appointments. Some patients prefer not to have to leave their home, catch public transport, wait in a room with other patients, or wear masks. Face-to-face consultations with masks have an effect on how empathic the clinician is perceived to be, particularly for those with long term relationships with patients in primary care. For trauma survivors, who can be triggered by catching public transport and who find their home an emotionally safe place, telehealth consultations may be a better modality to receive trauma informed care. Telehealth might enhance safety, trustworthiness and transparency, collaboration and mutuality. Survivors want choice and control, action and advocacy, recognition and emotional connection, all of which can be delivered by telehealth.
Before the COVID-19 pandemic, trials of digital health interventions via mobile devices or web-based platforms have shown acceptability and feasibility for survivors of domestic violence. Some survivors prefer this mode of delivery to face-to-face as they find it non-judgemental, practical and convenient. During the COVID-19 pandemic, suggesting use of these digital interventions through telehealth can provide access to screening, risk assessment, safety planning and connection to support services in a safe and private way.
Telehealth consultations may be the only way we can reach some survivors of sexual and domestic violence. It may require additional ways of communicating to ensure safety but the basic tenets of asking and responding empathically in an ongoing way are possible through telehealth.
Overall, for many survivors the benefits will outweigh the harms if a safe approach is used. It does appear that telehealth is here to stay and for some trauma patients this will be welcomed.
Kelsey Hegarty, GP and Chair of Family Violence Prevention, The University of Melbourne and Royal Women’s Hospital.
National sexual assault support
- 1800 RESPECT: National sexual assault, domestic family violence counselling service. Operates 24 hours/7 days a week.
- Phone: 1800 737 732
Blue Knot Foundation: For adults with experiences of childhood trauma including child sexual abuse
- Operates 9am-5pm Monday-Sunday.
- Phone: 1300 657 380
Bravehearts: For those wanting information or support relating to child sexual assault and exploitation
- Operates 8:30am to 4:30pm Monday to Friday.
- Phone: 1800 272 831
IF YOU ARE IN IMMEDIATE DANGER, PLEASE CALL 000
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.