Gender-based violence (GBV) does not take a break during times of crisis, disaster, or pandemic. In fact, it increases. Several countries have seen an increase in calls to domestic and sexual violence hotlines during disasters, and the COVID-19 pandemic is no exception.^1–4 Stay-at-home orders place a victim and perpetrator in proximity for longer periods of time than normal. In addition, financial stressors, a loss of job/income, and fear of the virus can all contribute to an increased risk of GBV. Staying at home also increases the risk of sexual violence.

In addition, disaster and pandemic situations create several unique challenges to providing care to victims of GBV, including:

• Access to Care: Emergency departments may be overwhelmed caring for disaster- and pandemic-related patients and may not be able to respond to other patients unless it’s truly a life-or-death situation. Patients may experience long waits in a busy, loud, crowded ED waiting room.
• Access to Sexual Assault Nurse Examiners (SANEs): These nurses may be recruited to the emergency department and other parts of the hospital to provide care. They may be too overworked and overwhelmed to provide SANE services. If their role is part of an additional assignment or overtime-based position, their forensic role may be suspended to focus on patients of the pandemic/crisis. If you have a community-based program that responds to the emergency department, its ability to enter your hospital may be limited by restrictions on visitors.
• Access to Rape Crisis Services: Many domestic and sexual violence programs may not be considered essential and may be forced to close during an emergency or pandemic. Shelter-in-place/at-home orders may prevent them from providing ED accompaniment services. They may not be considered essential workers. They may be prevented from providing hospital services by hospital visitation policies and the lack of personal protective equipment. Domestic violence shelters may be overwhelmed or unable to accommodate normal numbers of clients due to social distancing and gathering restrictions.
• Evidence Handling: Police departments and crime labs may be overwhelmed with calls and other cases. They may see a diminution in their workforce due to illness and quarantine as well. Physical evidence and recovery kits may not be picked up and processed in the usual, timely fashion. This creates storage issues at an emergency department during a chaotic period.

Solutions

The key to handling GBV patients during a disaster or pandemic is the same as anything else in health care: planning. The community should have as part of its sexual assault response team protocols a plan of what to do in a disaster, emergency situation, or pandemic. This planning should include all the key players within the community to ensure no victim is left out. This includes domestic, sexual, elder, and child violence advocates and crisis centers; the police department; the hospitals; the district attorney’s office; and other social service agencies such as protective services and victim advocacy organizations.

Some key points of a plan should include:

Social Service Agencies: Victims in the emergency department should have access to key social service agencies including rape crisis centers, domestic violence agencies, and child and adult protective services. Due to access issues, stay-in-place orders, and classification as nonessential personnel, video conferencing services may be utilized to provide virtual consultation, screening, and counseling. The agencies should come up with a plan for use of these modalities as well as access to hotline services. Remember, these services should be secured and HIPPA-protected. Women’s shelters may be overwhelmed or unable to accommodate their usual numbers of persons due to social distancing guidelines. Alternative shelter locations, such as hotels, should be designated.

Forensic Services: Victims of GBV, especially sexual assault, should have access to forensic nurses. Hospital-based programs may need to designate alternative sites to conduct medical forensic examinations such as a clinic examination room, an inpatient site, or even an alternate location. It may prove necessary to have a plan with multiple alternatives because space and availability may be become tighter as a pandemic continues.

If a mobile/regional SANE service exists, there should be assurances the nurses will have access to the emergency department for medical forensic care. This may include parking access, entry screening, specialized regional ID tags, and adequate space and resources to conduct examinations. Once again, alternative locations either at the hospital site or within the community may need to be considered and designated during a crisis.

Telehealth SANE services may be a viable alternative solution. There are a variety of models for its use, but essentially it can bring the SANE to the patient remotely while another health care professional conducts the examination and evidence collection. Telehealth SANE programs require agreements in advance and have specific state licensing restrictions that should be considered during disaster planning.

In the absence of these resources, staff not accustomed to providing sexual assault exams may be the only option. In that case, those workers should be provided with simple, easy-to-understand instructions on how to conduct examinations and how to collect, package, and store evidence. This should be described in a clear, easy-to-read manner and be part of the emergency department’s disaster plan.

Regardless of the SANE model, nurses should have access to the appropriate personal protective equipment to conduct the examinations. This can be provided by the hospital, sponsoring agency, or community as part of the planning process. During a pandemic, patients should be screened for potential disease/infection and the SANE notified of the results prior to patient contact. Laboratory testing for the disease/infection should not be required for an examination to occur.

SANEs may have other clinical duties that prevent or limit their ability to provide on-call coverage or conduct a medical forensic examination while on duty. A backup schedule with two or three nurses on-call may be needed. There should also be an emergency credentialing procedure to utilize forensic nurses from other hospitals or agencies at an institution during a crisis/pandemic.

Given the stress of the pandemic as well as the usual work of a SANE, resiliency and mitigation of vicarious trauma resources should be made available to the SANE.

Law Enforcement: During a crisis, disaster, or pandemic, the focus of law enforcement often changes. The plan should include provisions for the continuation of crucial services such as detectives, child abuse units, special victims’ units, and crime lab services. Investigations may need to use video and virtual interviews. This also holds true for forensic interviews conducted by children advocacy centers. Arrangements should be made for the prompt pick up and processing of evidence from the hospital or forensic examination site; however, hospitals may need to store evidence until it can be transferred to law enforcement.

Do-It-Yourself (DIY) Rape Kits: Several years ago, companies developed a DIY rape kit as a way to allow evidence to be collected on the survivor’s terms. There was harsh backlash from social service agencies, district attorneys’ offices, and states’ attorney general offices, and DIY rape kit use is still not endorsed by many of these entities.⁵ However, during the COVID-19 pandemic, the kits have started to make a comeback. One California county has actually included it in its pandemic response plan.⁶ In this plan, the police bring the DIY kit to the patient. The person is virtually connected to a SANE, who provides guidance on evidence collection, and an advocate who provides emotional support and counseling. The police then pick up the kit from the person.

Not every region has as sophisticated a response to using DIY kits, and the victim is often not linked to additional community resources. Because evidence collection is only part of comprehensive care for sexual assault victims, the use of DIY kits is not ideal. The main arguments against their use includes the lack of injury determination, lack of access to sexually transmitted disease/HIV testing and prophylaxis, lack of pregnancy prophylaxis, and lack of emotional support and healing that is often afforded through the usual exam process. In addition, because these kits must be purchased, they may prove difficult to obtain in a crisis and technically violate the Violence Against Women Act, which ensures people receive sexual assault exams at no cost. Finally, there may be legal challenges to their admissibility. For all of these reasons, DIY kits are not recommended.

Bottom Line

Disasters and pandemics have major effects on emergency departments, including changes in how they provide care to patients experiencing GBV. As these cases increase, there may be several barriers to survivors accessing care and resources.

It is imperative that patients have access to victim-centered, trauma-informed care during a crisis, disaster, or pandemic. Careful planning is needed to allow these patients to access care and start their healing process. How that care is provided may look different than it does under normal conditions.

Dr. Rozzi is an emergency physician, director of the Forensic Examiner Team at WellSpan York Hospital in York, Pennsylvania, and chair of the Forensic Section of ACEP.

Dr. Riviello is chair and professor of emergency medicine at the University of Texas Health Science Center at San Antonio.

References

1. Fraser E. Impact of COVID-19 pandemic on violence against women and girls. Social Development Direct website. Available at: http://www.sddirect.org.uk/media/1881/vawg-helpdesk-284-covid-19-and-vawg.pdf. Accessed May 21, 2020.
2. Palermo T, Peterman A. Undercounting, overcounting and the longevity of flawed estimates: statistics on sexual violence in conflict. Bull World Health Organ. 2011;89(12):924-925.
3. Almeron L. Domestic violence cases escalating quicker in time of COVID-19. Mission Local website. Available at: https://missionlocal.org/2020/03/for-victims-of-domestic-violence-sheltering-in-place-can-mean-more-abuse. Accessed May 21, 2020.
4. Mlambo-Ngcuka P. Violence against women girls: the shadow pandemic. UN Women website. Available at: https://www.unwomen.org/en/news/stories/2020/4/statement-ed-phumzile-violence-against-women-during-pandemic. Accessed May 21, 2020.
5. Addressing DIY sexual assault evidence collection kits: protecting our patients. International Association of Forensic Nurses website. Available at: https://www.forensicnurses.org/page/DIYkits. Accessed May 21, 2020.
6. Pauly M. DIY rape kit companies see the coronavirus as their chance for a comeback. Mother Jones website. Available at: https://www.motherjones.com/politics/2020/04/diy-remote-rape-kit-coronavirus. Accessed May 21, 2020.