EXECUTIVE SUMMARY

As telehealth visits play an important role in family planning during the pandemic, providers should be aware their patients might be closely monitored by their partners, especially in cases of intimate partner violence.

  • Abusers might check the woman’s phone messages, digital communication, and apps with messaging.
  • During videoconferencing, abusers might use spyware that can record everything on the woman’s phone, laptop, or tablet.
  • Physicians should keep in mind the abuser might hear the woman describe the violence, then might increase violence to regain control.

Screening patients for intimate partner violence (IPV) when clinician-patient encounters take place remotely is challenging. Contraceptive Technology Update (CTU) asked IPV researcher Eva PenzeyMoog, designer and founder of The Inclusive Safety Project of Chicago, about technology’s dangers and drawbacks and how family planning centers could continue to screen and help patients as the COVID-19 pandemic continues to disrupt the usual patient-provider visits.

CTU: How can family planning physicians, nurses, and other providers use technology to screen and help patients experiencing IPV? For example, how could they safely screen patients via telemedicine or a video call?

PenzeyMoog: It’s really important for doctors and nurses to understand the various ways the tech they’re using might be infiltrated by an abuser, as well as to remember the abuser might simply be in the same room or listening at the door.

In terms of getting around an abuser in the room, one thing that doctors can do is suggest the patient use headphones so they can ask the screening questions about intimate partner violence and the survivor can give one-word answers that don’t reveal the actual nature of the conversation.

It’s important to think of the absolute worst scenarios and plan for it. If I were the doctor, I wouldn’t say “Can you put on headphones? That will give us more privacy,” because that might tip an eavesdropping abuser off. Instead, I’d say “I’m having trouble hearing you, there’s some background noise. If you have headphones, using those will really help.”

When it comes to how an abuser might infiltrate the tech, a deeper exploration needs to happen for each piece of software that physicians are using to communicate with their patients. When it comes to apps with messaging, abusers might be looking through messages. We should expect that abusers will know the code to open the survivor’s phone, and that they’ll know their passwords as well. When it comes to videoconferencing software, physicians should be aware that abusers might be using spyware (also known as “stalkerware”) that can record everything happening on the survivor’s phone, tablet, or laptop. Spyware typically is much harder to identify since it’s designed to be completely secret. When we bring spyware, things can get really tricky for the person, in this case the physician, who is trying to understand if their patient is experiencing IPV and help them.

Ultimately, a deeper exploration needs to happen into how to get around this. But one thing physicians can do now is do their best to think about the worst possible outcome: that an abuser is watching the appointment through spyware and that if the survivor goes into detail about the abuse that the abuser might increase his violence in order to regain control.

One idea is that if a patient responds that yes, they are experiencing IPV, that the physician move on and do the rest of the appointment. At the end, tell the patient that they will need to be seen in person for further examination, or that there’s some procedure that simply can’t be recreated with a virtual appointment. This would give the survivor a really good excuse to get out of the house, since abusers are often really controlling about things like this, but a doctor’s appointment is very legitimate.

Then, the physician could try to help the patient in person and give them resources on paper or have them add a number for a domestic violence hotline in their phone under some other name. Of course, doing something like this has to be weighed against the risks of seeing someone in person during the pandemic. Ultimately, further guidelines should be developed with input from both technology experts and IPV experts.

One other really important note is to not make assumptions about the patient. If they seem uncomfortable when you ask about IPV, it may be because they know they’re being listened to or monitored, and are keeping themselves safe by pretending everything is fine. Survivors are the ones who know their abusers best, who know what might set them off, who know the steps they need to take to stay safe. The patient might already have received help, might be actively planning their escape, or might be waiting for the right moment to make a call.

Ask about IPV and do what you can to support them, but keep in mind that if a patient seems eager to drop the subject, they may be keeping themselves safe. This would be a good indicator that maybe you should ask for an in-person appointment to ask about IPV further, but don’t ever try to force someone to disclose their abuse, as it may make things more dangerous for them in the short term.

CTU: Researchers have said calls to IPV hotlines have increased. In your research, what have you found are some of the biggest concerns IPV victims are experiencing and how are they seeking help?

PenzeyMoog: One of the biggest concerns is that survivors have, in many cases, lost the respites they had from their abusers: leaving the house for work every day, driving their children to school and activities, visiting parents, even just going to the grocery store. We’re being encouraged to stay home as much as possible, which means less in-person contact with support networks and more time in the physical proximity of an abuser.

There’s been a clear shift from in-person support from domestic violence shelters and agencies to support happening over the phone, online, and in virtual chat sessions. Even though it’s devastating to see how much the numbers of calls and chats are increasing, it’s heartening, in a way, to know that survivors are reaching out to seek help. It means they’re finding ways to contact support services, often using ingenious methods to do it without their abuser noticing.

CTU: What are some of the best practices and recommendations — especially those from a healthcare provider’s perspective — for dealing with IPV?

PenzeyMoog: Since I’m a technologist, I’ll speak from that lens. Assume that patients may not have privacy, that their device may be being monitoring, that it’s even possible someone is watching your conversation in real time.

Don’t conflate a virtual appointment with the privacy of in-person appointments. Assume the worst and plan for that, and remember that your patient may be in a situation where they can’t safely disclose the abuse.