Emergency department (ED) encounters for sexual assault increased before the COVID-19 pandemic, decreased immediately after lockdowns were implemented, and fluctuated as the pandemic continued, an analysis of more than 10,000 such visits in Canada’s most populous province shows.
“In 2020, we hoped that the COVID pandemic would only last a few months. However, as it continued, we became increasingly concerned about limited healthcare access for survivors of sexual assault throughout the ongoing crisis,” study author Katherine A. Muldoon, PhD, MPH, a senior clinical research associate at the Ottawa Hospital Research Institute in Ontario, told Medscape Medical News.
“Unexpectedly, we found a 20%–25% increase in the number of survivors of sexual assault presenting for emergency care before the lockdown protocols were enacted,” she added. “After lockdown, the numbers dropped by 50%–60% and fluctuated throughout…the pandemic.”
As they develop new lockdown protocols, public health officials and governments should incorporate warnings of the risks of violence and state that survivors should still present for urgent care when needed, said Muldoon. “COVID-19 lockdown protocols have limited access to healthcare for survivors worldwide, and barriers are likely greater in low-resource settings and those heavily affected by COVID-19.”
The study was published December 29 in JAMA Network Open.
Both Sexes Affected
The researchers analyzed linked health administrative data from 197 EDs in Ontario, Canada, from January 2019 to September 2021. They used 10 bimonthly time periods to compare differences in the frequency and rates of ED visits for sexual assault in 2020–2021 (during the pandemic), compared with baseline prepandemic rates in 2019.
Sexual assault was defined by 27 ICD-10 procedure and diagnoses codes.
More than 14 million ED presentations occurred during the study period, including 10,523 for sexual assault. The median age was 23 years for female patients and 15 years for males. Most encounters (88.4%) were among females.
During the 2 months before the pandemic (January 11 to March 10, 2020), the rates of ED encounters for sexual assault among females were significantly higher than prepandemic levels (8.4 vs 6.9 cases per 100,000; age-adjusted rate ratio [aRR], 1.22), whereas during the first 2 months of the pandemic (March 11 to May 10, 2020), rates were significantly lower (4.2 vs 8.3 cases per 100,000; aRR, 0.51).
Among males, rates were higher during the 2 months before the pandemic, but not significantly different, compared with prepandemic levels (1.2 vs 1.0 cases per 100,000; aRR, 1.19). However, the rates decreased significantly during the first 2 months of the pandemic (0.5 vs 1.2 cases per 100,000; aRR, 0.39).
For the 12 months starting July 11, 2020, rates were the same as in 2019. In the final time period (July 11 to September 10, 2021), however, the rates were significantly higher than during prepandemic levels (1.5 vs 1.1 cases per 100,000; aRR, 1.40).
Further analyses showed a similar pattern for all age groups, community sizes, and income quintiles. Rates were predominantly above prepandemic levels for the two months leading up to the pandemic and below expected levels from the beginning of the pandemic onward. However, from July 11 to September 10, 2020 (during a trough in the summer, when sexual assaults are generally higher) and from May 11 to September 10, 2021 (also during a trough and the summer), the rates returned to prepandemic levels.
“The COVID-19 pandemic has caused many changes to society and health care delivery and access,” the authors write. “We recommend that the decision-making regarding the management of the COVID-19 pandemic include antiviolence considerations to evaluate how policies and protocols affect the risk of violence and ensure that those who need health care can access services without concern.”
“Specialized and trauma-informed clinics are the best solution for encouraging survivors to come for urgent care following a sexual assault,” said Muldoon. “Clinicians should be prepared and trained to provide the best possible care for survivors of violence and ensure that getting care is not retraumatizing. Fostering conversations about the common experience of violence and destigmatizing those exposed to violence remain the most important ways to create safer spaces and societies.”
Dedicated Care Pathways
Commenting on the study for Medscape, Samuel A. McLean, MD, MPH, director of the Institute for Trauma Recovery and professor of emergency medicine, psychiatry, and anesthesiology at the University of North Carolina at Chapel Hill, said, “This important work documents a reduction in visits by sexual assault survivors for emergency care and forensic evidence collection during times of pandemic surge. It’s impossible to know for certain if this reduction in visits is entirely due to a reduction in sexual assaults, but a number of lines of circumstantial evidence make this unlikely.”
The results highlight the importance of ensuring that sexual assault care is maintained during surges in emergency care volume, added McLean, who was not involved with the current study. “This can be done via methods such as dedicated care pathways that avoid prolonged survivor wait times for care, and public health messaging that informs the public of the continued ready access to care during surges. Evidence, including data cited by the authors, suggests that these same care-seeking reductions are occurring in the United States and elsewhere.”
The study was supported by the Ontario Ministry of Health and Long-term Care Applied Health Research Question Fund. Muldoon, study co-authors, and McLean report no relevant financial relationships.
JAMA Netw Open. Published online December 29, 2022. Full text
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