This study was conducted in Ottawa, Ontario, the fourth largest city in Canada with a census metropolitan population of 1.3 million. At the time of the study, there were 2650 COVID-19 cases in Ottawa (2240 recovered), 40,161 cases in Ontario (36,381 recovered), and 119,451 cases in Canada (112,709 recovered) . Data for this study come from two EDs at The Ottawa Hospital, a multi-campus tertiary-level care hospital, with a specialized Sexual Assault and Domestic Violence Program based within the EDs. The program is one of 36 specialized Sexual Assault and Domestic Violence Treatment Centers across the province of Ontario and is the only location in the region that collects forensic evidence and administers Sexual Assault Evidence Kits. Admitted patients are triaged to the Sexual Assault and Domestic Violence Program if they self-disclose or are identified by staff as experiencing sexual assault or domestic violence. The Sexual Assault and Domestic Violence Program offers 24/7 clinical care to individuals 16 years of age or older, including all women, men, transgender, and gender non-binary individuals. Emergency care includes injury assessment, documentation, and treatment; sexually transmitted infection (STI) testing; emergency contraception and pregnancy testing; HIV post-exposure prophylaxis; immunization for hepatitis B, hepatitis A, and human papillomavirus; forensic photo documentation of injuries; collection/storage of the Sexual Assault Evidence Kit ; crisis counseling; and risk/threat assessment and safety planning. There were no reductions or changes to program staffing, procedures, or services since the COVID-19 pandemic began, except for an increase in personal protective equipment (e.g., universal masking) as part of the hospital-wide policy.
This was an observational study of changes in ED admissions for sexual assault and domestic violence seen during the COVID-19 period compared to a time-matched control group from 2018. In Ontario, the provincial government declared a state of emergency in March 2020, to reduce the spread of COVID-19. This declaration allowed the government to shut down most public establishments (e.g., schools, childcare centers, libraries, recreational centers, restaurants, theaters, and concert venues) and most workplaces transitioned to remote work, where possible. By investigating the ED admissions data, a drastic decrease in admissions began on 4 March 2020, which we chose as the cutoff date. Data from March 4 to May 5, 2020, were categorized as the COVID-19 period (62 days) and compared to March 4 to May 5 in 2018 (pre-COVID-19 period). Case data came from a detailed registry of all patients seen in the Sexual Assault and Domestic Violence Program. ED patients are triaged to the program if they self-disclose or are clinically assessed as having experienced sexual assault, domestically violent event, or a physical assault by an intimate partner or other person. General ED admissions data came from the Health Records department at The Ottawa Hospital.
All cases were reviewed in detail, and all assault, clinical, and demographic data were extracted by research assistants (KD, AS). To ensure inter-rater reliability, 10% of the charts were randomly selected and evaluated by the Medical Director of the Sexual Assault and Domestic Violence Program (KS). The kappa statistic was 0.94 (95% CI 0.88–0.97) indicating strong inter-rater reliability.
Sexual assaults included any type of assault of a sexual nature, including oral, vaginal, or anal penetration; groping; or any unwanted sexual touching of body parts. Physical assaults included assault by bodily force, strangulation, or assault with a weapon/object.
Demographic characteristics included age, measured both continuously and categorized at 24 years of age; gender/sex (female vs male/transgender/non-binary); method of arrival (ambulance vs walk-in); and police involvement. Mental health conditions could be self-reported or previously documented in the medical charts and included depression, anxiety, and substance use or dependency. Information on the assailant(s) included whether the assailant was an intimate partner, unknown assailant, or multiple assailants. Assault-related information included psychological abuse (e.g., humiliating, threatening, controlling behavior), the use of weapons, strangulation, and location of assault (patient’s home, assailant’s home, outdoors, other). Clinical charts were reviewed for any documentation of visible injuries including lacerations, fractures, or contusions.
Health- and justice-related service provision included uptake of HIV post-exposure prophylaxis (PEP) and administration of the Sexual Assault Evidence Kit or forensic photography. PEP is offered to patients who arrive within 72 h of the assault and are considered moderate-to-high risk defined as follows: being assaulted by an assailant with a known HIV+ status, or an assailant with high risk of HIV (e.g., history of injection drug use, men who has sex with men, migrating from an HIV endemic area) or if there was a known or unknown exchange of body fluids via vaginal and/or anal penetration. PEP was categorized as a three-level variable: non-eligible, eligible but not started, and eligible and started.
Patients are eligible to complete a Sexual Assault Evidence Kit if they meet the following criteria: presenting 12 days following a vaginal/penile assault, 7 days following a digital-vaginal assault, 3 days following a penile/digital anal assault, and 24 h following a penile-oral assault. The Sexual Assault Evidence Kit was categorized as a four-level variable: non-eligible, eligible but not collected, collected and released to police, and collected but not released to police. Patients are eligible for forensic photography if they have visible injuries (e.g., bruises, lacerations, fractures), and the categories were as follows: non-eligible, eligible but not completed, and eligible and completed.
All analyses were conducted using SAS 9.4 . Descriptive statistics include frequencies and percentages for categorical variables. Continuous variables were summarized using median and interquartile range (IQR).
Total admissions and mean weekly admissions were calculated for the 2018 pre-COVID-19 period and the 2020 COVID-19 period using all-cause ED admissions, and specifically admissions to the Sexual Assault and Domestic Violence Program. The absolute difference was calculated as the differences between the two periods. The relative percent change was calculated as the difference between the two periods divided by the 2018 pre-COVID-19 totals and expressed as a percentage. Analyses comparing multiple years of data can be found in Additional file 1: Tables S1 and S2).
A Poisson regression (without offset term) was used to calculate the weekly case count ratio and 95% confidence intervals (CI) between the two periods for the number of patients seen in Sexual Assault and Domestic Violence Program patients. Sexual assault cases and physical assault cases were analyzed individually. Percentage relative reduction was calculated as 1/weekly case count ratio and expressed as a percentage.
The characteristics of the sexual assault and domestic violence patients were compared between the two periods using chi-square tests for categorical variables, and percent difference and 95% CI were calculated. Wilcoxon’s ranked sum test was calculated for continuous variables. All cases were included, and every record was analyzed (i.e., no missing data).
This study was approved by The Ottawa Health Sciences Network Research Ethics Board (Protocol number: 20170390-01H).