The United Kingdom does not feel safe during this global pandemic. We have witnessed devastating consequences of COVID-19 as the first country in Europe to reach over 80,000 deaths. The UK was the originator of a new, more virulent strain of the virus. We have seen structural inequalities widen, with racially minoritized communities disproportionally bearing the impact of both the pandemic and the measures taken to limit it (Paton et al, 2020). Of particular relevance to my research in the field of gender-based violence (GBV), cases of domestic violence and abuse have soared, with a growth of 50% in calls to the National Domestic Abuse helpline during the first lockdown and a 400% increase in web traffic for online support (Refuge, 2020). As of January 2021, having entered our third nationally mandated lockdown, many people are negotiating the safety of staying at home to limit transmission alongside the risks of enduring violence and abuse. Two thirds of women who lived with an abuser during lockdown reported that the abuse had worsened (Women’s Aid, 2020).
A significant but underexplored consequence of the coronavirus pandemic for those experiencing violence is the loss of spaces in which to seek help. Paradoxically healthcare services, which were previously positioned as ‘safe spaces’ for disclosing DVA, are now high-risk locations to be avoided. Fears of catching or transmitting COVID-19 in healthcare settings mean that, for many people, seeking medical support has become a last resort.
The changing terrain of safety and risk precipitated by the pandemic raises important questions about how we define ‘safe spaces’ and where they are located. The term ‘safe space’ emerged in the 1960s and 1970s among feminist, queer, and anti-racist activists in the U.S. Kenney (2001: 24) described these as spaces that provide ‘a certain license to speak and act freely, form collective strength, and generate strategies for resistance.’ While there are many ways in which medical systems work to contradict these characteristics of safe space – through power imbalances, epistemological battles over whose knowledge takes precedence, and the ever-present possibility that medical intervention may harm rather than heal – many practitioners, particularly those working in primary healthcare services, remain committed to Kenney’ principles. Kleinman’s (1988) description of the work of empathic witnessing still resonates within many general practitioners’ (GP) accounts of the purpose of their work:
Empathic witnessing … is the existential commitment to be with the sick person and to facilitate his or her building of an illness narrative that will make sense of and give value to the experience. ... This I take to be the moral core of doctoring and of the experience of illness
The practicalities of enacting empathic witnessing in medical encounters are especially important, given an increasing emphasis in the UK on the role of GPs in responding to abuse (IRISi, 2020). This has been driven by twenty years of activist and research collaborations championing primary healthcare services as confidential, accessible, local resources for survivors. The unique opportunities presented by Britain’s universal healthcare system, which is free at point of access, enables anyone to access a 10-minute appointment with their local GP. GPs act as a gateway to other services, meaning that GPs can connect patients with further support, such as local DVA organisations, mental health services and safeguarding teams.
This move to actively realign the role of GPs to address abuse reinforces that healthcare settings, as clinical spaces, are not inherently safe. Instead, they ‘should be understood through the relations that produce them’ (Roestone Collective, 2014: 1360). This emphasis on relationality shifts attention away from the characteristics of the space and towards the interactions taking place within them. From this perspective, there is significant work in collectively creating an embodied experience of safety in clinical interactions. Encounters between GPs and patients are not a priori safe but have the potential to be spaces when safe disclosures of violence and abuse can take place, dictated by the commitment of the practitioner to empathic witnessing and the context in which the interaction takes place.
Drawing insight from Sara Ahmed’s (2004) work on how emotion shapes interaction, fear often inhibits the ability of victims of violence to navigate public spaces in their search for support. Perpetrators may monitor and limit movement, and anxiety about stigmatising responses following disclosure contributes to ongoing victim silence. Local primary care services that relationally engage in producing their spaces as safe, by visibly promoting themselves as a DVA-aware practice and normalising discussions about DVA in consultations, are more likely to be seen as a legitimate space for people living with violence to speak about their experiences.
The pandemic has dramatically altered this landscape. Fear circulates differently and disrupts previous patterns of relating. Through my ongoing work with women affected by abuse, frontline clinicians and specialist DVA support services during the pandemic, I have been questioning what safety means if both domestic and public spaces carry risk. The work of realising safe interactions in primary care has changed in a number of crucial ways:
Navigating safety across the boundaries of private and public spaces
The first response of the UK healthcare system to limit transmission of COVID-19 was quickly switching to remote access (phone or video call) to prioritise appointments and limit the number of people physically visiting the space of a clinic. The relational work of interaction between patient and healthcare worker is now navigated between two spaces that are potentially unsafe in different ways: the private domestic space and the public medical space. There is a danger to raising the topic of DVA over phone or video, as there is less certainty about who might be listening. Disclosing violence to a healthcare professional could lead to a worsening of abuse if the perpetrator overhears. Equally, bringing a patient into the clinic involves weighing up risks about exposure to COVID-19 for both parties.
Materialising safety in remote consultations
Technology, such as computers and medical devices, has long mediated the relational work of interactions in healthcare settings. What remains less understood is the work of producing a phone- or video-call as safe. The loss of face-to-face interaction means subtle signs clinicians would often take as cues to ask about DVA are harder to interpret. Domestic violence and abuse are easily hidden by the many medical presentations linked to the pandemic, creating different challenges in bringing DVA to the forefront of a conversation. At a material level, women facing multiple disadvantages are less likely to have practical capacity to participate in remote consultations - such as access to phones with credit, computers with video capability, and opportunities for private conversation - meaning they are further excluded from support.
An overall drop in health consultations during the pandemic has reduced the opportunity for initiating discussions about abuse. Restrictive prioritisation processes limiting who gets to speak to clinicians and when they are able to do it has decreased the window of opportunity for patients to seek help at times that feel safe for them. When discussion of abuse becomes possible, this feeling of safety may be a fleeting. It has become vital to compress as much support as possible into one health interaction to combat uncertainty about when contact can be safely made again. This requires different expertise on the part of both clinicians and patients, who have to make rapid judgments about what actions are safe to take within a short window of time.
Sharing the burden
The relational work of creating safe spaces is dependent on clinicians themselves having strong links with specialist community support services. The violence against women and girls (VAWG) sector has worked tirelessly since the start of the pandemic to produce guidance and online training for healthcare providers and diversify provision of support. Clinicians have improvised solutions, inviting patients to visit for a face-to-face appointment so they can privately speak with support services on the phone. Clinicians described that the collective effort of working with specialist services sustains their engagement in addressing DVA: ‘That’s what the service offers, the confidence that there is somebody or people there who can help’ (Dowrick et al, forthcoming 2021).
Heather Rosenfeld and Elsa Notermans encourage us to ‘treat safe space as a living concept, identifying tendencies and variations in its use, and recognizing its situatedness in multiple contexts’ (2014: 1347). It is vital that we develop a better understanding of how we situate safety at a time when fear pervades so many parts of our lives, for both the communities we serve with our research and for ourselves. As the pandemic continues to unfold, examining moments where spaces have been successfully, if temporarily, enacted as safe will help us to navigate new pathways to support for those affected by violence and abuse.
I’d like to thank Emma Backe and the SFAA GBV TIG for the opportunity to write this column. Joining the TIG in 2016 expanded my understanding of GBV exponentially, and I am grateful for the opportunity to learn from such talented and committed peers. I also indebted to everyone at the IRISi social enterprise, who work tirelessly to address violence and abuse and provide tremendous support to UK and international GBV research.
Ahmed, Sara (2004) Affective Economies. Social Text 22(2): 117–39.
Dowrick, A, Feder, G, Kelly, M. (forthcoming 2021) Boundary-work and the distribution of care for survivors of domestic violence and abuse in primary care settings: perspectives from UK clinicians . Qualitative Health Research.
Kenney, Moira. (2001). Mapping Gay L.A.: The Intersection of Place and Politics. Philadelphia, PA: Temple University Press.
Kleinman, A. (1988). The illness narratives: Suffering, healing, and the human condition. New York: Basic Books.
IRISi (2020) Improving the General Practice response to domestic violence and abuse: A review of IRIS programmes in England, Wales and Northern Ireland to March 2020 and early findings from the COVID-19 pandemic. Bristol: IRISi. Accessed online 18.01.21: https://irisi.org/wp-content/uploads/2020/10/IRIS-National-Report-2020.pdf
IRISi (2020) COVID-19 advice and guidance. Bristol: IRISi. Accessed online 18.01.21: https://irisi.org/all-resources/covid-19-guidance-and-advice/
Paton, A, Fooks, G, Maestri, G and Lowe, P. (2020) Submission of evidence for the disproportionate impact of COVID-19, and the UK government response, on ethnic minorities and women in the UK. Birmingham: Aston University. Accessed online 18.01.21:
Refuge (2020) Refuge response to Home Affairs Select Committee report on domestic abuse during COVID-19. London: Refuge. Accessed online 18.01.21: https://www.refuge.org.uk/refuge-response-to-home-affairs-select-committee-report-on-domestic-abuse-during-covid-19/
Roestone Collective (2014) Safe Space: Towards a Reconceptualization. Antipode 46(5). https://doi.org/10.1111/anti.12089
Rosenfeld, Heather and Elsa Notermans (2014). Safe Space: Towards a Reconceptualization. Antipode 46(5): 1135-1159.
Women’s Aid. (2020) A Perfect Storm: The Impact of the Covid-19 Pandemic on Domestic Abuse Survivors and the Services Supporting Them. Bristol: Women’s Aid. Accessed online 18.01.21: https://www.womensaid.org.uk/wp-content/uploads/2020/08/A-Perfect-Storm-August-2020-1.pdf
Anna Dowrick a Research Fellow in the Medical Sociology and Health Experiences Research Group at Oxford University. She is passionate about using qualitative approaches to explore and address issues of social justice and has worked on topics ranging from gender-based violence to food security. In her current position she is exploring the impact of the pandemic on the healthcare response to domestic violence and abuse and the lived experiences of survivors of COVID-19. Before completing her PhD at Queen Mary University of London in 2019, she worked in policy and advocacy roles in the UK charity sector.
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