Violence and abuse are critical problems in the United States. Their effects in rural America are often exacerbated by limited access to support services for victims, family connections with people in positions of authority, distance and geographic isolation, transportation barriers, the stigma of abuse, lack of available shelters and affordable housing, poverty as a barrier to care, and other challenges. Abuse victims who live in small communities may be well-acquainted with healthcare providers and law enforcement officers. For that reason, they may be reluctant to report abuse, fearing that their concerns will not be taken seriously, their confidentiality will not be maintained, their reputations may be damaged, or that they may incur even more abuse. Another challenge for victims of domestic violence is economic dependence, which limits their ability to leave an abusive situation.

Building partnerships between healthcare organizations and community-based services, including domestic violence and sexual assault advocacy programs, can lead to increased staff engagement, comprehensive responses for survivors, and bi-directional referral protocols for patients and clients. Domestic violence and sexual assault (DV/SA) advocates have vast experiences working with survivors of violence and can assist them to identify ways to increase personal safety while assessing their particular risks. Advocates also maintain confidentiality and typically offer 24/7 services and support in-person, remotely by text or phone, and in some cases via mobile advocacy.

This guide addresses abuses that may take place in rural communities, including:

• Neglect
• Child abuse
• Domestic violence, also known as intimate partner violence (IPV)
• Sexual violence, including rape, assault, and abuse
• Abuse, neglect, and exploitation of vulnerable populations, such as elders and people with disabilities
• Bullying, harassment, and stalking
• Assault
• Homicide
• Human trafficking

For information about suicide, see RHIhub's Rural Mental Health topic guide.

Frequently Asked Questions

• How prevalent is violence and abuse in rural America?
• How does human trafficking affect rural communities?
• How does violence and abuse affect health outcomes for rural populations?
• What are adverse childhood experiences (ACEs) and how might they affect the health of rural people?
• How does poverty relate to violence and abuse in rural areas?
• How does rural healthcare access affect current victims and survivors of abuse?
• What services do rural victims of violence need?
• What can rural communities do to prevent violence and abuse?
• What are strategies that rural healthcare providers can use to identify and support victims of violence?
• How does violence and abuse affect Native American populations? What factors and barriers do Native American communities face in preventing and dealing with violence?
• What are the barriers to addressing rural domestic violence/intimate partner violence?
• What is trauma-informed care and how does it support survivors of violence and abuse?
• How does living in a rural community impact sexual assault victims and survivors?
• How does child abuse and neglect in rural communities compare to cases in urban areas?
• What concerns are there for protecting the rural elderly and other vulnerable rural populations from violence, neglect, and financial abuse?
• What is the impact of a rural setting on victims of harassment, stalking, and bullying?

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How prevalent is violence and abuse in rural America?

According to 2019 federal crime statistics, violent crime rates in nonmetropolitan areas were lower than the national average.

Crime statistics may be artificially low since not all crimes are reported. The Bureau of Justice Statistics' Criminal Victimization, 2016 notes that in rural areas only 42% of violent crimes and 55.8% of serious violent crimes (defined as rape or sexual assault, robbery, and aggravated assault) are reported to the police.

According to the Bureau's 2012 special report Victimizations Not Reported to Police, 2006-2010, reasons identified for the non-reporting of violent crimes include:

• Dealt with in another way/personal matter – 34%
• Not important enough to victim to report – 18%
• Police would not or could not help – 16%
• Fear of reprisal or getting offender in trouble – 13%
• Other reason or not one most important reason – 18%

See the 2020 National Crime Victimization Survey Factsheet for more information on reporting, data results from the NCVS, and survey details.

Like many other violent crimes in rural communities, sexual violence is often underreported. In the BJS 2006-2010 report, on average 65% of rapes and sexual assaults were not reported. For a more complete overview of rural sex crimes and perpetrators, see Sexual Violence in the Backlands: Toward a Macro-Level Understanding of Rural Sex Crimes, a 2014 article in Sexual Abuse: A Journal of Research and Treatment.

One common type of violence and abuse in rural communities is domestic violence or intimate partner violence (IPV). Victims of domestic violence can be of any gender or sexual orientation. Female victims, however, typically experience more severe impacts and health outcomes than male victims. For information on rates of male victimization, see the CDC's Intimate Partner Violence, Sexual Violence, and Stalking Among Men. This Community Action Toolkit offers information on addressing IPV affecting transgender people.

Domestic violence often escalates into repeated and more violent abuse, with a national average of 3 women killed each day by an intimate partner or spouse and nearly 1 in 4 women in the U.S. experiencing domestic or intimate partner violence during her lifetime. In a March 2015 policy brief, the National Advisory Committee on Rural Health and Human Services called on the Centers for Disease Control and Prevention (CDC) to include in the National Intimate Partner and Sexual Violence Survey a geographic variable showing level of urbanization to represent how IPV affects rural residents. The 2010 National Intimate Partner and Sexual Violence Survey found that lesbian and bisexual women were more likely to experience physical violence and IPV than heterosexual women. For more information on the impacts of IPV on lesbian, gay, bisexual, transgender, and questioning/queer people (LGBTQ+), see the National LGBTQIA+ Health Education Center's Recognizing and Addressing Intimate Partner Violence in Relationships of LGBTQ People: A Primer for Health Centers.

Neglect and abuse of children also impacts rural communities. A 2010 report to Congress from the Administration for Children and Families (ACF) states that the reported incidence for all categories of maltreatment except educational neglect was higher in rural counties than in urban counties, with rural children being almost twice as likely to experience maltreatment, including overall abuse, sexual abuse, emotional abuse, and neglect. However, the report's authors caution that this difference may not actually indicate a higher rate of abuse in rural areas but may be due to higher survey response rates in rural areas, differences in socioeconomic status and family size, or other factors.

The Health and Medicine Division, National Academies of Sciences, Engineering, and Medicine's 2014 report New Directions in Child Abuse and Neglect Research indicates a need for cooperative approaches in recognizing and reporting child abuse and neglect, particularly in geographically isolated areas. Child Maltreatment 2019 represents national data on child abuse and neglect. For more information about working with children affected by abuse or neglect, see Promising Futures.

Violence and abuse based on sexual orientation and gender identity is also a concern in rural communities and can include bullying, harassment, and assault in schools. According to the 2019 National School Climate Survey conducted by GLSEN (formerly the Gay, Lesbian & Straight Education Network), rural students reported LGBTQ-related victimization (including bullying, harassment, and/or assault) at higher rates than urban and suburban students:

• 76.4% of rural students reported victimization based on sexual orientation (compared to 68.8% of urban and 66.1% of suburban students)
• 62.7% of rural students reported victimization based on gender expression (compared to 59.8% of urban and 54.6% of suburban students)
• 59.2% of rural students reported victimization based on gender (compared to 57.5% of urban and 52.5% of suburban students)

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How does human trafficking affect rural communities?

The U.S. Department of Homeland Security (DHS) defines human trafficking as “the use of force, fraud, or coercion in exchange for labor, services, or a commercial sex act.” According to the DHS resource Human Trafficking 101, human traffickers exploit victims through promises of employment, a better life, manipulation, threats of violence, and imposed financial debt.

Common barriers that prevent victims from seeking help include physical, economic, or legal vulnerability; immigration status; fear of abuse or violence; distrust of government or law enforcement; and language barriers. The American Psychological Association's Report of the Task Force on Trafficking of Women and Girls notes that in the United States, labor sectors in which human trafficking is most often identified are also those that most frequently employ female migrant workers, such as the service industry, domestic service, home healthcare and nursing homes, and agriculture. The study suggests that widespread poverty in some countries leads migrant women into employment situations in the U.S. that may make them vulnerable to trafficking.

Research on human trafficking points to healthcare as a critical area of intervention. According to a 2014 article in the Annals of Health Law, 87.8% of human trafficking survivors had contact with a healthcare provider while they were being trafficked, though they may not have reported their victimization. The leading treatment sources reported in the study were hospitals and emergency departments (63.3% of victims sought treatment at these facilities), Planned Parenthood clinics (29.6%), and regular doctors (22.5%).

The Rural Monitor article “It's on Us”: Healthcare's Unique Position in the Response to Human Trafficking discusses ways healthcare providers can recognize and address trafficking. To provide a quick-reference tool, the American Hospital Association created a human trafficking card that lists 10 red flags for providers to be aware of when working with patients who may be victims. At the state level, the Nebraska Hospital Association developed its own Human Trafficking Toolkit with information for hospital administration and staff on screening, assessment, care, and policy.

The Power of Framing Human Trafficking as a Public Health Issue, a 2016 report from the U.S. Office on Trafficking in Persons, discusses a public health approach to trafficking that engages a wide variety of community stakeholders and organizations, including survivors and their families, law enforcement, human services organizations, faith-based organizations, employers, educators, first responders, and healthcare providers. The report approaches trafficking as an issue that affects all types of communities with multi-generational impacts.

The Health Partners on IPV + Exploitation, an initiative led by Futures Without Violence, works with community health centers to support survivors and those at risk of intimate partner violence, human trafficking, and exploitation, and to support prevention efforts. The Network is a National Training and Technical Assistance Partner (NTTAP) funded by HRSA's Bureau of Primary Health Care.

The Office of Trafficking in Persons offers an online training module, SOAR for Native Communities, which covers human trafficking in Native communities with an emphasis on relevant resources, cultural practices, and cross-jurisdictional coalition-building, and SOAR to Health and Wellness Training to build capacity to engage human trafficking victims at the community level. The Rural Monitor article Human Trafficking in Native Populations: Q&A with Commissioner Jeannie Hovland further discusses collective efforts between the federal and tribal governments to address trafficking in Native American communities.

For national data on human trafficking, see the 2019 Data Report from the Polaris Project.

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How does violence and abuse affect health outcomes for rural populations?

Violence and abuse lead to short-term and long-term physical and psychological injury for both rural and urban victims. However, barriers to accessing healthcare, limited access to support services such as domestic violence or sexual assault advocacy, and the lack of specialized healthcare responders paired with geographic isolation or limited daily contact with others can limit the ability of rural survivors to seek treatment for injuries. For example, Rural-Urban Disparities in Emergency Department Intimate Partner Violence Resources highlights barriers to care in rural Oregon, noting that rural emergency departments lacked resources to respond to cases of intimate partner violence, including screening tools and policies, on-site advocacy, and IPV training for staff, compared to urban emergency departments. This 2019 U.S. Government Accountability Office report offers information related to availability of sexual assault forensic examiners, noting that all six states consulted for the report did not have enough examiners to meet their needs, especially in rural areas.

According to the U.S. Department of Health and Human Service Office on Women's Health, immediate effects of violence and sexual violence can include:

• Bruises, cuts, and broken bones
• Concussion and traumatic brain injury
• Internal injury to organs
• Pelvic pain and vaginal bleeding
• Unwanted pregnancy
• Infectious diseases, including HIV and HPV
• Sleep problems

Some of these injuries require medical examination and/or x-rays, which may be challenging to access in remote or rural areas. Left untreated, these effects can lead to serious infection or long-term health problems. In addition, children and elderly people who are abused or neglected are at risk of traumatic brain injury and may not receive necessary follow-up care.

According to The National Intimate Partner and Sexual Violence Survey, 2010-2012 State Report from the CDC, U.S. women who experienced sexual violence, stalking, or IPV experienced higher rates of asthma, irritable bowel syndrome, chronic pain and headaches, difficulty sleeping, poor physical health, and poor mental health compared to women who had no history of abuse and violence. This 2008 Morbidity and Mortality Weekly Report article further discusses health outcomes and health risk behaviors associated with IPV.

Research on adverse childhood experiences (ACEs), discussed in detail below, explores the connection between violence, abuse, and neglect during childhood and health outcomes in adulthood. In Rural-Urban Differences in Exposure to Adverse Childhood Experiences Among South Carolina Adults, the authors note that almost 60% of rural South Carolina residents who participated in a study reported exposure to at least one ACE and that “families in rural areas may be less equipped to mitigate and manage the effects of ACEs” due to limited access to healthcare, care coordination, and human services. The authors also note that “Exposure to these traumatic events in childhood may increase an individual's risk for heart disease, liver disease, diabetes, cancer, depression, or other chronic illnesses later in life.” Another 2018 study in South Carolina found that participants who reported household dysfunction, emotional and physical abuse, and sexual abuse were far more likely to experience poor physical and mental health in adulthood. The study found that of those three ACE categories, survivors of childhood sexual abuse were most likely to report poor health outcomes. For more information on the long-term effects of ACEs, see this infographic from the CDC's Division of Violence Prevention.

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What are adverse childhood experiences (ACEs) and how might they affect the health of rural people?

The term adverse childhood experiences (ACEs) was coined in a 1998 study of health-related behaviors and childhood adversity experienced in the first 18 years of life. The 2018 policy brief Exploring the Rural Context for Adverse Childhood Experiences from the National Advisory Committee on Rural Health and Human Services defines ACEs as

“any form of chronic stress or trauma (e.g., abuse, neglect, and household dysfunction) that, when experienced during childhood and adolescence, can have both short- and long-term impacts on an individual's development, health, and overall well-being.”

Examples of ACEs include:

• Verbal, physical, and sexual abuse
• Physical or emotional neglect
• Having family members who are mentally ill, have substance abuse issues, or are incarcerated
• Witnessing family violence
• Having parents who separate or divorce

According to Adverse Childhood Experiences in Rural and Urban Contexts, 56.5% of rural residents who responded to ACE items on the Behavioral Risk Factor Surveillance System (BRFSS) telephone surveys between 2011 and 2013 reported some exposure to these traumas. The article and other research note that people who experience ACEs are at increased risk for developing chronic health conditions as adults and may struggle with behavioral problems and harmful health habits. For example, a 2018 article from the Journal of the American Medical Association finds that cumulative experiences of childhood trauma is linked to psychiatric disorder and poor health outcomes in adulthood.

The CDC offers a visual representation of the cascading mental and physical health impacts of ACEs, with each tier of the pyramid building on the damaging effects of the layers below:

Adults who experience childhood trauma may subject their own children to similar stresses, as noted in the Center for Child Counseling's 2020 article ACEs and Intergenerational Trauma. Researchers found that children raised by caregivers who reported 4 or more ACEs were 3 times more likely to develop depression and/or anxiety, as documented in a 2020 Children and Youth Services Review article. Another article, Safe, Stable, and Nurtured: Protective Factors against Poor Physical and Mental Health Outcomes Following Exposure to Adverse Childhood Experiences (ACEs) looks at positive factors that can offset ACEs, including growing up with a protective adult in a safe home, finding that protective factors may mitigate negative physical and mental health outcomes associated with ACEs.

ACEs and their impact on health and well-being can be prevented. For more information, see the CDC's 2019 publication Preventing Adverse Childhood Experiences (ACEs): Leveraging the Best Available Evidence and the Rural Monitor article Confronting Adverse Childhood Experiences to Improve Rural Kids' Lifelong Health.

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How does poverty relate to violence and abuse in rural areas?

In 2018, the poverty rate for nonmetro areas was 16.1%, which is higher than the 12.6% poverty rate for metro areas. For more on the breakdown of U.S. poverty by geography and demographics, see the USDA's Rural Poverty and Well-Being. According to a report from the U.S. Department of Justice, rates of violent victimization are associated with poverty level, with 38.8 victims per 1,000 persons categorized as poor and rural, compared to 13.3 victims per 1,000 persons categorized as high income and rural.

COVID-19 and Rural Poverty: Supporting and Protecting the Rural Poor in Times of Pandemic discusses particular issues facing rural communities related to poverty, including considerations to prevent violence and abuse.

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How does rural healthcare access affect current victims and survivors of abuse?

Victims and survivors of abuse in rural areas often struggle to find immediate and continuing access to healthcare and social services. According to Rural Victim Assistance: A Victim/Witness Guide for Rural Prosecution, few rural communities have resources such as sexual assault nurse examiner programs or rape and sexual assault crisis centers. The 2015 review article Intimate Partner Violence and the Rural-Urban-Suburban Divide: Myth or Reality? notes that the IPV resources that do exist in rural areas may have less funding and thus be less comprehensive than those in urban communities.

Isolation due to geographic location is also an issue for abuse victims. Distance to clinics and hospitals and lack of public transportation may make prompt access to healthcare impossible. Additionally, lack of providers plays a role in the overall care of victims and survivors of abuse, with limited funding and higher per capita costs for social services leaving limited resources for specialized staff to help with violence and abuse support.

When services are lacking, victims may be reluctant to report abuse due to the possibility that it will just make their situation worse.

Examples of innovative programs to support victims and survivors of abuse include the National TeleNursing Center and the Butte Child Evaluation Center. Opening Our Doors: Building Strong Sexual Assault Services in Dual and Multi-Service Advocacy Agencies offers resources for developing rural domestic violence and sexual violence initiatives through organizational partnerships.

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What services do rural victims of violence need?

Social Services

The National Rural Health Association policy brief Rural Community Violence: An Untold Public Health Epidemic recommends that rural communities support victims of violence by offering or establishing:

• Employment and vocational training
• Counseling
• Violence prevention programs in clinical settings
• Awareness campaigns promoting prevention and intervention programs
• Anti-bullying and mentoring programs in schools

Unfortunately, rural victims may face barriers to accessing services, including a lack of broadband internet and a dearth of available human services. The Rural Monitor article Human Services Deserts discusses how rural communities need professional social workers to meet the human service needs of their residents. See the Rural Services Integration Toolkit for more information on efforts to increase access to services for rural communities.

Transportation, emergency housing, and employment are essential for rural victims to leave abusive living situations and become self-sufficient. According to Rural Disparity in Domestic Violence Prevalence and Access to Resources,

“over 25 percent of women in small rural and isolated areas live more than 40 miles from the closest Intimate Partner Violence Program, compared with less than 1 percent of women living in urban areas.”

The NRHA policy brief notes that violence takes many forms, including murders and suicides, robberies, and bullying. The policy brief offers recommendations for preventing and responding to rural violence, including:

• Increasing awareness of the problem through media outlets
• Advocating for the allocation of resources at the local level
• Establishing funding partnerships to expand community resource centers
• Establishing and supporting batterer intervention programs

Advocacy and Legal Services

Abuse victims may need advocates to help them navigate the legal system or locate and use local social service and support programs. Rural victims may need these services even more because of close-knit community and criminal justice systems, often including familial relationships that can create issues of confidentiality and safety for victims. Advocates can:

• Provide expertise on victim safety and emotional support
• Help navigate financial systems to retain or regain assets and establish power of attorney, guardianship/conservatorship, or custody
• Assist with restraining or protective orders

The American Bar Association offers a no-cost Find Legal Help tool that connects people to professionals in their state. Many state sexual assault and domestic violence coalitions can assist survivors with accessing legal services. The Legal Services Corporation also provides a search tool to find legal aid in each state. Additionally, the National Clearinghouse on Abuse in Later Life provides a useful toolkit for assisting survivors of abuse: Rural Domestic and Sexual Abuse Program Advocates: Making a Difference in the Lives of Older Survivors of Abuse. The National Sexual Violence Resource Center offers The Advocate's Guide: Working with Parents of Children Who Have Been Sexually Assaulted.

Another consideration for healthcare-specific legal needs in rural communities is a medical-legal partnership. Such partnerships provide on-site legal aid in a medical setting (such as a clinic, hospital, or dental practice), and allow for a safe and immediate space for people who need help. More information about this type of partnership is available in the October 2016 Rural Monitor article, Bringing Law and Medicine Together to Help Rural Patients, and through the National Center for Medical-Legal Partnership.

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What can rural communities do to prevent violence and abuse?

Rural communities can band together to prevent and respond to violence and abuse through a Coordinated Community Response (CCR). This collaborative effort among healthcare providers, community groups, faith-based organizations, schools, criminal justice, and social service agencies allows for a broad opportunity to stop violence before it starts. Resources for Advocates & Educators from the National Sexual Violence Resource Center can promote cooperation between agencies and the larger community.

Futures Without Violence offers an evidence-based prevention and intervention resource called “CUES” to help providers educate their patients about the connections between IPV and human trafficking and their health, engaging them in strategies to promote wellness and safety. “CUES” stands for:

Confidentiality: Knowing your state's reporting requirements, sharing confidentiality requirements with your patients, and always seeing patients alone for part of every visit so that you can bring up relationship violence safely.

Universal Education and Empowerment: Providing patients with information about how relationships affect health, and assuring the patient that they can share any concerns about their relationships with you.

Support: In the case of domestic violence disclosures, referring patients to local domestic/sexual violence partner agencies or national hotlines, and sharing health promotion strategies and a care plan that takes surviving abuse into consideration.

Resources for prevention, intervention, and public education regarding elder abuse are available at the National Center on Elder Abuse's State Resources page. Additionally, RHIhub's Human Services to Support Rural Health topic guide has resources to help address child welfare and discusses the use of Family Resource Centers to assist those in rural communities.

Some communities sponsor programs for people who want to change their own violent or controlling behavior. For those interested in establishing an abuser treatment program in their region, more information is available at:

• Minnesota Program Development: The Duluth Model
• Emerge: Counseling and Education to Stop Domestic Violence

The CDC offers a variety of resources designed to bolster community support for violence prevention programs. These include:

• Technical Packages for Violence Prevention: Using Evidence-based Strategies in Your Violence Prevention Efforts – Strategies representing the best evidence to prevent or reduce violence and to improve well-being of communities
• Essentials for Childhood Framework: Creating Safe, Stable, Nurturing Relationships and Environments for All Children – Strategies to prevent child abuse and to help create safe neighborhoods and communities
• Using Essential Elements to Select, Adapt, and Evaluate Violence Prevention Approaches – Intended for practitioners, but may be useful for funders and people who provide training and technical assistance

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What are strategies that rural healthcare providers can use to identify and support victims of violence?

Rural healthcare providers often play many roles with little specific training to support victims of violence. There is a need for integration of screening and counseling for victims of violence and abuse in primary care practices. A March 2015 policy brief from the National Advisory Committee on Rural Health and Human Services suggests that routine screening for signs of violence or abuse should become standard practice for primary care providers and nurses. These professionals should be familiar with the existing resources in their communities, including non-traditional sources of domestic violence support such as churches, faith-based providers, and community organizations.

A 2018 statement from the U.S. Preventative Services Task Force recommends that women of reproductive age should be screened by clinicians for IPV and should be referred to support services if they screen positive, with evidence showing that ongoing support services are of greater benefit than short-term interventions.

Screening of elders for violence, neglect, and abuse is important since elders may be reluctant or unable to report being victimized. According to the National Center on Elder Abuse (NCEA), elder abuse is underreported. In response to this issue, NCEA offers a summary of screening tools available to health professionals. In addition to these resources, the University of Maine Center on Aging offers an elder abuse screening protocol and tool that has been tested and implemented in rural primary care practices.

Routine screening for intimate partner violence is recommended by the U.S. Preventive Services Task Force for all women of childbearing age. An October 2016 American Family Physician article, Intimate Partner Violence, provides recommendations for routine screening for domestic violence and includes examples of screening tools, as well as tips for discussing this issue with patients. IPVHealth.org is a resource that healthcare providers can use to learn more about the health impact of violence and abuse. It offers tools and resources for establishing a partnership between domestic violence agencies and health settings. A related project, IPVHealthPartners.org offers a toolkit, Prevent, Assess, and Respond: A Domestic Violence Toolkit for Health Centers & Domestic Violence Programs, based on the experiences of successful community health center/domestic violence agency partnerships. For more information on the federal Health Resources and Services Administration's response to IPV (which includes partnering with IPV Health Partners), see How to Address Intimate Partner Violence and Human Trafficking at the Community Level.

Healthcare facilities can also help raise awareness of services available by placing brochures and posters in exam rooms and rest rooms. For example, the Georgia Coalition Against Domestic Violence (GCADV) offers downloadable tip sheets and brochures. Futures Without Violence offers more than 50 multilingual safety card resources for a range of settings and patient populations that healthcare providers can make available to patients.

Facilities and providers can increase access to services for domestic violence, sexual assault, or other violence by providing a safe place for victims to meet with service providers (such as counselors or sexual assault nurse examiners). This may include a telehealth connection to counselors or other crisis intervention professionals located at a distance for those in particularly rural and remote areas.

The HRSA Strategy to Address Intimate Partner Violence is a collaborative effort to address IPV at an agency-wide level in partnership with other federal agencies and grantees. The Office on Violence Against Women (OVW) in the U.S. Department of Justice provides grants to communities, medical providers, and other service providers who are working to implement strategies to protect women and their children who are victims of violence and abuse. The Office sponsors the Rural Sexual Assault, Domestic Violence, Dating Violence, and Stalking Assistance Program, which provides targeted funding for rural communities and several funding programs for tribal communities. OVW provides technical assistance to communities and has created two versions of the National Protocol for Sexual Assault Medical Forensic Examinations: Adult/Adolescent and Pediatric, through the SAFEta Project.

Organizations successfully providing services for victims of sexual assault at the local level include Canyon Creek Services in rural Utah and the Eastern Plains Sexual Assault Response Team in South Dakota. For more information on the role of healthcare providers in responding to domestic and intimate partner violence, see the 2018 Rural Monitor articles Domestic and Intimate Partner Violence: Some Do's and Don'ts for Health Providers and The Ruralness of Domestic and Intimate Partner Violence: Prevalence, Provider Knowledge Gaps, and Healthcare Costs.

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How does violence and abuse affect Native American populations? What factors and barriers do Native American communities face in preventing and dealing with violence?

According to the Indian Law and Order Commission's 2013 report A Roadmap for Making Native America Safer, American Indian/Alaska Native (AI/AN) children experience post-traumatic stress disorder due to chronic exposure to violence at the same rate as veterans returning from recent wars and triple that of the general population. Additionally, a U.S. Department of Justice report from 2004 estimates assaults on women living on reservations to be as much as 50% higher than the next most victimized demographic.

According to a 2017 CDC report, 47.5% of AI/AN women reported intimate partner violence during their lifetime, and 40.5% of AI/AN men reported IPV during their lifetime (this statistic represents both metro and nonmetro populations). 28.9% of AI/AN women reported that they were victims of attempted or completed rape during their lifetime, a rate higher than all other reported racial/ethnic categorizations except multiracial women. Building on this research, a 2020 fact sheet from the CDC addresses multiple forms of violence affecting AI/AN populations.

Historical trauma also plays a role in responses to violence and abuse in AI/AN communities. In a May 2017 presentation to Indian Health Services staff, Maria Yellow Horse Brave Heart defines historical trauma as “cumulative emotional and psychological wounding from massive group trauma across generations, including lifespan.” A 2019 article from American Psychologist discusses responses to historical trauma from a psychological and clinical perspective, noting that it is important to be aware of the ancestral history of Native communities when approaching behavioral health but not to assume that all Native people suffer from the same kinds of trauma. The article describes a movement in psychological care for Native populations that considers intergenerational factors that contribute to behavioral issues including violence, abuse, and barriers to seeking help for victims.

The 2014 article Sexual Assault Services Coverage on Native American Land notes that as of 2011 only 30.7% of the 650 Census-designated Native American lands surveyed were within a 60-minute drive to facilities offering sexual assault examiner (SAE) or sexual assault response team (SART) programs. The study also noted that 381 of those lands have no services or access beyond the 60-minute perimeter of the study.

Tribal law enforcement and courts face complicated judicial authority and limited criminal jurisdiction in cases of abuse committed by non-AI/AN people on tribal lands, though some expansion of tribal authority was included in the Tribal Law and Order Act of 2010. Subsequently, the May 2013 Violence Against Women Reauthorization Act authorized special domestic violence criminal jurisdiction to tribal courts over non-Indian offenders. This Act includes a definition of a tribal coalition, which gives support to tribal service providers to help them establish and maintain culturally appropriate services such as shelters and rape crisis centers.

The StrongHearts Native Helpline offers advocacy and culturally-aware support for AI/AN victims and survivors of dating, domestic, and sexual violence, with chat advocacy and phone service. Additional resources that focus specifically on AI/AN populations include the National Indigenous Women's Resource Center and the Indian Health Service's Domestic Violence Prevention Initiative. Futures Without Violence also offers safety card tools, fact sheets, campaigns, posters and reports developed in partnership with Tribal and national partners.

The National Indigenous Elder Justice Initiative (NIEJI) also offers resources to support tribal capacity to access culturally appropriate support for those suffering elder abuse, neglect, and exploitation, including a Tribal Elder Protection Team Toolkit. The 2018 Rural Monitor article Indigenous People and Domestic Violence: Who's Bringing Solutions features AI/AN community initiatives to prevent and respond to domestic violence and IPV.

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What are the barriers to addressing rural domestic violence/intimate partner violence?

Access to healthcare, prevention, social and human services, and protection services in rural communities is often limited based on funding and availability of a healthcare workforce trained in domestic violence intervention. Despite this limitation, healthcare workers hold a key position in serving victims of IPV, as discussed in this 2020 policy brief from the Southwest Rural Health Research Center on IPV-related emergency department visits. The brief notes that:

“Recent data indicate prevalence might be similar in rural and urban populations, but hospitalizations related to IPV are greater in rural areas, suggesting difficulty accessing preventive services to intervene before violence escalates. Areas with few services are also associated with higher levels of IPV-related homicide.”

According to Rural Social Work Practice, rural women and children, in particular, have less access than their urban counterparts to domestic violence shelters, healthcare providers, mental health services, law enforcement, and court officials. Rural Disparity in Domestic Violence Prevalence and Access to Resources states that:

“rural women are also nearly twice as likely to be turned away from services because of the insufficient number of programs and inadequate staffing of community-based health programs and face barriers of access due to geographic distance and isolation.”

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What is trauma-informed care and how does it support survivors of violence and abuse?

The Trauma-Informed Care Implementation Resource Center defines trauma-informed care as an approach to healthcare that considers a patient's complete life situation, including past and present experiences involving trauma, to improve health outcomes and patient wellness. According to the center, “Trauma-informed care shifts the focus from ‘what's wrong with you?’ to ‘what happened to you?’”

A 2019 Center for Health Care Strategies blog post on a trauma-informed response to substance use disorder in rural Tennessee notes that trauma-informed care

“represents a paradigm shift toward a model of health care that values relationships over efficiency, and quality over quantity. It acknowledges that a lack of empathy and understanding between patient and provider poses a serious barrier to care.”

Rural survivors face additional barriers caused by the stigmas associated with abuse, IPV, and sexual violence and because of healthcare access issues. Trauma-informed care aims to overcome these barriers by making healthcare welcoming and safe for survivors and victims who to seek help.

Organizations like Trauma Informed Oregon (TIO) offer resources directed to state-level healthcare and health-related organizations such as this Road Map to Trauma Informed Care. In a 2016 post to their blog, TIO details the experience of staff at the rural La Pine Community Health Center, a Federally Qualified Health Center, as they implemented TIC through consultation and staff training. In addition, an issue brief from the Center for Health Care Strategies describes Key Ingredients for Successful Trauma-Informed Care Implementation. Both pieces emphasize the importance of attending to staff needs and possible secondary traumatic stress among healthcare workers as the organization implements trauma-informed care.

In addition to trauma-informed care initiatives, some community-based groups are exploring healing-centered frameworks for responding to violence, abuse, and trauma in a way that focuses on the person rather than their trauma. Healing-centered initiatives are also aware of culturally specific definitions of healing, health, and trauma. The Future of Healing: Shifting from Trauma Informed Care to Healing Centered Engagement describes these efforts, and Beyond Trauma-Informed Care is a Healing-Centered, Culturally Rooted Approach explores the applications of healing-centered efforts in Latino communities.

For more information on healthcare responses to various types of trauma and healing, see the 2019 Rural Monitor article Rising from the Ashes: How Trauma-Informed Care Nurtures Healing in Rural America. In addition, the Trauma-Informed Care Implementation Resource Center offers video materials and workforce resources.

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How does living in a rural community impact sexual assault victims and survivors?

In rural communities, victims and survivors of sexual violence may face challenges accessing support services and care, including limited transportation options, geographic isolation or remoteness, and limited phone service. As noted in a sexual violence prevention plan created by the New Mexico Department of Health, addressing rural sexual violence is challenging due to the lack of anonymity in close-knit communities in which an abuser may share the same network as law enforcement and due to rural cultural attitudes of self-reliance, independence, and resistance to outside intervention. For more information on rural sexual violence and reasons for not reporting rape, incest, or other sex crimes, see the 2003 report Unspoken Crimes: Sexual Assault in Rural America.

Community conversation and cooperation are important factors in establishing and maintaining survivor support. Resources that address rural community responses to sexual violence include Stopping the Stigma: Changing Public Perceptions of Sexual Assault in Rural Communities and Safe Havens' Rural Communities Responding to Sexual and Domestic Violence.

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How does child abuse and neglect in rural communities compare to cases in urban areas?

Exposure to violence and incidence of child abuse and neglect are generally higher in rural communities. According to The Health and Well-Being of Children in Rural Areas: A Portrait of the Nation 2011-2012, 8.9% of rural children have been victims or witnesses to neighborhood violence, compared to 8.6% in urban areas. The HRSA data brief Rural/Urban Differences in Children's Health notes that 8.5% of children from small rural areas reported witnessing parental violence, compared to 7.6% of children from large rural areas and 5.0% from urban areas. A 2018 fact sheet from the National Center for Victims of Crime notes that youth ages 12-14 experience violent victimization at higher rates than all other ages, with 40 out of 1,000 urban youth and 39 of 1,000 rural youth experiencing violent victimization based on 2015 data.

Family stress, caused by a variety of factors such as poverty, substance abuse, and health problems, adds to the incidence of child abuse and neglect by caregivers. The CDC's Technical Package for Preventing Child Abuse and Neglect notes that children in low socioeconomic status (SES) families experience child abuse and neglect at 5 times the rate of children in families with a higher SES. According to Rural Families with a Child Abuse Report are More Likely Headed by a Single Parent and Endure Economic and Family Stress, a 2010 report using data from the National Survey of Child and Adolescent Well-Being, over 60% of rural caregivers reported for child maltreatment experience high family stress, compared to 50% in urban areas. Rural families dealing with child maltreatment issues also had more difficulty paying for basic needs than urban families.

According to the same report, the most commonly reported type of child maltreatment in rural areas is child neglect, or the failure by the caregiver to provide needed age-appropriate care. Neglect makes up 46% of reported rural cases, compared to 28% for physical abuse and 14% for sexual abuse. More than a quarter of reported child abuse cases in both rural and urban locations include more than one type of maltreatment. Limitations of this study include a lack of uniformity in definitions and local changes in case coding, which make it difficult to pinpoint geographic and chronological trends.

In rural communities, child abuse or neglect is often underreported due to isolation and geographic remoteness, lack of social services or other support programs, lack of or limited foster care or emergency housing, and social stigma for survivors.

For national data on child abuse and neglect and state-level information, see the 2019 Child Maltreatment report from the U.S. Department of Health and Human Services.

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What concerns are there for protecting the rural elderly and other vulnerable rural populations from violence, neglect, and financial abuse?

Rural elders and other vulnerable rural populations who suffer violence and abuse have special considerations when it comes to the need for response, protection, and support, both as victims and survivors. Health concerns associated with aging, such as physical limitations and dementia, make elderly populations more susceptible to physical neglect and abuse, personal neglect, and financial coercion. Victims who have physical and cognitive disabilities may need advocates to help them access specialized services, resource materials, or interpret legal proceedings. The National Center on Elder Abuse, a part of the Administration on Aging, provides prevention strategies and intervention partner information. In response to the COVID-19 pandemic, Safe Havens, the National Clearinghouse on Abuse in Later Life (NCALL), and Futures Without Violence developed a resource for faith communities, COVID-19 and Abuse of Older Adults: Ideas for Increasing Safety and Strengthening Families in Faith Communities.

Futures Without Violence offers an Elder Resources page and the Aging With Respect safety card that healthcare providers and human service agencies can make available. The card contains information about elder abuse and exploitation, healthy and unhealthy relationships, and health impacts of those relationships.

The blog post Elder Abuse: A Public Health Issue that Affects All of Us recognizes elder abuse as a public health issue, noting that approximately 10% of adults over 60 have experienced abuse, neglect, and/or financial exploitation. The authors note that communities can support elders and look out for signs of abuse, citing this list of 12 actions that communities can take to prevent elder abuse from the National Center on Elder Abuse.

The Department of Justice's Elder Justice Initiative developed a resource guide in conjunction with its 2018 Rural and Tribal Elder Justice summit. In addition, the 2018 Rural Monitor article Late Life Domestic Violence: No Such Thing as “Maturing Out” of Elder Abuse discusses local interventions to address elder abuse and violence.

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What is the impact of a rural setting on victims of harassment, stalking, and bullying?

According to Perspectives on Civil Protective Orders in Domestic Violence Cases: The Rural and Urban Divide, a study showed that rural women who were granted protection orders were more likely to fear future harassment or harm than their urban counterparts. The authors suggest that reasons for this may include:

• Geographic isolation
• Lack of community services
• Higher percentage of rural women married to the people named in the protection orders
• Rural women more likely to be in long-term relationships with their abusers, and more likely to have children in common with them

Bullying, primarily associated with school age children, can be particularly harmful in a rural community where access to support services and small class size impede the administrator's ability to intervene or solve the problem effectively. According to The Differential Impacts of Episodic, Chronic, and Cumulative Physical Bullying and Cyberbullying: The Effects of Victimization on the School Experiences, Social Support, and Mental Health of Rural Adolescents, cyberbullying has become common in rural schools. Geographic isolation does not affect the bully's ability to harass the victim through electronic means. Chronic bullying of any type may harm mental well-being, long term self-esteem, and future success.

Bullying based on sexual orientation or gender identity is a problem in both rural and urban communities. A 2013 article in the American Journal of Public Health finds that LGBTQ youth who experienced bullying also engaged in riskier behavior compared to heterosexual-identified youth who also experienced peer victimization. The Gay, Lesbian & Straight Education Network (now GLSEN) discusses this issue in a rural context in their 2012 report Strengths & Silences: LGBT Students in Rural Schools.

Resources to help communities prevent bullying are available at StopBullying.gov. For an example of partnerships between healthcare providers and law enforcement to address bullying, see the 2018 Rural Monitor article Together We Can Be Bully Free: CAH and Law Enforcement Address Peer Victimization through School-Based Program.