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
This guide addresses abuses that may take place in rural communities, including:
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
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.
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 orientationand 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
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 Power of Framing Human Trafficking
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.
For national data on human trafficking, see the 2019
Data Report from the Polaris Project.
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.
Some of these injuries require medical examination and/or x-rays, which may be challenging to access in remote
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.
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
How does COVID-19 affect rural responses to violence and abuse?
Efforts to mitigate the spread of COVID-19, including recommendations or orders mandating staying at home,
quarantining, and remote work and schooling, can inadvertently make victims of abuse who are isolated at home
with their abuser vulnerable. According to the Substance Abuse and Mental Health Services Administration report
Violence and Child Abuse Considerations During COVID-19, the economic and social stresses of the
pandemic “may stimulate violence in families where it didn't exist before and worsen situations in homes
where mistreatment and violence has been a problem.” A 2020 Morbidity and Mortality Weekly
Report article describes the increased proportion of visits to emergency departments related to
child abuse and neglect during the COVID-19 pandemic.
“Many child protection professionals believe child abuse is likely to increase during the COVID-19
pandemic because most abusers are parents or siblings who now have more complete access to the child victim. In
turn, the victim may no longer have schoolteachers, faith leaders or other mandated reporters they can access
for help or who may detect a sign of abuse.”
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:
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.
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
When services are lacking, victims may be reluctant to report abuse due to the possibility that it will just
make their situation worse.
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.
“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,
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
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
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.
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
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
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.
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.
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
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.
“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
“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.”
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?’”
“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
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.
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.
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.