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. Those who suffer from abuse
are often isolated and disconnected from healthcare and social service providers, without an understanding of
how to access assistance. On the other hand, victims who live in small communities may be acquainted with
healthcare providers and law enforcement officers, but 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 because their abusers may be closely aligned with those who would otherwise
offer protection. Another challenge for victims of domestic violence is economic dependence, which limits their
ability to leave an abusive situation, particularly in rural communities with very limited resources for
relocation, especially secure locations. It is difficult in small communities to keep the locations of shelters
Building partnerships between healthcare organizations and community-based services, including domestic
violence, sexual assault, and child advocacy programs, can lead to increased staff engagement, comprehensive
responses for survivors, and bi-directional referral protocols for patients and clients. As a best practice,
domestic violence and sexual assault (DV/SA) advocates complete training curricula developed by recognized
industry leaders such as RAINN (Rape, Abuse & Incest National Network). 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. When available, advocates also maintain confidentiality and typically offer
24/7 services and support in-person, remotely by text or phone, and in some cases at a secure location of the
survivor’s choosing, known as mobile advocacy.
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 children, older adults, and people with
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, though rates of murder and rape are higher in nonmetropolitan areas than metropolitan ones.
Violent Crime in the United States, 2019 – Rates per 100,000 inhabitants
25,000 - 49,999
10,000 - 24,999
Murder and non-negligent manslaughter
Rape (revised definition)
*Includes state police agencies that report aggregately for the entire state.
Crime statistics may be artificially low since not all crimes are reported and not all allegations can be
substantiated. The Bureau of Justice Statistics' Criminal Victimization, 2016: Revised notes that in
areas only 42.0% 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. The Fourth
National Incidence Study of Child Abuse and Neglect (NIS-4) 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. This is also reflected in the 2021 article Rural Differences in Child
Reports, Reporters, and Service Responses that found maltreatment reporting rates were higher in rural
areas, but rates of confirmed maltreatment were similar in rural and urban areas.
The Health and Medicine Division, National Academies of Sciences, Engineering, and Medicine's 2014 report New
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 2022
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 2021
National School Climate Survey from GLSEN (formerly the Gay, Lesbian & Straight Education Network),
rural LGBTQ students experience more victimization and have less access to LGBTQ-related resources and supports
at school. Additionally, the 2016 article
Mental Health in Lesbian, Gay, Bisexual, and
Transgender (LGBT) Youth finds that LGBTQ youth may be unable to find respite from school victimization
because of challenges faced at home.
Hate crimes are defined by
the U.S. Department of Justice as “crimes committed on the basis of the victim's perceived or
actual race, color, religion, national origin, sexual orientation, gender, gender identity, or disability.”
While it is known that hate crimes occur in both rural and urban areas, data gathering techniques for hate
crimes do not provide a complete picture for either area. As noted in a 2019 report from the U.S. Government Accountability
Office, hate crimes from the Uniform Crime Reporting (UCR) Program in the Department of Justice are
undercounted, potentially by half, due to underreporting by both victims and law enforcement.
Despite these data collection challenges, researchers have worked to better estimate rural and urban hate
crimes. The 2018 study Hate Crime Victimization
Data in Pennsylvania: A Useful Complement to the Uniform Crime Reports compared UCR reported hate crimes
in Pennsylvania with hate crimes reported to a Pennsylvania state agency. The
study found that the UCR is more likely to underestimate hate crimes in rural areas. While the study reviewed
only Pennsylvania crimes, the authors suggest this model to estimate rural and urban hate crimes in other
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, onsite advocacy, and IPV training for staff, compared to urban
emergency departments. Similar barriers are found in Pennsylvania as discussed in Rural Availability of
Sexual Assault Nurse Examiners. This 2021 study found that consistent coverage of certified SANEs is
limited in rural areas, suggesting that sexual assault victims and survivors may receive lower quality treatment
compared to urban residents.
Some of these injuries require medical examination and treatment, which may be challenging to access in remote
or rural areas. Left untreated, these injuries can lead to serious infection or long-term health problems. In
addition, children and older adults 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 2016/2017 from the CDC, people who
stalking, or IPV experienced higher
rates of various health conditions such as asthma, irritable bowel syndrome, chronic pain and headaches, and
difficulty sleeping compared to women who had no history of abuse and violence.
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 difficult. 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. For more on issues related to accessing rural healthcare, see the Healthcare
Access in Rural Communities topic guide.
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. For more information on the challenges of accessing human services in
rural areas, see the FAQ How is the provision of human services
different in rural areas? on our Human Services to Support Rural Health topic guide. 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 specially-trained 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
Accompany victims to domestic violence and sexual assault examinations
Assist with applying to state crime victims compensation and reparations programs
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
The CDC offers a variety of resources designed to bolster community support for violence prevention programs.
for Action – Strategies
representing the best evidence to prevent or reduce violence and to improve well-being of communities.
Topics covered include Adverse Childhood Experiences (ACEs), Child Abuse & Neglect, Intimate Partner
Violence, Sexual Violence, Suicide, and Youth Violence.
For communities lacking local resources to address violence and abuse, national resources are available. The National Domestic Violence Hotline offers real-time support to
survivors of domestic violence through trained advocates who are available 24 hours a day, 7 days a week, 365
days a year. Preventive services are also available through their Love
is Respect service. This program aims to disrupt and prevent unhealthy relationships and intimate
partner violence by offering information, support, and advocacy to young people between 13 and 26 via phone,
text, and live chat.
How does poverty relate to violence and abuse in rural areas?
In 2021, the poverty rate for nonmetro areas was 15.4%, which is higher
than the 12.3% 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.
How does human trafficking affect rural communities?
The Administration for Children &
Families defines trafficking as the use of force, fraud, or coercion to provide labor or commercial sex.
Additionally, inducing commercial sex with a minor is trafficking even absent force, fraud, or coercion.
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; language barriers; not
identifying as a victim; and lacking an awareness of available resources.
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, sex work, and agriculture. The study suggests
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 the 2017
article Health Care and Human Trafficking: We are Seeing the
Unseen, 68% 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
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.
“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:
Additionally, children may fall under the category of secondary victim, defined as an individual suffering
negative experiences as an indirect consequence of a crime. In cases where a parent was the victim of more
severe abuse, children who are witness to domestic violence or sexual assault may not receive adequate victim
support as the focus of investigative efforts are the primary victim.
According to the same report, the most 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.
According to the NISVS
2016/2017 Report on Intimate Partner Violence, 57.7% of non-Hispanic AI/AN women and 51.1% of
non-Hispanic AI/AN men reported experiencing contact sexual violence, physical violence, and/or stalking by an
intimate partner during their lifetimes.
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
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
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.”
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.
What concerns are there for protecting rural older adults and other vulnerable rural populations from violence,
neglect, and financial abuse?
Rural older adults and other vulnerable rural populations who suffer violence and abuse have special
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 older adults 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 Administration for Community Living provides prevention
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 abuse of older adults and exploitation, healthy and unhealthy relationships, and
impacts of those relationships.
What are strategies that rural healthcare providers can use to identify and support victims of abuse?
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
sources of domestic violence support such as churches, faith-based providers, and community
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. The National Domestic Violence Hotline offers downloadable posters and
educational materials that are free to distribute.
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.
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 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