Violence and Abuse in Rural America

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 private.

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 disabilities
• Bullying, harassment, and stalking
• Assault
• Homicide
• Human trafficking

For information about suicide, see the Rural Mental Health topic guide.

Frequently Asked Questions

• How prevalent is violence and abuse in rural America?
• How does violence and abuse affect health outcomes for rural populations?
• 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?
• How does poverty relate to violence and abuse in rural areas?
• How does human trafficking affect rural communities?
• What are adverse childhood experiences (ACEs) and how might they affect the health of rural people?
• How does child abuse, neglect, and exposure to violence in rural communities compare to cases in urban 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?
• What are the barriers to addressing rural domestic violence/intimate partner violence?
• How does living in a rural community impact sexual assault victims and survivors?
• What concerns are there for protecting rural older adults 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?
• What are strategies that rural healthcare providers can use to identify and support victims of abuse?
• What is trauma-informed care and how does it support survivors of violence and abuse?

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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, though rates of murder and rape are higher in nonmetropolitan areas than metropolitan ones.

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 rural 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.

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 – 36%
• Not important enough to victim to report – 18%
• Police would not or could not help – 16%
• Fear of reprisal or getting offender in trouble – 15%
• Other reason or not one most important reason – 15%

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.

See the 2020 National Crime Victimization Survey Factsheet for more information on reporting, data results from the NCVS, and survey details. See Sexual Violence: United States Health and Justice Measures of Sexual Victimization for more information on the different ways the federal government measures sexual victimization.

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, according to a 2012 Psychology of Violence article. 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. In 2021, 34% of female murder victims were killed by an intimate partner. About 1 in 3 women in the U.S. experience 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 National Intimate Partner and Sexual Violence Survey 2016/2017 found that lesbian and bisexual women were more likely to experience intimate partner-perpetrated violence than heterosexual women. For more information on the impacts of IPV on lesbian, gay, bisexual, transgender, questioning/queer, intersex, and asexual people (LGBTQIA+), 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. 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 Maltreatment 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 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 2022 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 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 states.

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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, 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.

According to the U.S. Department of Health and Human Services 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 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 experienced sexual violence, 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.

Adverse childhood experiences (ACEs) can lead to poor health outcomes in adulthood. Information about the effects of ACEs on health status and health outcomes is included in the FAQ What are adverse childhood experiences (ACEs) and how might they affect the health of rural people?

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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? A Critical Review of the Literature 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 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.

Examples of innovative programs to support victims and survivors of abuse include the Massachusetts Department of Public Health TeleSANE 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. 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.

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 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

The National Domestic Violence Hotline Provider Search can be used to locate local assistance providers including legal services. 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 onsite 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.

The 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:

• Resources 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.
• 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

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.

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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.

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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 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 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 (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 Polaris Analysis of 2021 Data from the National Human Trafficking Hotline from the Polaris Project.

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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. The 2022 brief Rural-Urban Differences in Adverse and Positive Childhood Experiences: Results from the National Survey of Children’s Health reports that rural children were more likely than urban children to experience 4 or more ACEs. ACEs can have a multi-generational effect; in a 2020 Children and Youth Services Review article, researchers found that children raised by caregivers who reported 4 or more ACEs were 3 times more likely to develop depression and/or anxiety. 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.

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.

ACEs and their impact on health and well-being can be prevented. For more information, see the CDC's 2019 publication Adverse Childhood Experiences (ACEs) Prevention: Resource for Action, the Rural Monitor article Confronting Adverse Childhood Experiences to Improve Rural Kids' Lifelong Health, and the Exploring Rural Health podcast episode The Impact of Adverse and Positive Childhood Experiences on Rural Children, with Elizabeth Crouch.

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

Incidence of child abuse and neglect are generally higher in rural communities. 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 Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities 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 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.

Rural children can also be victims of violence outside the home. 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. 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.

For national data on child abuse and neglect and state-level information, see the Child Maltreatment 2022 report from the U.S. Department of Health and Human Services. For more on comparing abuse between rural and urban areas, see the 2021 article Rural Child Maltreatment: A Scoping Literature Review.

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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. A 2023 Morbidity and Mortality Weekly Report found that the prevalence of 4 or more ACEs is also highest among AI/AN adults when compared to other racial and ethnic groups. Additionally, the National Intimate Partner and Sexual Violence Survey (NISVS) 2016/2017 Report on Sexual Violence reports that 43.7% of non-Hispanic AI/AN women experienced rape, 32% experienced sexual coercion, and 58.1% experienced unwanted sexual contact in their lifetimes.

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 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 Native American Elder Justice Initiative (NAEJI) also offers resources to support tribal capacity to access culturally appropriate support for those suffering elder abuse, neglect, and exploitation. 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. The National Indian Health Board’s Information Hub: Adverse Childhood Experiences (ACEs) in Indian Country offers resources to increase awareness and capacity to address ACEs in tribal communities.

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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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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.

Disparities in care for sexual assault can be found as early as the forensic examination survivors undergo. The 2016 Government Accountability Office report Sexual Assault: Information on Training, Funding, and the Availability of Forensic Examiners notes that all six states consulted for the report did not have enough examiners to meet their needs, especially in rural areas. Similarly, the 2023 study Emergency Department Preparedness to Care for Sexual Assault Survivors: A Nationwide Study found that sexual assault nurse examiners (SANEs) are more likely to be available in urban areas than rural ones. The presence of a SANE can increase the quality of care received by the patient. Survivors attended by SANEs were more likely to receive trauma-informed care and continued support through follow-up resources. 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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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 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 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 strategies information.

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 health impacts of those relationships.

The blog post Elder Abuse: A Public Health Issue that Affects All of Us recognizes abuse of older adults 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 older adults 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 abuse of older adults 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 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 increasingly common in rural schools. Geographic isolation does not affect the bully's ability to harass the victim through electronic means.

The 2021 Gay, Lesbian & Straight Education Network (now GLSEN) National School Climate Survey evaluated LGBTQ students regarding online and in-person victimization in rural schools.

Chronic bullying of any type may harm mental well-being, long-term self-esteem, and future success. 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. 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.

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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 organizations.

Screening of older adults for violence, neglect, and abuse is important since they may be reluctant or unable to report being victimized. According to the National Center on Elder Abuse (NCEA), abuse of older adults 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 a screening protocol and tool for older adults that has been tested and implemented in rural primary care practices.

Routine screening for intimate partner violence and referrals to support services for victims is recommended by the U.S. Preventive Services Task Force for all women of childbearing age. In spite of this recommendation, a 2023 study found that rural women are more likely to experience intimate partner violence and that rural residents are less likely to be screened for violence and abuse when compared with urban residents. 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 Health Resources and Services Administration's response to IPV (which includes partnering with IPV Health Partners), see Addressing Intimate Partner Violence and Human Trafficking in Communities.

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.

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.

For more information on identifying and addressing human trafficking, including tools available to practitioners and administrators, see the FAQ How does human trafficking affect rural communities?

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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 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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