Authors: Sydney Li, Meghan Etsey, Brianna Clark, DO —- on behalf of AMWA Gender Equity Task Force


Image Source: The Learning Network & Canadian Domestic Homicide Prevention Initiative with Vulnerable Populations. (2021, January). “Stay with them”: Survivors of Intimate Partner Violence share insights on how friends and family can help. Western University. https://www.gbvlearningnetwork.ca/our-work/backgrounders/staywiththem/Survivors-of-Intimate-Partner-Violence-Share-Insights-on-How-Friends-and-Family-Can-Help.pdf

The growing reality of intimate partner violence (IPV) in rural communities should be a serious concern for both primary and acute care physicians. Before beginning medical school, Sydney worked in a family medicine clinic where she regularly interacted with a patient she’ll never forget. She was a soon-to-be mom, a recent immigrant, and always radiated joy when speaking about starting her new family. Her pregnancy progressed smoothly, and she eventually delivered a healthy baby girl. But during her postpartum follow-up visits, something had changed. She grew quieter. She had bruises on her arm. And for the first time, she asked to be seen alone. Like many who silently signal for help, she had nowhere else to go. And it made Sydney wonder—did we ask the right questions? Did we recognize the signs early enough? Did we offer her the support and resources she truly needed?

IPV, commonly referred to as domestic violence, is a significant and intersectional public health issue. It includes a range of abusive behaviors within intimate relationships – physical violence, emotional abuse, sexual assault, stalking, and psychological manipulation (Huecker et al., 2023). IPV not only harms individuals directly but also reinforces systemic inequities, especially in marginalized and rural communities.

According to U.S. crime data, approximately one in five homicide victims are killed by an intimate partner (Huecker et al., 2023). These rates are alarmingly higher among certain racialized groups. In New York City, for example, Black women represent just 13% of the population but account for 30% of intimate partner homicide victims (NYC Mayor’s Office to End Domestic and Gender-Based Violence, 2021).

Indigenous women in Canada are eight times more likely to experience intimate partner violence than non-Indigenous women, a disparity that is best understood within the context of intergenerational trauma resulting from colonization, forced assimilation, and systemic discrimination (Rizkalla et al., 2020). Additionally, Indigenous women living in rural and northern Canadian communities face disproportionately higher rates of IPV, often experiencing more severe forms of abuse compared to their urban counterparts (Rizkalla et al., 2020). However, these estimates may be variable and significantly underreported, highlighting the need for improved documentation, culturally safe reporting mechanisms, and more comprehensive data collection.

IPV during pregnancy is particularly concerning, as it is one of the most common health issues experienced by pregnant individuals – occurring at rates similar to gestational diabetes – and is a leading non-obstetric cause of maternal morbidity and mortality (Kozhimannil et al., 2024). The consequences of IPV during pregnancy are devastating: increased risk of hemorrhage, depression, suicide, preterm birth, low birth weight, and even neonatal death (Kozhimannil et al., 2024). These risks are even more pronounced in rural areas, where access to healthcare, safe housing, transportation, and support services is limited (National Rural Health Association, 2024). Despite the reach of IPV across all communities, rural survivors face unique and compounding barriers. Survivors in these areas are less likely to be screened and more likely to encounter gaps in support (Kozhimannil et al., 2024).

According to recent U.S. data (Kozhimannil et al., 2024):

  • Over 60% of rural IPV survivors were not screened before pregnancy.
  • 30% were not screened during pregnancy.
  • More than 50% were not screened postpartum.
  • Across the entire perinatal period, 1 in 5 rural survivors were never screened at all.

Rural women also face reduced access to transitional housing, medical providers, and law enforcement (Peek-Asa et al., 2011). Confidentiality can be compromised when perpetrators are personally connected to police or healthcare workers (Hanley & MacPhail, 2023). In many cases, survivors rely on cell phones for support, only to have them monitored, confiscated, or destroyed by abusers. While trauma-informed care is essential, in-person services remain scarce in rural regions. In places like rural Canada, the challenges persist. While awareness is improving, outdated beliefs still shape responses to IPV. Many still equate IPV only with physical violence, leaving emotional and psychological abuse under-recognized. Survivors often feel dismissed by legal, mental health, and healthcare systems that are still catching up (Letourneau et al., 2022).

The United States Preventive Services Task Force recommends routine IPV screening for all pregnant, postpartum, and reproductive-age individuals (2024). But how does this translate into practice?

  • The role of the clinician: Clinicians play a pivotal role in identifying and responding to IPV, and this begins with building trusting relationships with patients. Establishing trust requires prioritizing privacy during consultations, using clear and compassionate language, and ensuring continuity of care so that patients feel seen and understood over time (Battaglia et al., 2003). Screening should be universal, not based on assumptions or stereotypes, because abuse is often hidden behind fear or shame (Miller et al., 2021). Clinicians must also reflect on their own biases and experiences, which can impact how they respond to disclosures (Marlin et al., 2022). And without institutional support—protected time, training, and resources—even the most committed providers may struggle to respond effectively.
  • The role of the community: Strong partnerships with legal aid, shelters, mental health services, and social support agencies are essential. Addressing IPV also requires recognizing how structural forces like racism, poverty, substance use, and ableism intersect to shape survivors’ experiences (Wathen & Mantler, 2022).
  • The role of the institution: To ensure a consistent and effective response to IPV, healthcare systems should implement standardized screening protocols across all departments (Marlin et al., 2022). Standardized protocols across all departments (social work, nursing, etc.), embedded prompts in electronic health records, and regular staff training in trauma-informed care are vital. These steps help normalize screening, reduce missed opportunities, and empower patients to speak up (Williams et al., 2016; Wathen & Mantler, 2022). However, to truly advance equity, healthcare systems must also recognize and address the unique barriers faced by diverse populations, particularly those in rural and northern communities.

If you are experiencing IPV, your safety is the top priority. If you are in immediate danger, call your local emergency number right away. Consider creating a safety exit plan and identifying a safe place to go, such as a trusted friend or family member’s home, a local shelter, a hospital, or even a police station. When preparing to leave, try to pack essential items, including identification, health cards, medications, cash, and contact information for local support organizations. In the United States, you can reach out to the National Domestic Violence Hotline by calling 1-800-799-SAFE (7233) or texting “START” to 88788. Trained advocates are available 24/7 to offer confidential support, safety planning, and information about local resources.

If you are a clinician and suspect that your patient may be experiencing IPV, it is essential to respond with empathy, discretion, and awareness of available resources. Begin by assessing the level of immediate danger, whether children are involved, and follow local protocols while prioritizing the patient’s preferences and safety. When appropriate, connect the patient to community-based support services, such as local shelters, legal aid, or counseling. It is important to recognize that not all individuals experiencing IPV will choose to leave or report their partner. Clinicians must respect the patient’s autonomy and avoid pressuring them to take actions they are not ready for. Encourage all individuals to develop a personalized safety plan, one that prepares them for emergencies, exit strategies, and essential items to have ready if needed.

Bridging this individual-level care with broader systemic response is especially critical in rural settings, where IPV survivors—particularly those who are pregnant or otherwise marginalized—face unique barriers to accessing timely and specialized services. One essential but often underutilized resource is the Sexual Assault Nurse Examiner (SANE) program. SANEs are registered nurses with advanced training in conducting trauma-informed forensic exams, collecting evidence, and providing comprehensive medical care and emotional support to survivors of sexual assault and intimate partner violence. Their involvement can improve health outcomes, preserve legal evidence, and ensure survivors are treated with dignity and respect. However, rural hospitals frequently lack SANE coverage or only offer it during limited hours. In these cases, clinicians should be aware of regional referral systems and consider advocating for teleSANE programs—virtual networks that allow trained SANEs to guide local providers through forensic exams in real time. Partnering with SANE programs and Sexual Assault Response Teams (SARTs) can strengthen a clinician’s ability to offer coordinated, survivor-centered care and reduce the risk that patients fall through the cracks of an already fragmented system.

Addressing IPV in rural communities, especially among pregnant and marginalized individuals, requires urgent, tailored strategies that bridge the gaps in healthcare access, provider training, and systemic support. Emergency departments, family medicine clinics, perinatal care settings, and beyond all play a vital role in early identification, trauma-informed response, and sustained care coordination.

References:

  1. Battaglia, T. A., Finley, E., & Liebschutz, J. M. (2003). Survivors of intimate partner violence speak out. Journal of General Internal Medicine, 18(8), 617–623. https://doi.org/10.1046/j.1525-1497.2003.21013.x
  2. Hanley, N., & MacPhail, C. (2023). “You can’t meet everyone’s needs after-hours”: After-hours domestic and family violence services in rural and remote areas. Violence Against Women, 29(12–13), 2527–2550. https://doi.org/10.1177/10778012231183655
  3. Huecker, M. R., King, K. C., Jordan, G. A., & Smock, W. (2023). Domestic violence. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499891/
  4. Kozhimannil, K. B., Sheffield, E. C., Fritz, A. H., Henning-Smith, C., Interrante, J. D., & Lewis, V. A. (2024). Rural/urban differences in rates and predictors of intimate partner violence and abuse screening among pregnant and postpartum United States residents. Health Services Research, 59(2), e14212. https://doi.org/10.1111/1475-6773.14212
  5. Letourneau, N., McBride, D. L., Barton, S. S., & Griggs, K. (2022). Service providers’ perspectives: Reducing intimate partner violence in rural and northern regions of Canada. Canadian Journal of Nursing Research, 55(2), 165–175. https://doi.org/10.1177/08445621221128857
  6. Marlin, E. C., Beaudoin, C. F., Burke, L. G., Jagannathan, V., Berkowitz, S. A., & Gottlieb, L. M. (2022). Electronic health record–based modules to improve screening for social determinants of health and referral: A randomized quality improvement trial. JAMA Network Open, 5(7), e2218527. https://doi.org/10.1001/jamanetworkopen.2022.18527
  7. Miller, C. J., Adjognon, O. L., Brady, J. E., Dichter, M. E., & Iverson, K. M. (2021). Screening for intimate partner violence in healthcare settings: An implementation-oriented systematic review. Implementation Research and Practice, 2, 26334895211039894. https://doi.org/10.1177/26334895211039894
  8. National Rural Health Association. (2024). Maternal health & IPV in rural America: Policy brief. National Organization of State Offices of Rural Health. https://www.ruralhealth.us/nationalruralhealth/media/documents/advocacy/policy%20brief/nrha-policy-brief-rural-maternal-health-ipv-final.pdf
  9. NYC Mayor’s Office to End Domestic and Gender-Based Violence. (2021). New York City domestic violence fatality review committee: 2020 annual report. NYC Office of the Mayor. https://www1.nyc.gov/assets/ocdv/downloads/pdf/2020-FRC-Annual-Report.pdf
  10. Peek-Asa, C., Wallis, A., Harland, K., Beyer, K., Dickey, P., & Saftlas, A. (2011). Rural disparity in domestic violence prevalence and access to resources. Journal of Women’s Health, 20(11), 1743–1749. https://doi.org/10.1089/jwh.2011.2891
  11. Rizkalla, K., Maar, M., Pilon, R., McGregor, L., & Reade, M. (2020). Improving the response of Primary Care Providers to rural First Nation Women Who Experience Intimate Partner Violence: A qualitative study. BMC Women’s Health, 20(1). https://doi.org/10.1186/s12905-020-01053-y
  12. U.S. Preventive Services Task Force. (2024). Intimate partner violence, abuse of older vulnerable adults: Draft recommendation statement. https://www.uspreventiveservicestaskforce.org/uspstf/draft-recommendation/intimate-partner-violence-abuse-older-vulnerable-adults
  13. Wathen, C. N., & Mantler, T. (2022). Trauma- and violence-informed care: Orienting intimate partner violence interventions to equity. Current Epidemiology Reports, 9(4), 233–244. https://doi.org/10.1007/s40471-022-00307-7
  14. Williams, J. R., Halstead, V., Salani, D., & Koermer, N. (2016). An exploration of screening protocols for intimate partner violence in healthcare facilities: A qualitative study. Journal of Clinical Nursing, 26(15–16), 2192–2201. https://doi.org/10.1111/jocn.13353

About the Authors

Meghan Etsey is a fourth year medical student from St. George’s University. She has a Bachelors of Arts in Biology and a Bachelors of Arts in Nutrition and Dietetics from Bluffton University in Bluffton, Ohio. She served as the President of the St. George’s University’s Women in Medicine chapter in St. George, Grenada where she expanded relationships with the community and worked towards educating women and helping the youth. She is also a member of the Gender Equity Task Force and Sex and Gender Health Collaborative Committees within the American Medical Women’s Association. When she is not pursuing medicine, you can find her with her friends and family on different road trips and adventures exploring the world.

Dr. Brianna Clark is a proud osteopathic physician.  She has completed fellowships in Breastfeeding Medicine at the University of Rochester Lessons in Lactation Advanced Curriculum ( LILAC) and Climate Health Equity Fellowship ( CHEF) through the National Medical Association ( NMA). She spends her spare time thinking about innovative ways to provide equitable health care to all and create sustainable advocacy.

 

Sydney Li is a third-year medical student at St. George’s University, dedicated to advancing clinical knowledge, compassionate patient care, and promoting equitable communities. She strongly believes in nurturing community connections, supporting green spaces, and valuing social advocacy as integral parts of health and medicine. Sydney holds a Bachelor of Science in Population Health from Vancouver, Canada, and previously worked on the global Prospective Rural and Epidemiology (PURE) study, which investigates how societal factors influence chronic disease. Outside of medicine, you can find her on a mountain or local beach, exploring her neighbourhood cafes, or admiring her local park.

Formatting, publication management, and editorial support for the AMWA GETF Blog by Vaishnavi J. Patel, DO