FVS5

UNHEARD AND UNSEEN

Rural Women and Domestic Violence

Connie Adler, MD

ABSTRACT

Rural society and conditions can contribute to make domestic violence more difficult to escape. Physical and social isolation, the distance to and unavailability of services, and rural culture provide challenges to abused women and to health care provid- ers that are different from the obstacles seen in better-studied urban areas. Heightened awareness can aid in identification of abuse. Social action is necessary to change communities and to interrupt the cycle of violence.

Rhonda arrived in the emergency department. She had been brought in by the police when some neighbors complained about her screaming and being beaten. They had heard her screaming many times before, but this time seemed worse somehow and they called for help. The police had found her, intoxicated, in the rented shack; her husband had left with the car after beating her. The shack had a dirt floor and no running water. She wore an often-patched cotton dress and owned no underwear or socks. She had bruises all over her body from beatings with a stick and the broom. Her ear and one side of her face were totally disfigured from repeated assaults and she had lost much of her hearing. Her arms were lumpy from poorly healed fractures. She was an art college graduate who was never allowed out of the house. She was 40; she looked 100.

Domestic violence in rural areas is not different in kind from that found in more urban or suburban areas of the country, but there are a variety of factors--historic, cul- tural, and physical--that make abuse in the "country" more difficult to identify, to address, and to abolish. Peo- ple in rural areas like to see themselves as free of the violence, drug use, and other problems that plague our cities. Editorials, sermons, and essays extole the joys of quiet, peaceful communities where everyone knows one another and one never has to be afraid. This myopic vision is part of a conspiracy of silence to ignore the dan- ger in which women and children (and some men) find themselves daily. A recent review of rural health centers in Maine, done by a study group from family practice residency programs (unpublished study, L. Levasseur, "Physician Inquiry of Patient Abuse Experiences: A Study of Rates of Inquiry at a Family Practice Residency Clinic and a Rural Health Center ," Augusta, ME, 1993),

Address correspondence to Connie Adler, MD, PO Box 263, Far- mington, ME 04938 .

demonstrated just how prevalent abuse is in rural society. Of randomly polled men and women over 19 years of age, 2 5 - 4 5 % reported a history of significant physical abuse or present physical abuse, 1 0 - 2 8 % reported pres- ent or past sexual abuse, and 2 0 - 3 0 % acknowledged past or ongoing verbal abuse in an intimate relationship. (The numbers varied by clinic.) One hospital emergency department that used the same screening tool discovered an overall rate of 58% of people presenting there had experienced one or more of the types of abuse outlined. The Eastern Maine Family Practice Residency program screened all of its prenatal clinic users and found an 1 I% incidence of current abuse from the clients' partners. These numbers are not significantly different than other communities, but what is different is the refusal of the people of the towns and villages themselves to acknowl- edge the reality of this epidemic of violence.

THE CULTURAL AND SOCIAL FABRIC

Rural women have a heritage of strong, courageous predecessors who led outdoor, physically challenging lives. We would all like to see ourselves as "pioneer" women, taming the countryside and leading a "healthy" rural life with intact families. In fact, many of these large kinship groups of intermingled families with neighbor re- fated to neighbor do exist, and they can be a source of strength and comfort, of help through hard times, and of joyous celebration in good ones. Unfortunately, they come with a price tag, the "don' t talk" rule. Families are private and all too many have their own methods of dis- ciplining members to keep violence, abuse, and incest a secret.

ISOLATION

Physical isolation is one of the most profound differences between the cultures of abuse in urban and rural socie- ties, and often abusers compound the physical isolation with social and emotional isolation. Rural people live very far apart, often down bad, sometimes dirt roads that be- come impassible for weeks at a time. Distances to other homes, to a store, or to health care can be 3 0 - 5 0 miles in areas of Maine, and roads can be dangerous in winter and in "mud season." Secondary roads are often not

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plowed except by private arrangements or by owners. Access to vehicles is controlled by the abuser. He may take the only car to work, stranding a woman and chil- dren at home as long as he wishes, or he may control the keys or gas money so as to make sure that he is aware of her every movement. There is no public transporta- tion, no such thing as a taxi. Being far away from any other support or contact reinforces feelings of helpless- ness and dependency, as well as the need for interaction of any kind, even negative. In logging or farming com- munities, long, lonely summer days are often followed by long periods in winter when the partner is unemployed and always at home, watching every move, always in control.

In the contemporary world, dominated increasingly by the Internet, it becomes hard to imagine how discon- nected rural women can become. Abusers will often re- fuse to allow telephones or arrange them to accept only incoming calls. Even women who do have telephones are aware that calls to shelters or to health care providers are long-distance toll calls and show up on the telephone bill that the abuser scrupulously reviews.

A lawyer (from a small town about I hour out from our "big" town of 7,000) came in for her postpartum visit and asked why her husband was so mean. "What exactly do you mean?" I asked. She revealed that he constantly insulted her, told her she was ugly and stupid, and yelled at her. In the last week, he had twice slapped her so hard, he knocked her to the ground. "Did you call the police? .... Oh, no," she replied. "I couldn't. I know all of them and work with them every day in court. I'd be embarrassed to see them again."

Anonymity is virtually impossible in most rural commu- nities. People listen to police scanners to hear the calls that go out. They recognize their neighbors' names or addresses. If that fails, the local newspaper publishes all police calls, with addresses and often names. A call to the domestic violence hotline may put you in touch with a volunteer who is a cousin of your abuser. The police- man who is called to respond may be your partner's

Connie Adler is a family practice physician in western Maine who specializes in women's health care, especially obstetrics. She has lived and practiced in rural areas in Maine and Washington for 13 years. Dr. Adler has been on the board of directors or involved in shelters and abused women's advocacy programs since 1983. In addition to a very busy obstetric practice, Dr. Adler is chief of medical staff at her hospital and is the medical consultant to the Maine State Breast and Cervical Health Program, a CDC-funded screening program for breast and cervical cancer. Dr. Adler graduated from Cornell University (BA) and Tufts University School of Medicine, graduating with honors and an award for excellence in the "art" of medicine. She did her residency at the Maine-Dartmouth family practice residency in Augusta, Maine. She is bilingual in English and Spanish and has worked extensively with migrant farmworkers in eastern Washington State.

brother. Fear of public humiliation can often be exacer- bated by concern that the abuse will be ignored to save family "face" and that further isolation will follow, due to being ostracized by members of the extended family.

American society is not very tolerant of women who choose to live alone. This is even more true in rural areas where "coupling" pressures are intense. There is no place for single women who may be seen as a threat to the stability of other couples. Leaving one's abusive part- ner, therefore, means even more intensive social isola- tion because parties, events, and invitations that might have been open for a couple are not welcoming to a single woman, and there are few, if any, other forms of social interaction outside of work and church. Some fun- damentalist religions in rural communities reinforce both a man's sense of his right to his power at home and the pressure on a woman that her only proper place is as a part of a family, however dysfunctional.

Alcohol abuse, a problem endemic in rural communi- ties, has been shown to increase abuse (1). Many women in abusive relationships will also use alcohol, perhaps as a form of self-medication. The presence of firearms in many rural homes provides easy tools of intimidation. Although abuse crosses all socioeconomic lines, the over- whelming poverty of many rural areas further limits many women in their choices of response to ongoing abuse, denying them access to escape and to legal help.

SPECIAL POPULATIONS

All of the above implies that rural populations are ho- mogeneous; this is, of course, not the case. Women of color, Native Americans, and migrant farmworkers live in rural areas in relatively large numbers. An African- American woman in many counties can be virtually sure that the policeman she calls will be white, with his own stereotypes of black families. She also knows that all the social work agencies and probably the shelters are staffed by white women.

Native American women who have remained on res- ervation land have a wide range of cultural traditions, depending on their heritage. Some Native American groups have organized to combat the dilution of their culture and to strengthen the position of women in the tribe. For many women, however, reservation life has left them without much of their ancestral values and has re- placed it with a culture of poverty and hopelessness. Maintaining self-esteem and self-worth can be particu- larly difficult in this situation. Alienation from the au- thorities is especially profound. A Native American woman has no reason to trust either a nontribal police officer or social service worker, given the history of these interactions. Tribal authorities address the issues of do- mestic violence with varying degrees of interest.

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Migrant farmworkers are among the most isolated of all groups. Even U.S. citizens who travel with the crops face the invisibility of most migrants. The nature of the constant movement and the distance from fields to towns both work to keep women and children completely at the mercy of the male head of household. Women may have no contact with the outside world and no way to make contact. Noncitizens from Mexico, Haiti, Guatemala, El Salvador, the Dominican Republic, and other countries are further intimidated by fear of the Immigration and Naturalization Service (INS). Any contact with social ser- vices, police, or shelters could mean being reported to the INS and deported and/or separated from any re- maining family. Return to some of these countries can mean death to members of opposition groups. Fear of the INS prevents contact with any agencies of govern- ment.

Teenagers of all colors, especially teen mothers, face particular difficulty in trying to escape abusive partners. There is a recurrent theme of revictimization of teens. They are seen as "loose" and "running around" by the people to whom they look for help. They are labeled "immature" and "too needy" by caseworkers, and their need for age-appropriate social outlets are seen as friv- olous and engender blaming the victim for the behavior of the abuser. In addition, family violence can be a learned behavior. Teens have often learned from abusive parents and have no other model of interaction in a re- lationship.

RECOGNIZING ABUSE

The need for universal screening for domestic violence cannot be overemphasized. It is essential to ask the ques- tion. Simply asking about abuse may produce greater than 10% positive responses. For the many women who are hesitant to disclose abuse initially, further probing should be done if warning signs are present. The partner who insists on being present for any interview and who dominates all conversations is very suggestive of exces- sive control. Another suspicious situation is the woman who frequently changes appointments at the last minute (so that bruises will not show). Although there are cer- tainly families that cannot afford telephones, telephone service is truly a lifeline in rural communities and, gen- erally, families will forego other things to have a phone. Refusing to obtain telephone service is another tool of control. The woman who is left at home with no car and no telephone may be at risk and may warrant further concern. A woman may report that she is not allowed access to the family checkbook or that she is only allowed to go out with her husband or her mother-in-law. "Lock- ins" are not an uncommon occurrence wherein the male partner leaves for work each day with the woman locked

in her house, too far away from anyone else to make contact.

Pregnancy is an especially high-risk time for violence to begin or recur in the family (3). Nationally, fully 20% of all pregnancies are burdened with abuse, and family violence has been shown to increase the risk of miscar- riage and low birth weight babies. It is probably the most common complication of pregnancy. Other indicators that abuse may be happening at home are injuries that do not match the explanation for them, chronic vague complaints (especially of abdominal or pelvic pain), sui- cide attempts, alcohol abuse, and depression.

Nancy underwent a vaginal hysterectomy for unremitting menorrhagia. Five days later, she was in the emergency room with heavy vaginal bleeding. She admitted that her husband had forced her to have sex despite her recent surgery. She refused to go to a shelter because the farmhouse in which they lived was actually hers and she had a small herd of sheep that were her only income. She could not take them with her, and, if she left them behind, he would destroy them. A re- straining order was useless because she lived so far out of town the police would never be able to patrol.

BARRIERS TO ACTION

Distance to services and lack of transportation remains an enormous obstacle to support of women in danger (2). Abused women have great difficulty getting to sup- port groups, health care appointments, or counseling be- cause they may live so far from these services. Similarly, intervention programs are required to expend excessive amounts of resources on transportation and cannot make 24-hour-a-day commitments to pick up women or to take them to shelters. The sheriff's department may not have the staffing to allow it to pick up a woman 20 miles away and to take her to a shelter 30 miles in an- other direction, leaving half a county without coverage.

Shelter facilities tend to exist only in urban areas. A rural community cannot support a full-time shelter. For women and children leaving their homes and whatever support they have, traveling to an urban area and an unknown environment is especially frightening. Traffic, noise, and the crush of population are alienating and so intimidating that women refuse to stay. Many commu- nities have tried to deal with this problem by establishing "safe houses." The problem with safe houses in rural areas is that they do not stay secret for long. Soon the abusers know where to look for their partners, and nei- ther the woman nor the other occupants of the house are safe any longer. Volunteers who staff safe houses or hot lines also quickly become known and are subjected to harassment by relatives and neighbors who disagree with what they do.

The inavailability of legal services presents another barrier to women in abusive situations. There is a lower

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concentration of lawyers in rural areas, and fewer judges are familiar with domestic violence law. Rarely are free legal services available, and few lawyers are willing to do pro bono work. Lawyers, too, may be afraid of the dis- approval of their "buddies" and golf partners if they be- come very involved in domestic violence issues.

Shame and fear keep many women from pursuing counseling services, but the chronic shortage of mental health care providers in rural areas exacerbates this sit- uation by making it very difficult to obtain counseling ser- vices. For example, counties of 75,000 people covering areas the size of Rhode Island will have one or no psy- chiatrists. Psychiatric social workers, clinical psycholo- gists, and other providers are overworked, and some might mistakenly suggest family counseling instead of in- dividual work to strengthen the woman involved.

Health care providers can, of course, help by identi- fying the abuse and counseling the woman, but, again, many are afraid of raising the issue because they do not know how to or do not want to deal with the conse- quences. Additionally, fear of loss of confidentiality is a major issue in rural areas. Provider office staff and emer- gency room staff know the families of the patients and their partners. The abused woman may see them again at church or at school and may fear that word would get back to her abuser that she has been talking.

If a woman desires to leave her home, her options in rural America may be severely limited. There are few jobs not tied to the land and farms, and livestock are not mov- able the way factory or office skills can be. Housing is scarce, child care often even less available. Distant shel- ters make it even harder to find employment. Transpor- tation is another barrier to be overcome.

SUMMARY

The physical isolation of rural living makes more difficult the identification of domestic violence and its ameliora-

tion. There are aspects of country living that often serve to convince the abused woman or child to "keep the se- cret"--the "good old boy" network, community pres- sure, and lack of anonymity.

Rural institutions and traditions of neighbor helping neighbor can, however, be turned around and used to strengthen the position of women in the community and to prevent or to stop domestic violence by ostracizing the perpetrator rather than the victim. Rural communities can organize to acknowledge the reality of violence in their homes and to work toward ending the violence and to provide a new start for women escaping intolerable situations. Rural communities are often small enough that a single person or small group of people can make a big difference. A single enlightened police chief can change how an entire county responds to domestic vio- lence calls. Continually raising the issues of domestic vi- olence and abuse as a health care concern can be a very powerful tool. Health fairs, "healthy community" coali- tions, and booths at county fairs can all become avenues to reinforce the need to end the abuse for the health of the men, women, and children of our communities.

Rural America can draw on the heritage of generations of people who learned to help each other to overcome adversity. The same spirit of shared responsibility that draws people together to fight a flood can be mobilized to combat this epidemic. As health care providers, we need to be involved in the identification of women at risk and the organization of our communities to prevent fu- ture tragedies.

REFERENCES

1. Kantor G, Straus M. Substance abuse as a precipitant of wife abuse victimizations. Am J Drug Alcohol Abuse 1989; 15:173-89.

2. Reflections on rural realities: National Coalition Against Do- mestic Violence Rural Task Force resource packet. Washington, DC: National Coalition Against Domestic Violence, 1991.

3. Stewart DE, Cecutti A. Physical abuse in pregnancy. Can Med Assoc J 1993; 149:1237-8.

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