The neighbors nervously listen, while terrifying screams echo through their walls and collide with thundering threats and belittling vulgarity. The sound of dishes shattering against the kitchen floor — flung across the room in a fit of rage — sting in the concerned neighbors’ ears.
They wait for her to flee her apartment and seek refuge from her abusive husband across the hall.
But not all women have a safe haven from domestic violence next door, across the street or even around the block — especially in rural Minnesota, where the next doorstep can be miles down the road.
Last year, approximately one out of five women in rural Minnesota were victims of at least one type of domestic abuse — physical, emotional or sexual. The same percentage of cases occurred in urban areas.
But unlike their counterparts in urban and suburban areas, these women have to seek help while contending with issues of isolation and a lack of anonymity. Help can be literally miles away, if they are even willing to seek it. Rural women also face the fear that their private matters could be heard by the community.
Each year, the University Medical School churns out almost 70 percent of the state’s physicians, many of whom will inevitably practice in rural Minnesota. Domestic abuse experts say health care providers must learn to be sensitive to the issues women face while living in a rural environment.
Although few studies have been conducted exploring violence against women in rural areas, a recent public health study examined the prevalence of domestic abuse against women seeking care in rural Minnesota clinics. Researchers found that isolation and anonymity are the principal barriers that women in rural communities and their physicians must cope with.
“If someone is having a problem, we wanted to know what level of reluctance these women have to getting help from health care providers,” said Dr. Jon Anderson, a statistician from the University of Minnesota-Morris and investigator in the study.
Researchers surveyed more than 1,600 women seeking care in rural Minnesota clinics and at Women, Infants, and Children voucher pickup sites. The vouchers provide government aid for mothers and their children.
Anderson said the study might underestimate the extent of violence and abuse because the survey was not offered to women who were accompanied by a spouse during their visit.
Trapped in isolation
There are fewer resource centers for victims of domestic abuse in rural Minnesota than in the Twin Cites metro area. For example, the battered women’s shelter in Fergus Falls serves women for the nine surrounding counties.
Some women have to travel more than 75 miles to reach the nearest resource site. But even when women have resources available, they do not always feel comfortable or willing to seek help.
Even though new developments in communications are making the world increasingly smaller, the number of isolated women in rural Minnesota continues to rise.
Marion Kershner, a public health nurse in rural Ottertail County and principal investigator in the study, said isolation entails a lack of access to telephones or vehicles and few social contacts — not only physical distance from neighbors.
Although most people in rural Minnesota have phones and vehicles, Kershner explained that many times abusive men use isolation as a tool for power and control.
“They disable vehicles or take the keys and rip phones out of the wall using violence as a form of control,” Kershner said, adding that women without the use of phones or vehicles have to walk for miles to reach neighbors.
Susan Hadley, founder of WomanKind: Support Systems for Battered Women, and adjunct professor at the University’s Medical School, explained how a severe case of isolation ended fatally.
A 42-year-old woman from rural Minnesota was transferred to a Minneapolis hospital after experiencing complications with diabetes.
Yet before she died, weighing only 66 pounds, doctors discovered she had been a victim of domestic abuse. Doctors found that her husband had denied her access to a phone, to a physician and to her medication.
“She was literally a prisoner in her own home. If she was in the Twin Cities she would have had a better chance,” Hadley said.
But many times even when women in rural areas can get to a source of help, they are reluctant to do so because they fear other people in the community will find out.
Lack of anonymity
Many women fear that not only will their abusers find out they are seeking help, but that the people in their community will as well.
Rural communities are often close-knit social networks. Men and women know one another; they work together and their children go to school together. Everybody knows what everyone else is doing, despite considerable distances between neighbors. But unlike urban centers, rural communities offer few places women can go if they need help.
The victim’s spouse might have a brother on the police force or the doctor could be her husband’s hunting buddy, Kershner explained.
Women need to know and feel safe that when they report domestic abuse their case will remain confidential and discreet. Both Kershner and Hadley said physicians should provide a private phone for women to use when seeking counseling.
Hadley suggested that physicians disseminate plenty of literature on domestic abuse in their offices and waiting rooms, but she warns doctors to be subtle.
“When I first started this, I used to give women everything I could find that was printed on paper, but then their husbands found it and beat them,” Hadley said.
“We’ve learned since then. Now I have little tear-off tabs she can put under the sole of her shoe with a number she can call for help. You have to be incredibly discreet,” she explained.
Anonymity is also an issue when a woman finally decides to leave her abuser. In metro areas, a woman can leave her home in Richfield and move to Brooklyn Park without leaving her family, her job and her friends. Women in rural Minnesota do not have the same option.
Because rural communities are so small, victims have to travel hundreds of miles to relocate.
“You totally have to reorient your life and learn about your options and resources,” Hadley said.
The physician’s role: screen, identify and refer
The primary role of a physician in treating victims is to screen for domestic abuse and catch it before it becomes increasingly problematic.
“Routine screening is the single greatest method health care providers have,” Hadley said.
Both Hadley and Kershner advocate screening for abuse during every routine clinic visit. “Now we’re getting most of our cases in the ER,” Hadley said. “I’d like to see screening at all annual exams like pap smears and mammograms.”
Most women are not likely to bring up abuse during annual appointments. Only 15 percent of the victims in her survey had ever talked to a doctor or nurse about abuse, Kershner said.
Health care providers have not been oriented to the problem and haven’t been thoroughly educated about the issue, Kershner added.
Although Kershner admitted younger physicians are asking more questions, many doctors still avoid dealing with domestic violence.
Kershner said physicians have many common responses when dealing with the frustration of treating domestic abuse: “I can’t fix this problem, so I don’t want to get involved. I’ll treat the bruise or fix the broken bone, but I’m not a social worker.”
Hadley agreed that it is not the doctor’s responsibility to “fix” the victim’s situation. She explained that physicians must ask women about their situations and identify the type of abuse that is occurring and refer them to a trusted resource.
However, Hadley admits rural physicians have fewer resources to which they can refer women.
She likened the screening process to the movie “Field of Dreams” when she said, “If you ask the victim, they will acknowledge.”
Tonight, the University’s Program Against Sexual Violence is sponsoring its “Take Back the Night” rally to garner support for combatting violence against women. The event begins at 6:30 p.m. at Coffman Union.