Barriers Faced by American Indian Women in Urban Wisconsin in Seeking Help Following an Experience of Intimate Partner Violence

Abstract

American Indian¹ (AI) women experience high rates of intimate partner violence (IPV) and face many barriers when help-seeking. This study aims to understand better the context of IPV and help-seeking behaviors for urban AI women after experiences with IPV. Postcolonial and Indigenous feminist frameworks framed this critical ethnography study. Semistructured interviews with 34 AI IPV survivors² living in Wisconsin urban areas were conducted. Our findings highlight context-specific structural barriers to help-seeking after experiences of IPV heightened by the COVID-19 pandemic. Context-specific and survivor-led interventions are necessary to address and reduce barriers that urban AI women face.

Background and Significance

Nurses have a critical role in supporting, treating, and preventing intimate partner violence (IPV) in women’s lives, especially for populations at the most significant risk for violence. IPV in the lives of American Indian (AI) women is one of the most significant public health and human rights issues occurring in AI communities today. According to the 2010 National Intimate Partner and Sexual Violence Survey report conducted by the National Institute of Justice, up to 84.3% of AI women have experienced any violence by an intimate partner in their lifetime (Rosay, 2016). This includes 55.5% of AI women who have experienced physical abuse by an intimate partner and 42.2% experiencing severe physical abuse by an intimate partner (Rosay, 2016).

Researchers must pursue the development of new knowledge to identify the unique needs of AI women who have experienced IPV in the local context. Specifically, there is a gap in the literature surrounding the phenomenon of IPV against AI women living in urban and metropolitan areas. To date, there are no studies published about the incidence or prevalence of violence, nor the individual lived experience of IPV in the lives of AI women in urban or rural areas of Wisconsin. This study was thus conducted to address this gap in understanding the needs and barriers to help-seeking of AI women living in urban areas in Wisconsin. In this study, we seek to address a significant gap in the literature and strive to center the voices of AI women through research led by an Indigenous nurse researcher (enrolled member of Bad River Band of Lake Superior Chippewa) and an IPV survivor.

Barriers to Help-Seeking

Despite the severe negative impacts of IPV, many women do not seek help after experiencing IPV, particularly ethnic minority women (Satyen et al., 2019; Women of Color Network, 2006). Help-seeking behavior is any behavior or activity that involves an external source of help, such as requesting advice, information, treatment, or general support in response to the problem being experienced (Satyen et al., 2019).

In the case of IPV, help-seeking that involves the healthcare system is a priority as this is the context in which nurses are most capable of minimizing barriers to help-seeking for women. There are unique circumstances within the context of communities of color, including AI communities that may account for the underreporting of IPV or barriers to help-seeking after experiencing IPV (Nnawulezi & Sullivan, 2013). The patterns of help-seeking behaviors or barriers experienced are not identical across cultural groups, but instead, they are contextual and vary on a variety of factors, including geographic location and cultural norms (Satyen et al., 2019). IPV support services, including shelter, food, group therapy, legal assistance, and advocacy, are often inaccessible to ethnic minority women (Hawkins et al., 2017; Klevens et al., 2012). Commonly cited barriers include lack of awareness of services, inability to access services, fear of consequences, and lack of resources (Robinson et al., 2020).

Other types of barriers involve inadequate structural responses (e.g., lack of enforcement of restraining or protective orders), barriers to healthcare access, and lack of or inaccessibility to professional and community resources, as well as IPV-related stigma (Overstreet & Quinn, 2014). Other reported factors for ethnic minority women include finances, insurance, stigma, and cultural beliefs (Robinson et al., 2020). The individual lived experiences of IPV may differ for AI women based on their geographic location, depending upon where they live. Therefore, it is critical to gain a localized understanding of urban AI women’s experiences and the barriers that they face after an IPV incident. For example, access to care in tribal health centers is primarily impacted by geographic location and tribal affiliation (Raglan et al., 2016). Overall, up to 70% of AIs live in urban areas today due to federal relocation policies, resulting in the loss of access to tribally affiliated health care services through Indian Health Services in urban areas (Casselman, 2016).

AI women also tend to not seek help from mainstream healthcare facilities because of a lack of trust in healthcare providers and healthcare facilities where services are often not culturally relevant or healthcare providers who are not culturally aware (Deer, 2015; Hamby, 2004). Many AI women may avoid seeking help after experiences of violence as a result of colonial history. Within mainstream healthcare systems specifically, AI women may fear or even expect a racist response from healthcare professionals; this could include anticipation of their experience being invalidated or being victim blamed (Nnawulezi & Sullivan, 2013; Ohio Alliance to End Sexual Abuse, 2021). Additionally, silence is a trauma response that must be recognized and understood by providers. This is because AI women’s voices have been silenced over hundreds of years through colonial power imbalances and they may feel that it is not safe to speak out about the violence that they experience (Deer, 2015).

Since the individual lived experiences of IPV and the barriers to help-seeking are unique to each survivor and are impacted by a variety of factors, gaining an understanding of why AI women are unable to get help or choose not to seek help after an experience of IPV in the local context is critical. Without medical or psychological intervention, ongoing or repeated instances of IPV against women are associated with depression, anxiety, posttraumatic stress disorder, and other mental health conditions (Childress, 2013; Evans-Campbell et al., 2006; Stockman et al., 2014). Without access to shelter or resources, repeated IPV acts can lead to serious physical injury or even loss of life (Burnette, 2015). Women may also experience a reduced quality of life due to IPV, which impacts self-care and education, employment, and women’s overall well-being and contribution to society (Stockman et al., 2014).

COVID-19

During data collection for this study, which occurred over four months, we began experiencing a global crisis due to the COVID-19 pandemic. Disasters and pandemics can create further complexity in how IPV is experienced (Parkinson, 2017). This particular urban metropolitan area was already seeing an uptick in homicides before the pandemic, with twice as many homicides seen in 2020 as were seen the previous year; two of every five of these homicides were related to domestic violence (Lutheran, 2020). Consistent with global trends, IPV and sexual assault advocates in Wisconsin began to report an increase in self and police referrals to their agencies by women experiencing IPV after the pandemic began (Lutheran, 2020). AI women experiencing IPV are at particularly increased risk for harm due to the “stay at home” measures put in place to combat COVID-19, because home is not necessarily the safest place for them. The constant messages by health officials and the media of “Safer at Home” can inadvertently send the wrong message by ignoring the violence that may be occurring behind closed doors in the home. These messages also do not convey how emotionally challenging it can be for survivors, who are traumatized due to being trapped at home with their abuser, and how increased isolation minimizes women’s ability to seek help. Fear of seeking shelter or services may also be exacerbated by fear of contracting and becoming ill with COVID-19 (Lutheran, 2020).

Ethnic minority populations are at a higher risk of contracting COVID-19 or experiencing severe COVID-related illnesses (CDC, 2020). This is due specifically to the health inequities formed at the intersections of structural racism and poverty, which for AIs are also rooted in ongoing colonization (CDC, 2021). In many parts of the country, AIs are disproportionately affected by COVID-19. At the first writing of this article, infections in the Navajo nation have surpassed infections in New York City, the previous epicenter of the pandemic during its first wave in Spring 2020. Since the first case of COVID-19 was first reported on the Navajo Nation Reservation in mid-March, infection rates per capita have soared to the highest in the country compared with any state in the US (Cheetham, 2020). At the time of manuscript revisions, the Navajo Nation has a higher vaccination rate than the United States at large, and AIs were the most highly vaccinated racial/ethnic group in the US, thanks to strong tribal public health responses and effective vaccination campaigns (CDC, 2021). Still, vaccination rates vary across AI tribal nations and urban communities, and many tribal nations, including the Navajo Nation, are now seeing surges, in part due to the lower vaccination rates of surrounding communities (Lukpat & Hassan, 2021). While the Navajo Nation is not representative of all tribal nations, their experiences are demonstrative of the ways in which the COVID-19 pandemic unveiled and exacerbated existing health inequities for communities of color and AI communities, and the necessity of contextualizing health inequities in a local context. Thus, for AI women already experienced high rates of IPV before being safer at home and economic precarity amplified IPV risks, the pandemic therefore represented a heightened and disproportionate threat to life from both COVID-19 and IPV.

Methodology

Our qualitative study was conducted using a critical ethnographic approach because it calls for an examination of the patterns of power and domination in social and political interactions and addresses the processes of injustice or unfairness (Madison, 2012). In-depth interviews with 34 AI women took place in urban cities in Wisconsin during the spring of 2020. We used postcolonial and indigenous feminist epistemologies to inform our analysis of the contexts in which IPV occurs. Indigenous feminism is a theoretical lens and intervention that promotes social justice and human dignity by bringing to light the centuries of injustice and oppression experienced by Indigenous peoples and by promoting their inherent right to self-determination and self-governance (Huhndorf & Suzack, 2010; Luebke et al., 2021). A postcolonial feminist approach seeks to disrupt the legacies of dominant discourses within Western feminist activism while emphasizing the human consequences of globalization and oppression on colonized populations (Luebke et al., 2021; Racine, 2011; Wallaschek, 2016).

The use of critical feminist frameworks is valuable to advancing nursing science because it allows for a comprehensive analysis of the barriers impacting AI women’s access to services, taking into account sociopolitical structures and historical processes from the survivors’ perspectives. Mkandawire-Valhmu (2018) emphasized that a critical feminist perspective encourages us not only to recognize the adverse health outcomes experienced within communities but also enables us to acknowledge and appreciate the “strengths and capacities they possess on which we can build to address problems affecting human health” (p. 3).

Sample and Setting

A significant gap exists in our knowledge of AI survivors’ experiences of violence and help-seeking, particularly in urban environments and specifically in the state of Wisconsin. Violence against AI women and people is an urgent crisis in Wisconsin, which is home to 12 sovereign tribal nations (11 of which are federally recognized). Attorney General Josh Kaul, for the State of Wisconsin, created a statewide task force in 2020 to address the disastrous rates of violence against Indigenous women and the numbers of missing and murdered Indigenous women, girls, and people in this state; the lead author and researcher of this article is a member of the said task force (Kaeding, 2020). Unfortunately, there have been three instances of IPV-related homicides of AI women in the past two years (Butts, 2021; Kerhin, 2021; Vaisvilas, 2021) which have necessitated prioritized response.

University and local tribal human subjects’ approvals were both obtained before data collection. This study included participants who were purposively selected. Inclusion criteria for the participants included (a) adult female, (b) having experienced lifetime IPV including physical, emotional, psychological, and/or sexual abuse, (c) self-identify as being Indigenous or AI, (d) currently residing in urban areas of Wisconsin, and (e) not currently at risk for harm or violence. Interviews took place with 34 AI survivors of IPV that resided in urban areas of Wisconsin as their primary residence, although several of the survivors frequently travel back to their reservations in rural areas of the state. Tribal affiliation was asked but is not shared to further protect survivor anonymity. Demographic details are listed in Table 1.

Table 1.

Demographic Data for Women Interviewed (n = 34).

Participant age:
18–25	6
26–35	9
36–45	10
46–55	9
Current marital status:
Single	18
Married	3
Divorced	10
Separated	2
Widowed	1
American Indian descendant or enrolled in a federally recognized tribe:
Yes	34
No	0
Children:
Yes	29
No	5
Average number of children	2.7
Currently pregnant:
Yes	2
No	32
Education level:
Some HS	2
GED	2
HS graduate	7
Some college	9
Associates degree	2
Bachelor’s degree	8
Graduate degree	4
Current employment status:
Full-time (40 h/week)	9
Part-time (<40 h/week)	7
Volunteer work	1
Not employed	2
Disabled	3
Unemployed r/t COVID	12
Annual household income:
Less than $10,000	7
$10,000–$19,999	4
$20,000 to $29,999	5
$30,000–$39,999	10
$40,000–$49,000	2
$50,000 or more	6

Two survivors who volunteered for interviews were excluded for safety concerns. Both survivors were previously working before the COVID-19 pandemic but were impacted when the stay-at-home order was declared. Both survivors were sheltering at home with their abuser and could not safely participate in a phone or video interview. Both survivors were provided with information on available resources in the area in which they lived.

Recruitment

AI survivors were recruited in collaboration with several local health facilities, shelters, community centers, and social service agencies primarily serving AIs. Snowball sampling, which relies on existing study participants to recruit future participants from among their family, acquaintances, or other community members, was critical for recruiting participants for this study (Ritchie et al., 2014). Many of the survivors interviewed were referred by other study participants or through nonparticipant volunteer peer referrals within the community. Recruitment strategies such as peer referral and snowball are vital when conducting research in communities that are challenging to gain trust and entry into, such as AI or vulnerable communities, especially due to the highly sensitive nature of the research topic of IPV (Gerassi et al., 2017).

The bulk of data and information that nurses and the scholarly community have on the issue of violence against AI women comes from colonized sources, and not from AI people or survivors. Therefore, it is significant that this research, led by an AI woman and a survivor, recenters the voices of fellow AI survivors, thereby challenging hegemonic and exploitative colonial norms of knowledge production. Many women interviewed commended the research and felt safe, felt relief, and empowered from sharing their stories with someone they trusted and shared life experiences with. The stories of the survivors were collected with respect and care because it is understood by the AI researcher that our stories are animate and have life. The stories of survival are to be shared to break the cycle of silence, not to further pathologize or oppress. The inclusion of survivors in the development of interventions is a critical component of the deconstruction of oppressive research and healthcare practices and promoting the resiliency and empowerment of AI survivors of IPV.

Data Collection and Analysis

A semistructured interview guide was reviewed with tribal key informants and revised, as needed, to ensure cultural sensitivity before conducting interviews with participants. Interview questions included asking how the survivor defines violence, their experience with violence, and what services were accessed after experiences of violence. Data was collected through individual interviews between the first author (principal investigator) and survivors from February to May 2020. Interviews were conducted in English. There was no plan to have interviews in any other Indigenous languages since there are so few fluent Indigenous language speakers. Thirteen interviews were conducted face-to-face, and 21 interviews were conducted via Skype or over the phone due to the social distancing mandates related to COVID-19. Demographic data were collected to contextualize the lives of the AI survivors (Table 1). All participants were given a $50 gift card for their time and participation in the study.

The interviews were audio-recorded and professionally transcribed. Using postcolonial and Indigenous feminist thought as a guide, the data was read several times and initial patterns and themes were identified and linked together. More specifically, data was analyzed using ethnographic coding methods designed by LeCompte and Schensul. The first author (1) first identified the items, (2) identified patterns consisting of collections of items or categories of items that seem to fit together or are related to one another and delineated, and (3) identified groups of patterns or relationships among patterns that begin to build a cultural portrayal of women’s experiences in relation to help-seeking (LeCompte & Schensul, 2009).

Guba and Lincoln (1989) recommended using strategies for establishing rigor in qualitative research, such as credibility, dependability, confirmability, and transferability of the research data. Dependability was established through methodological and analytic memos recorded in a research log to provide an audit trail for decisions made throughout the study, as well as through verification of identified themes by two graduate students and a research mentor. Two elder AI community members served as cultural guides and provided ongoing spiritual and emotional support to the researcher during the study. Credibility was established through member checking. Five of the 34 survivors volunteered and consented to further participation in the member-checking process. The member-checking process was explained, and participants were reminded that it was safe to provide honest feedback and that their stories were valued. During the member-checking process, survivors were asked if the interview transcript represented their perspectives. All five survivors validated the accuracy of their deidentified written transcripts and verified the themes of interpretations of data to ensure that they were consistent with their experiences with IPV. The verification of themes happened through both phone and email follow-ups, with participants providing additional context to themes or further discussion about their experiences. This allowed for open and rich conversations about the themes, including providing additional insights on further implications of COVID-19 for survivors. Credibility was further established through peer debriefing throughout the research process. Confirmability was enhanced through a field journal that kept documenting in-depth and continuous observations and reflections during the research process, recognizing that reflexivity in the form of acknowledging one’s values and biases in conducting research is critical to study credibility.

Results

Of the 34 survivors interviewed, 23 or 68%, refused or were unable to seek medical attention or other types of care after an IPV experience(s) even if they sustained an injury, and 24% of survivors (8 of the 34 interviewed) received medical care only because the IPV was witnessed and a call to 911 was made on their behalf. Six of the survivors interviewed (17%) sought other types of help, such as a domestic violence shelter, counseling, or a call to the police. This article seeks to increase our understanding of the barriers that urban Wisconsin AI survivors face when seeking help following an experience of IPV. We found that financial-related barriers and barriers to accessing existing resources were the most prominent themes describing barriers to help-seeking across all interviews. These common barrier themes reveal the unique experiences of urban AI women and the complex intersecting factors that make help-seeking difficult after experiencing IPV. Each of the survivors experienced individual circumstances and contextual or structural barriers for why they could not access or refused help after a particularly dangerous situation.

Subthemes that fell under the main theme of financial-related barriers include (1) I Didn’t Have Anywhere to Go and No Way to get to Help, which speaks to survivors’ concerns about finances, housing, homelessness, and transportation, including COVID-19-related concerns; (2) I Don’t Have any Insurance, which speaks to survivors’ reluctance or refusal to seek medical or other care due to insurance concerns. Subthemes that fell under the major theme barriers to accessing existing resources include (1) the native community is so small, which speaks to the privacy concerns that survivors had that prevented them from seeking or accessing help; (2) distrust and discrimination, which speaks to survivors’ inability to access help because they were not believed, listened to, or taken seriously, as well. More specifically, survivors discussed feeling invisible in racist and sexist interactions with law enforcement and within the healthcare system; (3) lack of culturally relevant care, which speaks to survivors’ struggles with needs that were greater than the resources were able to provide for them; and (4) I didn’t know where to go for help, which speaks to the lack of awareness of resources that are available. This theme was further exacerbated by the COVID-19 pandemic, which saw many resources for IPV survivors limited or closed altogether. Personal barriers such as fear of retaliation or fear of increased violence are beyond this article’s scope and will be discussed in a future publication.

Financial-Related Barriers

Survivors spoke about their struggles with homelessness, housing-related challenges, poverty, and lack of transportation to access help after experiencing IPV. Of the 23 survivors, comprising 68% of those interviewed, who did not seek care or help after an experience of IPV, 10 of the women (44%) specifically cited fear of homelessness or housing challenges as their primary barrier to leaving an abusive relationship or dangerous situation. The remaining 13 (56%) of survivors cited financial barriers, lack of insurance, or transportation as the reason for not seeking help. The COVID-19 pandemic only served to heighten survivors’ limitations in seeking help, compounded by the trauma or stress of being quarantined with an abuser. During the study period, 12 of the 34 (35%) women interviewed had recently lost their employment due to the COVID-19 pandemic and mandates for social distancing. Many survivors worked in service industry jobs such as gaming, food service, or bartending and had either been laid off or furloughed.

I didn#x2019;t have anywhere to go and no way to get to help.

Lack of housing impacts AI survivors’ ability to leave a potentially dangerous situation. Housing is an immediate and essential need for survivors of IPV. The additional barriers and complexities that AI survivors face, such as poverty, homelessness, lack of transportation, and limited resources, may compound the trauma experienced and hinder them from seeking and obtaining help. A lack of housing is a significant burden for AI survivors that are rooted in the colonization of intergenerational poverty. Not accessing the help that they need puts survivors at risk for severe injury and even death.

Olive,³ a mother of a 1.5-year-old, describes how she returned to an abusive relationship to avoid homelessness because she felt that she had no other options. She explained, “I tried to get help when it (IPV) first started … I was homeless and scared … which is why I always went back. My parents didn’t care about me and my friends were sick of the drama.” Olive’s experience was typical for many of the other survivors who had limited family support.

Danica, a divorced mother of a 4-year-old child, explained how she was forced to stay in her home with her abuser because she was in school full-time and relied on his income. She also did not have family or friends’ support, which compounded the trauma that she was experiencing.

I put up with the abuse too many times to count. I told my parents about it at first and my Dad actually asked me what I did to upset him enough to hit me. I asked if I could move back home, even though it meant leaving the city. I was told that I “made my bed and needed to sleep in it.” I knew right then that I didn’t have anyone. I didn’t want to be homeless, so I stayed, but then it got worse.

The abuse continued until an incident that required medical attention. Danica’s abuser was finally arrested, but she ended up losing the home because she could not afford to pay for it on her own.

Amelia, a single mom of three children, described how she experienced homelessness after a particularly dangerous instance of IPV. She began living with her now ex-partner when she discovered that she was pregnant with her first child. She explained, “I had to live with him because I had nowhere else to go. And living in that house for five years was like living in absolute hell.” After years of living with her abuser, Amelia experienced severe physical abuse that happened in a public area where a witness contacted 911, and she was taken to the hospital for treatment. Once she recovered from her injuries, she was taken to a domestic violence shelter for a short while and then eventually moved in with a family member who cared for her children while she recovered.

Landlords are primarily interested in protecting their financial interests and may refuse to allow women out of a lease with an abuser after an experience with IPV. As a result, survivors stayed in abusive relationships because they needed housing. Jessica described how she ended up homeless due to IPV, resulting in her having to live in her car for several months because she could not get out of a lease with her abuser. She explained:

After the abuse … I ended up pretty much just living out of my car because I couldn’t afford a place of my own. I was living in my car for about six months before the lease that I had signed with him had ended and I could enter a new lease and actually live somewhere.

Jessica’s situation exemplifies how survivors must navigate complex legal issues, including leases with landlords to obtain safe housing while experiencing IPV.

Nora, a mother with two young children, shared how she remained in an abusive relationship also for fear of being homeless. She moved to a large city from a smaller reservation-based town to be with her boyfriend, who ended up abusing her. She explained:

Right now, I did go back to him … but I really did try to leave and was told that there are no shelters available. And it’s pretty scary being homeless here, it’s huge and I’ve probably seen a tiny part of it, so that’s part of it too.

Nova, a single mother with three children under the age of 8, found it challenging to find housing or employment because of her criminal record, highlighting the complex barriers that survivors face when trying to leave an abusive relationship. She explains:

We need more homeless shelters. A shelter would have been awesome. That’s why I stayed as long as I did. It’s so hard to find housing, especially (with a record). It’s hard, even if you’re not, but it’s 10× harder if you are. Having a record has really messed up my life. I guess that’s why I feel like not trying anymore because I already have such a bad record that I’m never going to be able to get a good job or a place to live.

Nova’s story reiterates how the lack of housing or shelter can be dangerous for survivors because they often feel that they have no other option but to stay.

Several survivors expressed their concerns about how the COVID-19 pandemic has created additional barriers to seeking help by adding layers of stress, uncertainty, and complexity to an already complicated reality. Mia, a pregnant single mother with two small children, moved from her reservation to a city to put distance between her and her abuser. She discussed her unfamiliarity with domestic violence resources since moving to a city and her concerns about the COVID-19 pandemic and how that would impact the services available to her and other survivors.

Back home, that’s really all I know, but not here. There’s a shelter there, but it’s so small. And I feel with the pandemic, like what’s going on now, and with domestic violence, there’s a lot of cases. There is a need for more housing, maybe just a lot of help with getting homes because I know a lot of women, they either live with their abuser and then sometimes when you wanna get away it’s hard to get away if you share a home together. Like right now, with everyone stuck at home together because of the virus.

Milla, a single mother with four children, discussed how she is concerned not only for herself but also for others in AI communities about the struggles that survivors face during the COVD-19 pandemic due to the shelter-in-place orders. She stated, “we’re being quarantined in our houses … a lot of talk in tribal communities is, what about the people that are home with their abuser in there?”

Some of the survivors interviewed did not have access to personal transportation. Of the 12 participants that were interviewed face-to-face, four did not have transportation to the interview. Two of the women took the city bus to the interview site from a different part of the city, and it took them 1–1.5 h to take the bus each way to the interview, depending upon which direction from which they were arriving. This was discovered after the participants arrived at the interview and demographic data was collected. One of the participants was given a ride home after the interview, and the other participant chose to take the bus back home. After learning about transportation challenges, the remaining participants were asked if they had transportation to the interview site. Two participants requested a home interview because they did not have transportation available to get to the interview. Before the interview started, the participants without transportation expressed how stressful it was not to have transportation, especially with children in the home.

Tina, a divorced mother of two children, described how she did not have a vehicle when she experienced IPV, which resulted in her having to flee from her abuser late at night on foot. She explained, “I opened the door, and I went running downstairs barefoot outside, and I asked the neighbor if I could use her phone and she wouldn’t let me because I probably looked like a crazy woman.” Tina was finally able to find a phone and called her sister who lived in another city. “I called my sister in California and she called an Uber for me to take to my friend’s house.”

Some of the survivors expressed their concerns specifically about finances related to the COVID-19 pandemic. The added stress of the pandemic manifestations, such as loss of jobs, income, or social isolation, serves to compound the difficulties that AI survivors may face when trying to leave an unsafe situation.

Anna expressed concerns about her recent job loss and how it impacted her ability to keep her housing. She explained,

I’m still waiting for unemployment … I’ve had troubles applying because my claim was rejected, and it is being investigated. They don’t think that I’ll be called back to work until late summer, so I don’t know what we’re going to do.

I don’t have any insurance.

Some survivors refused or reluctantly accepted medical care after sustaining IPV injuries because they did not have medical insurance. The financial concerns related to not having insurance or resources for services prevented some survivors from seeking help which exacerbated the traumatic experience of an IPV-related assault. There is often a false assumption by non-Natives and mainstream agencies that AI women receive free healthcare for being an enrolled tribal member. Not only is this not true, but AI women are more likely to be low-income and unable to access care in a city, and any unexpected medical bill is detrimental.

Cheyenne, a single mother of a 7-year-old child, refused medical care after she sustained significant IPV-related injuries because she did not have medical insurance. She explained:

I refused to go to the emergency room after he hit me even though I should have gotten stitches because I didn’t have any insurance and I didn’t want a bunch of bills … I think a lot of people assume that because I’m Native that it’s going to be free, but that’s not true.

One survivor who reluctantly accepted care faced a large medical bill that caused her stress after an IPV-related experience. Nora was significantly injured by her current partner, which resulted in her being taken to the hospital via ambulance. She did not have medical insurance and was unemployed. Resultantly, she was unable to pay the bill. She explained:

One night he punched me hard … and someone called the police because I was running around yelling and screaming outside. The ambulance took me to the hospital even though I didn’t want to go because I don’t have any insurance … and the total bill is $15,000 and they keep calling me and I have no way to pay anything.

Barriers to Existing Resources

Survivors shared their challenges in help-seeking or accessing services that met their needs due to contextual and structural barriers, including privacy concerns, feeling invisible due to racial discrimination, specifically distrust of law enforcement and/or medical professionals, and lack of access to culturally sensitive care, and being unaware of available resources in the community.

The native community is so small.

Some survivors refused or were reluctant to seek help from services specifically for AI women due to privacy concerns. Chelsea explained that she avoided care at any agencies specifically for AI women because she was concerned for her privacy. She stated:

There really aren’t many resources here for Native women … because this Native community is so much smaller. People are constantly gossiping. They know where the health center is and know when the group times are, or if they don’t know, they know somebody that they can call and find out.

Ashley, a single mom of five children, experienced severe physical abuse by her ex-partner. She explained how she chose to not participate in any counseling or support groups after her IPV attack:

In the Native community … I didn’t want everybody to know my business. And I’m a private person … I know it was known what happened to me, but sometimes you don’t want to get around other individuals that have had it (IPV) happen to them because they might know who you are.

Distrust and discrimination.

The feeling of invisibility, or not being heard or believed, was a concern by several interviewed survivors related to inadequate structural responses. Additionally, when some survivors did seek care, they spoke openly about their experiences with racism and dehumanized treatment, which resulted in their needs not being met. This impacted survivors’ ability to receive needed help or services and deterred them from seeking help in the future. This theme appeared repeatedly when discussing interactions with law enforcement, demonstrating that for survivors, particularly AI survivors and other survivors of color, police do not represent safety. The intersections of AI women, and particularly low-income AI women, and the institutions and people that have power and money such as in policing and medicine were exemplified through this theme.

One survivor, Chelsea, had experienced abuse by her partner on more than one occasion and felt that her concerns were not taken seriously. The last time that she experienced abuse by her now ex-partner, she explained that the only way to get an emergency response to IPV was:

[To] Say that we had a gun, because of the repeat behaviors and the calls … they take longer to respond. They have said to me in the past, “oh yeah, they’re just fighting, whatever, they’ll just pass out or something, so there was a risk of a false report just to get help …. They notice you’re Native American, and they just want the quick fix … It feels like I’m invisible … so what’s the point in even calling for help.

Zoe described how she felt invisible after she experienced abuse from her partner, and her neighbor overheard the situation going on in her apartment and called the police. She explained how her concerns were not taken seriously by the police because “he was a white man and I was a Native American woman living in a white community.” She remained in the home, in fear, because the perpetrator was not arrested for the assault.

Some survivors’ who attempted to seek help were not taken seriously or even resulted in their arrested. By being wrongly arrested, survivors experienced an injustice by the very system that was supposed to protect them. Not only did this exacerbate distrust, but it also placed women at higher risk of severe injury or even death because they become even more reluctant to seek help, particularly in a crisis.

Chelsea explained that she called the police for help when the abuse with her ex-boyfriend began but then stopped reaching out for help when the perpetrator was never held accountable for his actions. She explained:

I did call the police a few times after abuse, a lot of it was when I was intoxicated. They didn’t take my injuries or anything seriously. They would make me leave for the night and cool down and let my abuser stay and they never arrested him because I would fight back, or they didn’t believe me.

Milla experienced a similar situation in which she was arrested after being physically assaulted by her ex-partner because she was on probation. She explained:

He came home drunk one night and started hitting me and we were fighting… and “cause we lived in an apartment, somebody must have heard the screaming and they called the cops and I’m the one who went to jail.” Cause I was on probation. I wasn’t even doing anything. He didn’t go to jail, and he’s the one who hit me.

Lack of culturally relevant care.

Hailey, a single mother of two children, described how she attempted to seek counseling after experiencing IPV with her ex-partner, but she did not receive the help that she needed because of a lack of cultural understanding. Describing her interaction with a counselor, she explained,

I didn’t like it … she just had no cultural understanding and really struggled with the way that I had relationships in my life … no understandings around kinship and relationships and family … she had a very individualistic sense of what was right, and it did not fit very well and made me feel ashamed. So, I never went back to counseling there, or anywhere again.

I didn’t know where to go for help and there’s no support now.

Some survivors experienced barriers to help-seeking because they were not aware of available resources. For example, Chelsea utilized the emergency room after IPV experiences with her ex-partner before she was aware of any other services available. She explained:

The ER isn’t helpful. If it’s not life and death, then ‘okay go away’… but that (the ER) was my way out, that was my go-to that night, I didn’t know where else to go (for help), I didn’t have anything else.

Lilly was also unaware of the services available to her, so she did not seek care after experiencing physical abuse from her ex-partner. She explained, “I wasn’t aware of any resources… I felt very isolated and alone. I didn’t get any real help.”

One survivor, Zoe, knew that there were services available in her county, but was not aware that she could utilize resources in other counties. She explained:

At the time of the abuse, I was living in this one county, and on three different occasions I did call a shelter program in my county. And every time they were like, “Well, we don’t have room for you.” And they basically told me that I was out of luck. I didn’t know that you could cross county lines, or anything like that. I thought it was a county program where you had to be living in your county to benefit it.

One survivor avoided seeking care due to the assumption that she was not eligible because she did not have children. She explained:

I didn’t try to get help during the abuse. I just assumed that only women with kids or women that were beaten so badly that they had to go to the hospital could stay in a shelter or get help. I just didn’t know what to do. I didn’t know my choices; I didn’t know that I could just talk to somebody about it.

Even if and when survivors were aware of some resources, those resources often did not meet the needs of survivors. This theme of survivors’ needs being greater than the resources available was exacerbated by COVID-19. Social distancing mandates in response to the pandemic created further barriers to the already limited available resources. For example, Anna expressed frustration when she tried to seek help after experiencing IPV with her ex-partner but could not get the help that she needed. She explained:

I try to build a relationship with someone like, they would just give me an hour of their time, and I think, Oh, we are going to get everything done, and then they drop the ball and I fall through the cracks.

She continued to explain that it had become even more challenging to access help due to the COVID-19 pandemic. She explained:

I’m still seeking help right now, but with all of the Coronavirus stuff, everything is at a standstill, so it’s really kind of hard … I’ll have to wait and hopefully go once things kind of start to return back to normal.

Luna, who was married with two children, expressed her concern about the cancellation of face-to-face support groups due to the social distancing mandates. She expressed how women who relied on support groups and talking circles, such as herself, would get support during the pandemic. She stated, “we were doing support groups for women. But now it’s all canceled because of the Coronavirus. So, there’s no support now.”

Discussion

Our findings center on the voices of urban Wisconsin AI survivors and the barriers they are confronted with when deciding how and whether to seek help after experiences of IPV. Aligning with existing research, participants reported IPV to be prevalent in urban AI communities. We demonstrate through our findings the complexities of help-seeking for AI women in urban environments. The barriers to help-seeking after IPV experience are directly tied to structural barriers resulting from colonization and the intersection of racism, sexism, and poverty. The ongoing COVID-19 pandemic has exacerbated women’s experiences of IPV and the barriers to help-seeking.

Economic precarity and poverty were direct structural barriers to help-seeking for AI survivors of IPV. Poverty itself is racialized and gendered. Women are more likely to live in poverty than men across all racial and ethnic groups, and women of color are far more likely to live in poverty than white women, with AI women being more likely to live in poverty than any other group of women (IWPR, 2015). Our findings highlight the need for safe and affordable housing as a crucial concern for AI survivors of IPV in urban areas and for advocacy services to provide support to help find housing. Our findings also reveal that some AI survivors are reluctant to leave abusive relationships for fear of homelessness, which puts them at greater risk for injury or even death. The literature shows that IPV and sexual assault are the leading causes of homelessness and housing insecurity for women, particularly for women of color (National Women’s Law Center, 2021). Desmond (2016) discussed how women of color experience challenges with accessing and maintaining stable housing in urban environments where African American women are evicted at rates three times as high as White women (Desmond, 2016). African American women, particularly with lower incomes, are evicted at much higher rates than women of other racial groups for reasons such as having children, poverty, and landlord-tenant gender dynamics (Desmond, 2016).

Our findings demonstrate that the COVID-19 pandemic had a significant impact on survivors’ lives, such as job loss or layoffs, loss of income, exacerbation of housing insecurity, being quarantined with an abusive partner, and loss of or restrictions of available resources. These additional stressors and barriers impacted survivors’ ability to leave potentially dangerous situations. The COVID-19 pandemic also compounds the complexities that survivors with young children face who cannot attend school and the struggles to find safe childcare. Our findings demonstrate the urgency of informing scholars and healthcare and social service providers about the impact that the pandemic has had on barriers to seeking help for urban-based AI survivors, especially considering the continued uncertainties associated with the trajectory of this pandemic.

Our study also shows that there are fears of contacting law enforcement due to distrust. Much of the literature has focused on the distrust between reservation-based AI survivors and law enforcement related to issues of tribal sovereignty and jurisdictional confusion. Our study indicates that the same applies to urban AI women experiencing IPV due to distrust issues. Our findings also align with the literature in that many AI survivors do not report IPV to authorities. Many women of color are reluctant to report IPV to the authorities for fear of subjecting themselves or loved ones to a system they perceive as culturally, racially, or sexually biased, that was designed by White patriarchy and therefore White patriarchy (Beniuk, 2012; Women of Color Network, 2006). The reluctance to call the police or seek emergency care after a particularly dangerous experience puts survivors at risk for the escalation of harm or death. Women of color, including AI women, and less likely to be seen as victims of IPV and other types of violence and deserving of justice due to negative implicit biases held by law enforcement (Beniuk, 2012). Instead, they are often seen as deserving of harm, or their concerns are not considered a priority if they are harmed. This is because AIs, particularly AI women, have historically been dehumanized and left with little legal recourse (Casselman, 2016). Oftentimes women of color are subjected to criminalized survivorship after experiences with IPV. They may be arrested or incarcerated after victimization of violence for various reasons including for acts of self-defense against perpetrators, or for trying to protect the perpetrator (Malangone, 2020). Crenshaw (1991) explained further that race and culture are factors that feed into the suppression of help-seeking behaviors surrounding instances of IPV, stating that “women of color are reluctant to report abuse or call the police because of a general unwillingness among people of color to subject their private lives to the scrutiny and control of a police force that is frequently hostile” (Crenshaw, 1991, p. 1257).

The survivors’ voices from this study can lay the foundation to support policy changes that reflect a rethinking of the assumption that police provide safety for IPV survivors. For example, what could a domestic violence response team look like if it did not involve the police? How could a survivor-centered and decolonized approach to IPV responses better meet the needs of violence survivors who have not been served by the carceral system?

In addition to challenges with access to medical and other services, there are many reasons why AI survivors may distrust healthcare workers or be afraid of accessing the healthcare system. These include survivors’ experiences with racism and dehumanizing treatment. Non-AI individuals, including law enforcement or other helping professionals, may hold a negative implicit bias fed by negative racist stereotypes (Beniuk, 2012). The historical disrespect and mistreatment of AIs by healthcare providers are responsible for much of the inherent distrust that survivors still have of the healthcare system. This dejected history includes the common knowledge in AI communities of the nonconsensual sterilization of AI women by Indian Health Services from 1970 to 1976, during which an estimated 25%–50% of AI women were sterilized (Rutecki, 2010). Victims of sexual assault are sometimes wrongly blamed for what has happened to them by police or healthcare workers, particularly if there were involved in sex trading, or thought to be dressed provocatively (Amnesty International, 2007). Therefore, possessing a deeper understanding of the structural and contextual factors that increase the risk of IPV for various populations of women is essential for nurses and allied professionals. The risk of neglecting to contextualize women’s experiences with IPV by considering the oppression and structural racism in which IPV occurs for AI women only serves to uphold White supremacist ideologies.

Our study highlights that many urban-based AI survivors who desire to leave a violent situation have limited access to culturally specific IPV-related services, particularly after-hours emergency care, advocacy, and sexual assault nurse examiner (SANE) services. Additionally, many programs or services are designed by mainstream agencies and intended for use by women of color. AI women who manage to access these programs and services often find staff with limited cultural awareness and program supports with little cultural safety or relevance (Klingspohn, 2018). The lack of culturally specific or trauma-informed care available to AI survivors of violence was evident from our findings as several survivors reiterated that they refused help after experiences of violence because of a previous negative interaction with healthcare, allied, or law enforcement professionals.

Additionally, financial concerns coupled with not having insurance can exacerbate the traumatic experience of an IPV assault. Many survivors outright refused or reluctantly accepted medical care after injuries because they did not have medical insurance. The impact is that survivors are not provided services to mitigate the consequences of the violence and begin healing and repairing their lives.

Although many of the survivors either refused care or help or experienced barriers in seeking help, some survivors did seek and receive help. Of the 11 survivors (32% of those interviewed) who did seek and receive help, they felt most comfortable accessing care from agencies that provide care specifically to AI community members, or they traveled back to their reservations to seek help. This highlights the need for additional resources for urban-based AI women that is culturally specific, safe, and accessible, especially during times outside of typical “business hours.” Therefore, women who do not anticipate feeling safe when seeking resources tend to avoid doing so. This represents a need for systemic overall within our healthcare systems to better serve survivors, particularly AI women and other women of color. We can begin to do this by learning about the history of the medical establishment with minorities, in this case, AI survivors, and how it may affect trust and women’s ability to feel safe enough to make an IPV disclosure and seek help. However, it is simply not enough to just learn about colonial history, but rather about being informed by communities on how to create a supportive care environment encompassing colonial including more nursing practices centered on decolonial approaches.

Our study also reveals that not all AI survivors are aware of the available resources. This may be due to a variety of reasons such as recently moving to a city from a reservation or rural area or moving from one urban area to another or just not being aware of the resources existent in the community in which they are living, especially if IPV is a new experience for them. Even when AI survivors were aware of resources, those resources were severely limited, even more so since the onslaught of the COVID-19 pandemic. These findings emphasize the need to ensure that support for IPV survivors is expanded and targeted in times of crisis, with a focus on reaching otherwise isolated survivors. Additionally, there is a need for social services, healthcare, and advocacy agencies to collaborate to ensure that all women are aware of the resources available in their communities. Creating awareness can be done through social media campaigns, outreach, and collaboration with community-based agencies where women frequent or access services, including grocery stores and gas stations. Outreach to AI community leaders and having information readily available at pow-wows and other AI community events is another way of communicating available resources.

Limitations

This qualitative study is not without limitations. Our study relied on self-reports from participants. IPV is a highly sensitive topic, and AI survivors may have felt unable to provide their accurate perceptions or felt afraid to disclose anything that could be considered unlawful. The use of telephone and skype interviews for some of the interviews was not ideal. We would have preferred to interview all the survivors in person to allow for a closer analysis of nonverbal communication on the part of the women participating. However, due to the social distancing mandates related to the COVID-19 pandemic, it was not possible to interview all the survivors in person. Nevertheless, our analysis demonstrated consistency between the narratives of the women interviewed in person and those interviewed using other channels.

Conclusion and Implications

AI women experience IPV at disproportionately high rates, which is associated with devastating impacts on health and well-being. The experience of IPV is not universal. AI women have unique, complex, and intersecting needs after experiences of violence. Historical and contemporary contexts shape women’s intersecting identities, while environments also influence the experiences of IPV and the ability to access help, resources, and services. AI women often hesitate or cannot access help and needed services after experiences of violence because their needs are often not understood or met by mainstream agencies. As the largest body of healthcare professionals, nurses are often the first ones to interact with women who have experienced IPV. Nurses must, therefore, be prepared with a deep understanding of the realities and needs of women who have experienced IPV. Nurses can use the knowledge gained through this study to develop a critical consciousness about the relationship between the intersection of IPV and other structural barriers to help-seeking by victims.

Through this study, we provide a localized understanding of IPV by analyzing AI women’s individual lived experiences. The narratives that inform our analysis were made possible by creating a safe space for survivors to tell their stories and engage in meaningful change for their communities. Gathering women’s stories of experience and survival will allow us to uplift Indigenous women’s voices in the generation of knowledge, as well as to uphold their inherent right to self-sovereignty (inherent right to self-govern). The inclusion of survivors in the development of culturally specific interventions is a critical component in deconstructing oppressive research and healthcare practices and restoring trust between researchers and participants in tribal communities. This study provides a starting point to address IPV more effectively among Wisconsin AI women, as well as to inform future practice that is Indigenous, and survivor-centered.

Author Biographies

Jeneile Luebke, PhD, RN, is an Anna Julia Cooper Postdoctoral Nurse Research Fellow at the University of Wisconsin–Madison, School of Nursing. She received her BS and MS degrees in Nursing from the University of Wisconsin–Madison, and her PhD at the University of Wisconsin–Milwaukee. She identifies as Anishinaabe/mixed-race and is an enrolled member of Bad River Band of Lake Superior Chippewa. Her area of research and expertise includes gender-based violence in the lives of Indigenous women, community health, and utilization and application of postcolonial and Indigenous feminist frameworks.

Peninnah Kako, PhD, is an Associate Professor in the College of Nursing and the DNP program director at the University of Wisconsin–Milwaukee (UWM). Dr. Kako maintains her clinical practice as a Nurse Practitioner where she takes pride in providing health care for underserved populations. Areas of research and expertise include improving healthcare access for underserved populations locally and internationally. Her research expertise and interests include healthcare access, Global Health research on women and HIV/AIDS, and sub-Saharan Africa, using ethnographic and mixed methods approaches.

Alexa Lopez, PhD, is an Assistant Professor in the College of Nursing at the University of Wisconsin–Milwaukee (UWM). Dr. Lopez received her PhD in Experimental Psychology from the University of Vermont in 2014, where she concentrated on examining substance use disorders and associated behaviors in vulnerable populations. She completed a postdoctoral fellowship in Tobacco Regulatory Science from Virginia Commonwealth University, and she joined the faculty at UWM in 2019.

Marin Schmitt, MS, is a PhD Student at the University of Wisconsin–Milwaukee, Zilber School of Public Health, with a concentration in Community and Behavioral Health Promotion. Areas of research include mental health, qualitative methodology, and implementation research.

Anne Dressel, PhD, CFPH, MLIS, MA, is director of the Center for Global Health Equity and assistant professor at the University of Wisconsin–Milwaukee College of Nursing. Her research seeks to understand and address the health needs of marginalized populations locally and globally.

Kathryn Klein received her MA in women and gender studies from the University of Wisconsin–Milwaukee in 2021.

Lucy Mkandawire-Vahlmu, PhD, RN, is a Professor at the University of Wisconsin– Milwaukee, College of Nursing. Dr. Mkandawire-Vahlmu’s areas of research and expertise include violence in the lives of women and the utilization and application of the feminist methodology in research with third-world women.