COLUMBUS, Ohio -- Sometimes, the impacts of physical abuse run deeper than a scar, and researchers in Ohio are digging deeper into cognitive injuries caused by domestic violence.

Working with researchers from Ohio State University, the Ohio Domestic Violence Network's CARE project discovered that a majority of survivors have lived through extensive violence directed at the head, neck and face, and through strangulation.

At ODVN's Center on Partner-Inflicted Brain Injury, Director Rachel Ramirez said such injuries can be linked to brain trauma.

"So, when we think of the very first picture of a battered woman being a woman with a black eye, we now should be thinking that that woman very well could have had a concussion, and her brain could have been hurt," Ramirez said.

The project's work was featured in a recent federal report, which recommends improved data collection on brain injuries from intimate-partner violence.

According to Ramirez, with better data comes a better understanding, which will help providers better serve survivors.

Ramirez explained that brain injury often is not diagnosed and not well understood by domestic violence prevention programs or survivors. It can manifest in such cognitive challenges as problems with attention or memory; such physical problems as headaches and fatigue; and emotional issues, including depression and anxiety.

"When these issues are untreated and unidentified, things end up getting worse for the survivor," she added. "They aren't getting better; they don't understand what happened to them, and they blame themselves -- instead of understanding what happened to them as a result of an injury that wasn't their fault."

ODVN has developed a new conceptualization of brain injury, known as the CARE framework. CARE stands for "connect, acknowledge, respond, evaluate."

Ramirez described the framework as focusing on building positive relationships with survivors, and acknowledging and responding to the individualized needs of each person accessing services.

Ohio's domestic violence shelters provided emergency housing to nearly 10,000 people last year, and advocates are calling for a funding boost.

Providers said they are unable to meet demand, especially for the nearly 73,000 residents seeking counseling, court advocacy and other non-shelter services.

Mary O'Doherty, executive director of the Ohio Domestic Violence Network, said the volume of calls and the severity of cases has worsened since the pandemic.

"They are seeing survivors with more severe injuries, survivors describing more lethal situations," O'Doherty observed. "I hear regularly that the calls to our crisis lines are more complicated, are scarier for the advocates who are receiving the calls."

Ohio Gov. Mike DeWine has allocated $20 million for domestic violence services in his proposed budget, but the funding still needs approval from the state legislature. Dozens of advocates gather in Columbus today for the Ohio Domestic Violence Network's Advocacy Day to meet with lawmakers on the issue.

Last year in Ohio there were more than 80 domestic-violence related homicides, including the deaths of children.

Even with the funding increase, Ohio continues to spend less per capita for domestic violence services than its neighbors, including Pennsylvania, West Virginia, Kentucky, and Indiana. O'Doherty pointed out investments in services ultimately save taxpayer dollars.

"Those are costs associated with medical care, property damage, law enforcement, emergency response, child protective services, legal fees, and the loss of life of survivors, including end-of-life expenses," O'Doherty outlined.

According to the Centers for Disease Control and Prevention, nationwide the lifetime economic cost associated with medical services, criminal justice, and other costs related to intimate partner violence totals more than $3 trillion.

Gov. Mike DeWine recently announced he's providing $30 million to boost rape crisis services statewide, after years of federal funding cuts.

Jennifer Seifert, executive director of the Ohio Survivor Advocacy Outreach Program, said the trauma associated with sexual violence demands a tailored response that crisis centers are staffed and trained to address.

"And that can be all the way from a civil protection order to perhaps filing a Title IX complaint, if they're a college student," she said, "or all the way to maybe mobilizing some housing resources or reporting to law enforcement, getting the evidence collection done at a medical facility."

Since the start of the pandemic, crisis centers have had to cut staff and reduce service areas, as centers saw a 55% jump in monthly hotline calls, along with a rise in survivors seeking emergency shelter, legal advocacy and mental-health services.

Emily Gemar, director of public policy at the Ohio Alliance to End Sexual Violence, explained that the services people need throughout their lifetime to recover from sexual violence, and that the response from law enforcement and prosecutors offices can be costly. She said for every act of sexual violence prevented, more than $122,000 in lifetime costs are averted.

"We know that by investing money into prevention, which was one of the primary reasons for the state funding for sexual assault services, that we are actually saving our state money and improving the quality of life for for all Ohioans," she said.

Rose Beltre, the alliance's executive director, said centers are grappling with how to expand coverage across the state, retain existing services and reach into new areas, and asked, "How can the centers maintain adequate staff to be able to provide services for survivors, holistic and comprehensive services?"

According to the National Intimate Partner and Sexual Violence Victimization Survey, nearly one in five women and one in 67 men have experienced some form of sexual violence in their lives.

Ohio community groups seeking ways to increase support for sexual assault survivors living with disabilities. A January 23rd training session hosted by the Ohio Alliance to End Sexual Violence will focus on how law enforcement, hospitals, and other institutions can provide equitable services.

Natasha Larson, director of training and member engagement with the Alliance explained it is common for perpetrators to be closely linked to their victims, and can often include family members or staff at a caregiving facility. She said people with disabilities are at higher risk for assault because their abuser can interfere with attempts to report it.

"They may tamper with things," Larson said, "like withholding any assistive technology that they have - mobility aids, communication devices - things that allow them to perform daily tasks."

A 2012 nationwide survey, the first of it's kind published by the Spectrum Institute, found more than one-third of respondents were victims of repeated sexual abuse. More information on the training is online at 'oaesv.org.'

Nicole Kass Colvin, manager of coordinated community responses with the Alliance, added society often views those with disabilities as asexual, and points out that people born with disabilities are less likely to be taught the proper names of body parts, or the definitions of sexual assault and consent.

"This leads to a lack of comprehensive sex education and consent education, which increases risk," she said.

Kass Colvin said Ohioans can help protect their loved ones with disabilities by advocating for increased accessibility in their communities and workplaces.

"When we are able to know ahead of time how to access or activate a trauma-informed qualified interpreter, or services that have accessible spaces, then we're better able to respond to those situations," she said.

Children with disabilities are nearly three times more likely to experience sexual violence, according to the World Health Organization.