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.

The Me Too movement prompted sexual abuse victims to come forward with their allegations of rape and harassment. Yet, the increase in these occurrences both nationally and statewide show repeated incidents.

Sexual violence is a nonconsensual act, either through physical or verbal behavior.

The Indiana Coalition to End Sexual Assault and Human Trafficking is an advocacy, training and technical assistance resource for people who have faced sexual violence.

Coalition President and CEO Beth White explained the state's most vulnerable targets are often silent.

"We are worse for high school girls who experienced sexual violence while in high school, we are worse for the general population as well," said White. "So, when someone comes forward to report that this has happened to them, we always say a number of things that are important. Number one, we start by believing that people don't generally make false allegations about this problem."

An Indiana University report shows females in 9th-12th grades in Indiana schools have the second highest rate in the nation of forced sexual intercourse.

This month, the organization will open the state's sixteenth rape crisis center, Hope's Voice will serve Davies and Knox counties in southeastern Indiana.

The centers are commonly co-located with a domestic violence shelter, or another social service organization.

Researchers say sexual assault survivors should understand the perpetrator seeks to take away power and control - and most survivors do not file a police report or tell a friend, family member, or teacher out of embarrassment or shame.

White pointed out the coalition emphasizes the importance of regaining the control that has been taken away, and she works to encourage communities to talk about the issue and seek solutions, which are often multifaceted.

"Indiana has a problem," said White, "and we want people to know there is help, there is hope and there is healing that can occur when people do come forward if they feel that they can."

Centers for Disease Control and Prevention data show survivors are more prone to smoke, abuse alcohol and drugs and engage in risky sexual activity after their experience.

The assault can also impact a survivor's ability to work, attend school or maintain personal relationships.

As federal Victims of Crime Act funding continues to impact Kentucky's domestic violence shelters, advocates say they are applauding lawmakers decisions to include $6 million of the state budget's general fund for shelter and program operations, alongside a one-time allocation of $7.1 million to offset the impact of VOCA cuts.

ZeroV's CEO Angela Yannelli said the funding will ensure life-saving programs for people in crisis continue to serve those who rely on them - and who often have no where else to turn.

"We are extremely grateful to the General Assembly for listening to us," said Yannelli. "We've been talking about this since the interim session, about how VOCA has really impacted us."

According to the latest report from the National Network to End Domestic Violence, last year more than 1,000 adult and child survivors relied on Kentucky's emergency shelters and programs, that provide transitional housing, transportation, housing advocacy, legal support, therapy, and other supportive services.

Darlene Thomas, who is executive director of a Fayette County shelter, Greenhouse 17, said without continued funding, her organization would lose the ability to provide holistic wraparound services for survivors and their children.

"Housing, emergency financial assistance, help with getting back to employment," said Thomas, "we do all of the pieces to help people move from crisis to self sufficiency."

The state has also taken steps to protect survivors who want to exercise their right to vote.

A new program allows survivors of crimes, including intimate partner violence, sexual assault, and stalking, to hide their address on public records, including from voter rolls.

More information about the Safe at Home program is on the Kentucky Secretary of State's website.

April is Sexual Assault Awareness Month, and Ohio is expanding its qualified rape crisis centers serving rural areas in the central and southeastern regions of the state.

Taylr Ucker-Lauderman, chief engagement officer with the Ohio Alliance to End Sexual Violence, explained that qualified centers have to meet certain criteria, and typically provide crisis intervention, legal and medical assistance, counseling and referrals to other local resources. She said collaboration among centers to assist sexual abuse survivors and educate the public about violence prevention is critical.

"One really exciting outcome of 2023 is that we did see two additional rape crisis centers identified as qualified rape crisis centers, which means that they are supported by the Alliance," Ucker-Lauderman said.

One in four women and about one in 26 men have experienced completed or attempted rape, according to the CDC. If you or someone you know needs help, call the National Sexual Assault Hotline. It's available 24 hours a day, seven days a week, at 800-656-4673.

Ucker-Lauderman added survivors of sexual assault often need housing and other basic resources, noting these services are especially needed in geographically isolated areas, and are often unavailable if domestic violence isn't co-occurring. Rape crisis centers may be one of the few options sexual violence survivors have.

"That means increasing the capacity of the service providers across the state, making sure that they have the training that they need, the funding, the staff," she said.

Molly MacMath, executive director of COMPASS Rape Crisis Center in Northeastern Ohio, said while centers, hospitals and police departments play a critical role in preventing sexual violence, communities should be working to come up with creative ways to approach the issue.

"There's so many other entities within our communities that really play a role in the awareness and prevention of violence," MacMath said.

According to Ohio Alliance to End Sexual Violence's annual report, last year rape crisis centers across the state provided 556 nights of shelter through the Alliance's Meaningful Access Housing Program.