Box 1: Clinical Indicators of IPV General ● Presenting with vague signs and symptoms; history not consistent with examination findings; delay in seeking care; repeated cancelled visits; partner always present for visits; patient seems fearful or defers to partner Physical health ● Injuries, including bruising, especially if multiple and at different stages of healing and typically involving the head, face, and neck ● Chronic physical conditions, including sleep disturbance, pain, and functional symptoms Mental health
● Depression; anxiety; posttraumatic stress symptoms ● Substance use; suicidal thoughts and behavior; self-harm Reproductive health ● Sexually transmitted infections; sexual dysfunction
● Unwanted pregnancy; prenatal and postnatal complications including fetal injury Adapted from Intimate Partner Violence: Recognizing and Responding Safely (MacMillan et al., 2020) . Cultural Considerations: Individual Level
Hulley et al., 2022) . Moreover, these cultural factors may influence not only how the victim experiences or perceives the abuse but also how he or she experiences or perceives the healthcare and social service systems (Njie-Carr et al., 2021) . It is important that providers recognize the many and varied considerations for culturally diverse populations with regard to IPV. 2021) . Often, a significant concern is how the abusive partner may be treated by the formal systems that are involved in reporting IPV, such as the criminal justice system (Gillum, 2021) . The fear of these systems and the long- term effect they can impose on a family and community can be enough to make the individual stay in the abusive relationship rather than put another, even a perpetrator, into that system. Further, the survivor may have concerns about betraying their community by notifying law enforcement or other professionals (Burton & Guidry, 2021) . reactions of family and friends (Ullman et al., 2020) . In other cases, survivors may feel ashamed that they cannot resolve the abusive situation on their own or that their efforts to seek support have failed (Waller & Bent-Goodley, 2022) . community or familial rejection, there may be significant fear of being hurt or harmed because of revealing something that was expected not to be shared. It is thus critical for providers to consider this issue because it may be difficult for clients to share what they are experiencing. There is both fear associated with telling and fear of the potential consequences of disclosure (Ullman et al., 2020) . is abusive (Barrios et al., 2021) . This perception creates an added pressure to find someone and stay with the person even if the relationship is not ideal and sometimes even if the relationship is abusive. These internal issues create a profound vulnerability for women in particular, since some cultures value heteronormative and/or masculine values significantly more than those associated with the feminine (Daoud, 2021) .
Providers must also be cognizant and thoughtful when screening for IPV in individuals from cultural backgrounds unlike their own. Survivors who are from minoritized groups, are recent immigrants, and/or are part of cultural or religious groups unfamiliar to the provider may be dealing with multiple issues, including language barriers, discrimination, acculturation, and undocumented status (Green et al., 2024; Racial or Cultural Loyalty Many communities of color experience stereotyping, discrimination, and other types of bias, which can cause individuals to seek ways of refuting the suppositions about the community. This can lead to differences in reporting and help-seeking for IPV if the survivor is seeking to protect themselves or the abusive partner from experiencing racism and discriminatory treatment (Monterrosa, 2019) . While it is difficult for some people outside of the group to understand this, the fear of racism and discriminatory treatment from outside of the community is significant (Burton & Guidry, Shame Many survivors particularly describe fearing what they perceive as great shame in experiencing IPV (Burton & Guidry, 2021) . In such cases, disclosing the abuse may seem to the survivor to be an unthinkable act of community or cultural betrayal and may also cause them to fear the Telling Is Taboo The idea that communities should not work with or engage law enforcement is another prevalent notion that may also be a barrier to addressing IPV. In some cases, individuals are discouraged from accessing formal provider systems and encouraged to be quiet about what is going on regardless of how badly they are being affected (Burton & Guidry, 2021) . Where survivors have witnessed poor outcomes for others with regard to reporting or disclosing IPV, such as Family and Community Pressures to Be Partnered In addition to the reasons previously mentioned, family and community may encourage survivors to be silent out of a belief that marriage or partnership is more desirable than relief of abuse. Family members may encourage a woman to stay in the relationship if the perpetrator is a solid financial provider, particularly if there are children involved, or suggest that finding a partner is so difficult that the victim should hold on to the perpetrator even if the relationship Faith and Religious Responses In faith-based communities, there are additional concerns for both the provider and the patient. It is thus vital that practitioners be aware of how faith and religion can be
manipulated and utilized to keep women in abusive relationships instead of helping them to escape from the violence. While faith-based providers can be strengths in the
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