"I Will Never Be Enough Because My Skin Color Isn't Right": Structural Racism and Healthcare Access Following...

Background: Nonfatal strangulation (NFS) is one of the most lethal forms of intimate partner violence (IPV) that is associated with increased risk of future homicide, yet it frequently goes unrecognized within healthcare settings. Black women experience disproportionately high rates of IPV while simultaneously facing structural barriers to healthcare access. Little research has examined how Black women survivors experience strangulation and navigate decisions about seeking care following NFS and other potentially lethal forms of IPV. Methods: This secondary qualitative analysis draws on interview data from 28 Black women survivors of IPV who participated in a larger community-engaged mixed-methods study conducted during the COVID-19 pandemic in an Upper Midwestern state. Of these, 17 (60.7%) both reported experiencing strangulation on the parent-study survey and described experiences consistent with nonfatal strangulation during their qualitative interviews and comprised the analytic sample for the present analysis. Guided by Black Feminist Thought, semi-structured interviews examined survivors' experiences with violence, safety, help-seeking, and interactions with healthcare and social service systems. Data were analyzed using thematic analysis following Schensul and Schensul. Results: Three interconnected themes were identified. First, survivors described racism and anticipated discrimination as significant barriers to seeking healthcare following strangulation. Second, shame, stigma, and fear of judgment contributed to self-silencing and avoidance of formal services. Third, survivors described strangulation as a terrifying and potentially lethal form of violence occurring within broader histories of polyvictimization and cumulative trauma. Despite experiencing serious symptoms, many participants avoided healthcare because they feared retaliation from abusive partners, anticipated dismissive treatment, or believed healthcare systems would be unable to protect them. Together, these experiences illustrate how structural racism, institutional mistrust, and gendered violence intersect to shape healthcare decision-making. Conclusions: Findings suggest that barriers to care following strangulation extend beyond individual help-seeking behaviors and are deeply rooted in structural inequities. Improving outcomes for Black women survivors requires enhanced provider training on strangulation assessment, trauma- and violence-informed approaches, culturally responsive care, and healthcare system reforms that address racism, mistrust, and survivor safety. These findings have important implications for reducing disparities in IPV-related health outcomes and improving responses to high-lethality violence.