Partner-Inflicted Brain Injuries

A step-by-step guide to recognizing, understanding, and advocating on behalf of those affected by intimate partner violence (IPV) related traumatic brain injuries.

IF YOU BELIEVE THAT YOURSELF OR SOMEONE YOU KNOW IS EXPERIENCING INTIMATE PARTER VIOLENCE, DO NOT HESITATE TO FIND IMMEDIATE SUPPORT BY CONTACTING THE RESOURCES PROVIDED BELOW:

The National Domestic Violence Hotline

Domestic Violence Shelters in the United States

Love is Respect: National Teen Dating Abuse Hotline

Rape, Abuse & Incest National Network's (RAINN) National Sexual Assault Hotline

National Resource Center on Domestic Violence

Table of Contents:

Connecting Partner Violence and Brain Injuries

“We have overlooked this pandemic for too long: traumatic brain injuries in women subjected to intimate partner violence”

- Eve Valera, PhD

Let’s break this quote down…
What is a Traumatic Brain Injury? What is Intimate Partner Violence?

Dr. Valera defines intimate partner violence and traumatic brain injuries. She then goes on to explain the significance of their connection.

Let’s review that video a little closer: What is a traumatic brain injury (TBI)?

Traumatic Brain Injuries (TBIs) have various gradients of severity (e.g. moderate, severe), but for the purposes of our discussion of intimate partner violence, we will focus on mild traumatic brain injuries (mTBIs), which are the most common form.

Mild Traumatic Brain Injury (mTBI) as defined by the Center for Disease Control (CDC):

“A concussion is a type of traumatic brain injury—or TBI—caused by a bump, blow, or jolt to the head or by a hit to the body that causes the head and brain to move rapidly back and forth. This sudden movement can cause the brain to bounce around or twist in the skull, creating chemical changes in the brain and sometimes stretching and damaging brain cells.”

NOTE: A direct blow to the head is not necessary in order for someone to sustain a brain injury. An mTBI can also occur via whiplash when someone receives a hit to another area of the body.

Brain injuries from intimate partner violence can also be caused via strangulation.

What is intimate partner violence (IPV)?

Intimate Partner Violence (IPV): violence perpetrated by a current or former romantic or sexual partner.

NOTE: IPV is a sub-group of domestic violence. It is important to recognize that brain injuries can occur in other realms of domestic violence, such as injuries inflicted by parents on children (child abuse) and other family members on elders (elder abuse). While these types of domestic violence-related brain injuries will not be discussed on this page, you can learn more about these populations on our website.

So...how prevalent is IPV? Here are some quick facts:

So...how prevalent are brain injuries from IPV? Consider the following images:

Click on each image above to learn more.

Diagnosing the Injury

“Women don’t know they are sustaining these brain injuries…they go unnoticed and unacknowledged, but they may have long-lasting effects.”
— Eve Valera, PhD

Why are women unaware that they’re experiencing TBIs?

To answer this question, there are two important considerations:

  1. The general difficulty that surrounds diagnosing a traumatic brain injury.

  2. The symptomatic overlap between a traumatic brain injury and intimate partner abuse (e.g. depression, anxiety, difficulty concentrating, etc.).

We will consider these factors one at a time…

Difficulty Diagnosing TBIs

Essentially, the biological processes that dictate the presence of a TBI are too small to be detected by typical clinical screening devices. This means…

  1. The brains of people with mTBIs will appear normal on typical MRI or CT scans,

  2. No medical professional is able to “see” the patient’s brain injury, and

  3. A brain injury can only be diagnosed by symptoms.

This means that brain injuries are inherently “subjective” and patients can present with a wide range of symptoms, which makes mTBIs easily misunderstood by others and exceptionally difficult to treat for healthcare professionals.

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Symptomatic Overlap Between IPV and TBIs

“As a statewide leader in [domestic violence] who had lead a trauma-informed initiative around the state, never once had I mentioned brain injury, and how did we manage to miss that?”

- Rachel Ramirez, Founder and Director of The Center of Partner Inflicted Brain Injury

Many of the symptoms of a brain injury and intimate partner violence are similar…

Venn diagram showing overlap between symptoms of IPV and TBIs. Symptoms were obtained via a cross-reference comparison of symptoms listed for “domestic violence” or “concussions” on the PsychCentral and CDC websites, respectively.

And as discussed above, with no clinical screening tools (e.g. MRI, CT) able to detect a brain injury, it becomes very easy to mistake typical signs of a traumatic brain injury as symptoms of intimate partner violence.

This is why it is essential that proper screening practices are used.

Screening for an IPV-related TBI

Disclaimer: There are many different screening tools that are currently being both recommended and used by various state-wide organizations. In six states, there are conflicting recommendations for different screening tools from different state organizations.

With that being said, valid screening tools should:

  • Include open-ended questions that allow the participant to explain their story.

  • Not include any invasive, probing questions that can trigger historic brain trauma.

  • Recognize that consciousness is a continuum (i.e. some patients will experience a loss of consciousness while others will only have a partial loss of memory).

  • Be administered via paper and pencil so as not to trigger light sensitivity and related symptoms of people experiencing a brain injury.

  • Be conducted in a safe environment without any partners or other family members present.

  • Provide safety-planning and connect women with desired resources should they screen positive for an IPV-related TBI.

Below, I have provided examples of two screening tools that are commonly used in both the research and treatment of IPV-related TBIs.

HELPS Brain Injury Screening Tool

This HELPS tool comes from the SOAR Project, or an organization for “Supporting Survivor of Abuse or Brain Injury Through Research.” It is currently recommended from statewide domestic violence organizations in 11 states.

Ohio State University TBI Screening Tool

This is a screening tool that has been around for years from the Ohio State University. The version shown below has been adapted for a clinical setting, hence why it is longer and more in-depth than the HELPS screening tool shown above. It is currently recommended by statewide domestic violence organizations in two states.

Until further research is conducted to determine the gold standard for IPV-related TBI screening, it is important that professionals continue to use one of these recommended screening measures.

Understanding the Research

Women & Girls as a Research Population


“Women and girls suffer silently or scream for help where there seems to be none for too long - they are our mothers, daughters, granddaughters, sisters, nieces, and friends”

— Marilyn Spivack, President of the National Head Injury Foundation, Emeritus

TBIs resulting from IPV can happen to both men and women. However, because the majority of research concerns those inflicted upon women, we must consider the unique position of women (and girls) as a research population in the field of TBIs before considering research on IPV-related TBIs more specifically. This unique position is summed up quite succinctly by Marilyn Spivack above: overlooked and forgotten.

Perhaps a brief history lesson will be helpful…

Following World War II, there was lots of sudden interest in studying the effects of brain injury, primarily in response to injuries sustained via the war (e.g. explosions) or the sudden boom in sports participation (e.g. football). Because of this focus on combat and sports, which were spaces dominated by men in the 1940s/1950s, much of the brain injury research was correspondingly male-centric.

So…what’s the problem?

These are no longer spaces dominated by men. Women comprise nearly 15% of all active military personnel. More girls are playing heavy contact sports such as tackle football and hockey in 2020 than ever before. And yet, doctors are still unable to prescribe unique recovery plans to a 10 year-old girl with a concussion or a post-menopausal woman in her 60s experiencing a TBI. This is a significant problem as preliminary research suggests there are many ways in which women differ from men in their symptom presentation, recovery process, and incidence when it comes to traumatic brain injuries. Let’s review some of these differences below…

Women Differ in Incidence

Dr. Tracey Covassin of Michigan State University conducted her dissertation on the prevalence of concussions sustained by women and men across similar sports. Critically, she discovered that women sustained concussions (mTBIs) at significantly higher rates relative to men in sports like soccer, basketball, and softball; this finding has since been replicated numerous times. Dr. Covassin hypothesizes this is due to higher numbers of female-specific hormones and/or women’s decreased neck strength and mass.

Tracey Covassin, PhD

Women Differ in Symptomatology

Dr. Odette Harris and Dr. Maheen Adamson of Stanford University found that veteran women who experienced a TBI are:

These were comparisons made relative to male peers who received TBIs from similar incidents. While there may be physical reasons behind these differences (see below), women’s unique symptomatology extends to the general female population:

Odette Harris, MD, MPH; Maheen Adamson, PhD

Women Differ in Recovery

Dr. John Leddy and Dr. Barry Willer of the University of Buffalo found that while women presented with significantly more initial symptoms than men, these symptoms were significantly reduced when women were prescribed a light aerobic exercise routine instead of prolonged rest. This demonstrates how women benefit from different recovery options than men.

Women Differ in Structure

Axons are nerve fibers in the brain. Dr. Doug Smith of the University of Pennsylvania conducted a ground-breaking study that used imaging technology on the brains of female and male rats/humans. He discovered that female axons were smaller and had fewer microtubules or “train tracks” to transport molecules up and down the axon (see right). This meant that female axons were more fragile and likely to break from the blunt force caused by TBIs.

Figure from the landmark study by Dr. Doug Smith of the University of Pennsylvania Medical School.

This is all to say…

Women are an undoubtedly unique and commonly overlooked population in the field of concussion research. Each year, there are more studies published to further differentiate women as a distinct group within the field. This is important context for understanding the oversight of IPV-related TBIs and is essential knowledge before delving into parter-inflicted brain injury research more specifically. If you are still interested or want to learn more about these above points, check out this edition of the Brain Injury Professional.

What do we know about the consequences of IPV-related TBI?

Much work on the consequences of TBIs in women affected by intimate partner violence has been conducted by Dr. Eve Valera of Harvard Medical School. She is a pioneer in the field of IPV-related TBIs and lead one of the first published studies on the topic in 2002. Fortunately, she is "here" to explain her research below:

To Summarize

  1. In a sample of 99 women, 75% had experienced one traumatic brain injury, and 50% had experienced more than they could count.

  2. The more brain injuries a woman sustains, the poorer a woman performs on measures of memory, learning, and cognitive flexibility.

  3. This higher number of brain injuries was also associated with higher rates of depression, anxiety, and PTSD.

  4. Neuroimaging has revealed that these women have less neural network connectivity based on the number of brain injuries sustained.

    For 2 and 3, these findings were not accounted for by abuse severity, psychopathology, or substance abuse. In other words, these were direct consequences of the TBI and not intimate partner violence alone.

At-Risk Groups

VETERANS

There are over 2 million female veterans in the United States. This group of women displays a 1.6 times higher rate of experiencing IPV than their non-military peers.

Many studies in the field have been lead by Dr. Katherine Iverson and Dr. Terri Pogoda from Boston University. So far, they have found that female veterans with an IPV-related TBI history had significantly higher levels of depression and PTSD, greater utilization of Veteran’s Affairs (VA) healthcare, and poorer perceived physical health than women who experienced IPV to the head region, but had no diagnosed TBI.

INCARCERATED WOMEN

Katherine Iverson, PhD

Terri Pogoda, PhD

According to a CDC pamphlet on TBI in Prisons and Jails:

  • Approximately 27% of inmates report receiving a TBI, compared to just 8.5% of women nationally.

  • Female inmates convicted of violent crimes are more likely to have sustained a pre-crime TBI and/or physical abuse.

  • Symptoms of brain injury (e.g. irritability) may be misinterpreted as insolence and punished.

With women at such a high risk of experiencing IPV (and subsequent TBIs), it is possible that these brain injuries prompt the erratic behavior that causes crimes or violent outbursts.

“80% of incarcerated women are mothers and TBIs affect 50% of this population. These women experience poor maternal outcomes like postpartum depression, substance abuse disorder, and anxiety.”

Monica Nguyen, MPH

MINORITY WOMEN

Dr. Monique Pappadis of the University of Texas Medical Branch has been leading the research on minority women and the unique difficulties they face regarding TBIs.

  1. Racial minorities have greater difficulty reintegrating into their communities following a TBI. This includes resuming household duties, workplace responsibilities, and social activities.

  2. Hispanic and Black participants were found to have many misconceptions regarding TBIs, specifically about symptomology and recovery.

  3. Promisingly, Dr. Pappadis found that these misconceptions could be corrected via educational interventions.

In the context of IPV, many minority women have misconceptions that may further impact their ability to seek treatment. In addition, minority women might have more trouble leaving violent IPV situations due to difficulties resuming household/workplace duties.

MOTHERS

“Intimate partner violence is often a life-threatening event to both the mother and the fetus.”
— Hamisu Salihu, MD, PhD

Dr. Salihu of the Baylor College of Medicine found that battered mothers had adverse pregnancy outcomes, including low birth weight, preterm delivery, infant mortality, and maternal mortality.

However, even after delivery, these women can experience erratic behavior from their repetitive TBIs that serve as additional hardships towards readjusting to their former lifestyle. These hardships become particularly salient for mothers who not only have to care for themselves but also their children. In addition, the presence of children can increase a woman's inability to escape from an abusive relationship.

What about IPV-related TBI in men?

Great Question!

Here is what we do know:

Could these symptoms be the result of TBIs?

It is certainly possible. At this time, the prevalence of traumatic brain injuries from IPV in male populations has yet to be formally investigated. However, it certainly should be as these men are a distinct population that face their own unique challenges towards receiving adequate treatment such as…

  1. Many men hesitate to seek treatment due to fears that they will be ridiculed or embarrassed.

  2. Male victims attest that the police will fail to respond, take a report, and in some cases, will even arrest the man as the violent perpetrator despite there being no evidence of injury to the female partner.

  3. Domestic violence support resources such as hotlines will assume the man is the perpetrator and even direct them to batterers’ programs.

These internal and external barriers that male victims of partner-inflicted TBIs face can increase their difficulty in finding the treatment and resources that they need.

Introducing Supportive Organizations

Fortunately, there are lots of great non-profit organizations that are working to raise awareness and support for victims of parter-inflicted brain injuries. We will highlight a few of these organizations and the resources they offer below:

SOAR conducts research on IPV-related TBIs with the hope that their findings will educate healthcare providers (and the female survivors) so these brain injuries can be both diagnosed and treated. They have 3 main phases…

  1. Explore the prevalence and severity of partner-inflicted brain injuries among these women via 1:1 interviews or lab-based assessments.

  2. Educate the professionals working with survivors of intimate partner violence by designing training tools that provide the knowledge and skills needed to support those with a TBI.

  3. Empower a community-based support system by using their organization to bring together service providers in health care, brain injury support, and gender-based violence sectors.

They have already published various articles and presentations within the research field to begin supporting these women.

Paul van Donkelaar, PhD, Co-Founder & Principal Investigator

Karen Mason, Co-Founder & Director of Community Practice

“By providing excellence in support, housing, education, & community, we work to restore hope and a future to those overcoming challenges before them.”

Val Fuller, President of The Cridge Centre for the Family

The Cridge Centre is a Canada-based national organization; it is a fantastic example of how even local organizations can make a tremendous difference in the lives of women affected by partner-inflicted brain injuries.

The Cridge Centre provides this support by…

What about COVID-19?

“As the coronavirus pandemic is felt across all corners and communities, I have been particularly concerned by the realities of those living in an abusive environment, as their opportunities for support are reduced by the lockdown.”
— Irene Sobowale, Chief Executive Officer of The Disabilities Trust

Following the COVID-19 pandemic, there has been an increase in gender-based violence in the Palestinian territories, Mexico and Brazil have seen a spike in calls to domestic violence hotlines, and police officers in the city of Jingzhou, China report receiving three times as many domestic violence calls during this past February compared to the same month in 2019.

As a result of the pandemic, women experienced:

COVID-19 is not the only pandemic facing society. There are millions of women experiencing IPV and subsequent TBIs (now exacerbated by COVID-19 mitigation strategies) that desperately need better support networks and response strategies during this time.

Becoming an Advocate

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