An emerging understanding: brain injury deeply impacts domestic violence survivors

When a professional football player gets slammed into the field and hits his head, a referee blows the whistle and the play stops. A medical team rushes out, and typically the player is taken out of the game for a concussion evaluation. Their concussion is identified quickly, and they are closely monitored, given education and information about concussion (also known as a traumatic brain injury or TBI), and supported in their healing.

Picture this. A person is at home and their partner hurts them. Perhaps they were strangled and experienced blurred vision. Maybe they were hit in the head or were pushed or shoved onto a hard surface.  Anyone who has worked in domestic violence knows that victims of abuse are often hurt in the head, neck and face. When ODVN does training on this topic and asks domestic violence professionals how often they work with survivors who have been hurt in the head, neck or face, the consistent answer is, “All the time.”

Playing a sport and being in an abusive relationship are two situations that are about as different as can be. In abusive situations, the victims don’t get to wear protective equipment like helmets and pads. No referee stops the assault. There rarely is immediate medical care – or if there is, it often focuses on obvious external injuries like cuts or broken bones, rather than internal hidden damage to the brain. Survivors might not feel comfortable or safe reaching out to police, medical care, or other safety services, due to previous negative experiences, fear, or lack of knowledge or access to services. These barriers are heightened for survivors who are members of marginalized communities, including people of color, LGBTQIA+, immigrants, people with disabilities, and people who are poor or have economic barriers.

There has been little study on the specific intersection of brain injury, domestic violence, and marginalized communities. But disparities exist in both research on brain injury and violence. In brain injury research, preliminary studies show racial and ethnic minority groups report higher rates of traumatic brain injury, are less likely to receive follow-up care and rehabilitation, and more likely to have poor psychosocial, functional, and employment related outcomes.

Survivors of domestic violence who’ve suffered brain injuries can have a range of signs and symptoms, such as challenges with time management, problem-solving, anger management and impulse control. Many of these symptoms of brain injury make daily life as well as accessing domestic violence services more difficult. Professionals often have little patience for these challenges, and no awareness that this might be directly related to the brain injury and trauma survivors have endured. It’s imperative that first responders, medical professionals and others who work with domestic violence survivors be trained to understand how TBI and strangulation can present physically, behaviorally and cognitively—both in the immediate aftermath of an assault and in the long term.

Increasingly, researchers are beginning to identify what some describe as a silent epidemic of brain injuries among survivors of domestic violence and those who are killed by their intimate partners.

In the United States, nearly 1 in 3 women and 1 in 10 men experience rape, physical violence or stalking their lifetimes, according to the National Domestic Violence Hotline. Severe violence directed at the head, neck and face tends to be experienced mostly by women, with men causing the violence, though this is not always the case  The lack of knowledge of brain injury from domestic violence  in other diverse groups including men, LGBTQIA communities, immigrants, older individuals, and different racial, ethnic and socioeconomic groups is an significant gap in knowledge that must be filled. But we will continue to share what we know of this issue now, which mostly focuses on women.

Violence related disparities have shown that black women have increased rates and severity of domestic violence as well as a higher risk of weapons and intimate partner homicide. In addition, studies among black women have shown that probable TBI created greater odds of injuries, including ones that require medical care, as well an increased risk for PTSD and depression. Studies also suggest many women of all different background have experienced at least one mild TBI – with survivors describing being punched and strangled, their abusers slamming their heads against floors, walls, doors, refrigerators, bathtubs, the hoods of cars. Survivors also describe being choked, strangled, or assaulted in a way that made it hard to breathe.

Eve M. Valera, an associate professor of psychiatry at Harvard University and a research scientist at Massachusetts General Hospital, estimates the number of brain injuries among domestic violence survivors to be around 1.6 million per year, and argues that more comprehensive epidemiological work on the issue is needed. Valera, one of the leading researchers on the incidence and presentation of TBI in domestic violence survivors, found in one study of 99 women who had experienced intimate partner violence that 75% had sustained at least one TBI from violence caused by a partner, and 50% sustained multiple TBIs. Ohio’s research with ODVN member programs found that 81% of survivors had been hit or hurt in the head, neck or face, with 49% said they were hurt too many times to count. 83% of survivors had been choked or strangled. All service providers in Ohio who work in domestic violence are working with survivors impacted by brain injury, whether they know it or not.

While the data regarding TBIs specifically in cases of domestic violence is scant, researchers also are beginning to discover that the pattern of these injuries may be different in these cases than with brain injuries in other settings – for example, among athletes such as football, hockey or soccer players who suffer contact injuries or for military veterans.

Domestic violence cases often involve repeated assaults over a period, violent shaking, sometimes strangulation, and a multitude of other ways people can be hurt that deprives the brain of necessary oxygen, causes neurological damage, and can bring a person close to death. Strangulation is a strong risk factor for domestic violence homicide, including increasing homicide risk 7.5 times if strangled a single time and closer to 10 times if strangled repeatedly. For survivors not killed by their partner,  researchers now suspect that some cases, the damage isn’t caused by a single dramatic hit that produces a severe concussion. Instead, in cases like  Chronic Traumatic Encephalopathy (CTE) or other long-term neurodegenerative diseases, it can be the result of repeated or multiple hits to the head which over time and with cumulative impact can produce severe damage. Other research, like the research detailed below, has shown no evidence of CTE.

Research also is beginning to show that women may sustain concussions more easily than men, and that symptoms for women may take longer to resolve. 

Researchers from The Brain Injury Research Center of Mt. Sinai and the Office of the Chief Medical Examiner of New York studied the brains of 14 women who had died during a two-year period in New York City.  All had endured intimate partner violence; their median age at death was just 35; all of their brains showed signs of damage. Before death, these women had a wide range of health problems related to their neurological damage, including stroke, psychiatric or substance abuse disorders, and, in half the cases, epilepsy.

Kristen Dams-O’Connor, director of the Brain Injury Research Center and lead author of that report, said as the report was released in 2023 that the pervasive impact these brain injuries can have on the lives and cognitive functioning of those who suffer intimate partner violence is often unmeasured and undetected.

“If someone with a brain injury misses an appointment, it may not be because they’re ungrateful for the help or they don’t care about the service being offered,” Dr. Dams-O’Connor said in that news release. “If they lose their temper, it may be a manifestation of neurobehavioral dysregulation attributable to the traumatic brain injury. If they remain in a violent relationship, it may be that they don’t have the cognitive and executive function skills, or resources, required to orchestrate a safe and successful path to safety. This is not something the survivor should be blamed for.”

The consequences of that hidden damage can echo through almost all aspects of a survivor’s life – with some manifestations of concussion not emerging until weeks or months after the injury. Someone who’s experienced a concussion or have brain damage from strangulation may have difficulty with memory or answering questions about what happened, which could lead a police officer or emergency room employee to consider them less reliable or believable.

Race, gender, immigration status, and economics may play a role as well. ODVN’s report, Seeking Safety, Equity and Justice, highlighted experiences of survivors from marginalized groups, especially when seeking services. LGBTQIA+ survivors were less likely to contact the police. People of color had the most difficultly getting help from police, courts, and social services. Women of color, LGBTQIA+ persons and other marginalized communities experience more systemic violence and have higher rates of domestic violence and report disconcerting experiences with people in authority, a product of both implicit and explicit bias. Survivors of color report concerns often not being taken seriously by authorities, being blamed for situations, or feeling they were not heard.

Domestic violence survivors with brain injury need our support, advocacy, and services that meet their individual needs in a culturally responsive way and takes into consideration the unique impact that brain injury can have on a person’s ability to access and successfully engage with services. We can provide education on brain injury to survivors, who also are almost universally unaware they could be impacted by brain injury. We can learn from survivors about their experiences and respond to them in ways that affirms and supports their journey to safety and healing, which looks different for everyone.

While we are just beginning to better understand brain injury and domestic violence, ODVN’s Center on Partner-Inflicted Brain Injury is committed to providing support to Ohio and our nation on better understanding and addressing brain injury from violence. We will continue to focus on culturally aware and responsive approaches that center the lived experiences of survivors. For anyone interested in learning more about this intersection, please join Ohio’s Brain Injury from Violence CARE Alliance, co-chaired by ODVN and The Ohio State University or reach out to Rachel Ramirez, the Founder of The Center on Partner-Inflicted Brain Injury at rachelr@odvn.org.

RESOURCES  

ODVN’s Center on Partner-Inflicted Brain Injury, with information and resources for survivors and professionals.

Ohio Brain Injury from Violence CARE Alliance, a multidisciplinary group of over 60 organizations working together to better understand and address brain injury from violence.

Documentary film “This Hits Home,” featuring stories from survivors of domestic violence about their experience with brain trauma, as the findings of research about how repeated TBIs can lead to lifelong neurological impairment. View the film trailer here; this 2023 documentary can be streamed, rented or purchased on Amazon Prime.

This NPR story from 2022 features ODVN’s Rachel Ramiez and Dr. Eve Valera (both mentioned in the article) and discusses the complexities of brain injury from violence.  

The New York Times reported in 2022 that the cumulative impact of repeated blows to the head can lead to significant neurological impairment, but many concussions related to domestic violence go undetected and untreated.