Eve Valera, PhD
Intimate partner violence (IPV) is a common experience for women. IPV is any physical, sexual, and/or psychological violence perpetrated against a past or current intimate partner (e.g., girlfriend/boyfriend, husband/wife, dating or sexual partner). It is the leading cause of homicide for women globally and the most common form of violence against women.1 It has been estimated that approximately one in three women over age 15 experience physical or sexual IPV in their lifetime.2 Women who are rich, poor, old and young can become effectively “trapped” in partner violent relationships as a result of the partner’s coercive and controlling tactics (e.g., threats of murder, deportation and child abduction, and financial control). Although some groups of women are disproportionally affected by IPV (i.e., severity), this form of violence crosses ALL ages, races, ethnicities, sexual and gender identities, cultures, and socioeconomic levels. Men experience IPV too, but data are currently lacking on brain injury from IPV in men, so by necessity this article is focused on women.
IPV frequently causes brain injury. IPV can result in acquired brain injuries (BI) either from external forces to the head (e.g., hitting the head with a fist or hard object, slamming the head against a hard object, wall or floor), or from hypoxic-ischemia via strangulation. Epidemiological data on the prevalence of IPV-related BI are scant, but a nationally representative study found that approximately 6.2 million women reported a loss of consciousness from the abuse of a partner.3 As loss of consciousness is only one of several criteria for diagnosing BI, the number of women sustaining IPV-related BI would be expected to be much higher (and is substantiated by other data presented below). By comparison, there are approximately 3.8 million women with a history of breast cancer in the U.S. including women undergoing current and having completed past treatment.4 So even without considering a majority of potential BIs, there are nearly twice as many women sustaining IPV-related BIs than suffering from cancer in the US. Yet the time, funding, research and resources devoted to breast cancer are far greater than that for IPV-related BI. A similar statement can also be made about the amount of time, funding, and resources that are devoted to understanding mostly male athletes and military servicemembers relative to women experiencing IPV-related BI, despite evidence indicating IPV is a frequent cause of BI in women.
COVID-19 has increased rates and severity of IPV globally. Historically, upticks in IPV have been observed with both natural disasters and economic crises. After Hurricane Katrina physical violence towards women increased nearly two-fold in the surrounding Mississippi areas.5 After the Great Recession (2007-2009), unemployment and economic hardship were associated with abusive behavior towards women.6
Consistent with initial concerns, media reports around the globe have indicated spikes in rates of IPV and increases in the severity of violence including IPV-related femicide. In a recent study conducted in the United States,7 IPV-related injuries identified in radiological reports during COVID-19 were 1.8 times greater compared to the past 3 years, and the number of more severe or “deep” injuries was 1.1 per victim compared to 0.4 previously. Additionally, media reports in the United Kingdom indicated a doubling of femicide in the first few months of COVID-19 “lockdown”.8 For individuals experiencing IPV during the COVID-19 pandemic, the threat of violence is increased because of new economic uncertainties and hardships, and because of the unintended consequences of mitigation strategies aimed at curbing the pandemic. For example, women may be forced to “lockdown” with partners who use violence thus increasing exposure to violence, and/or women may isolate themselves from family or friends who may otherwise be able to assist them.
The likely increase on IPV-related BI is going largely unnoticed by the public. Unfortunately, the increase in IPV-related BIs has received little attention both in the lay media and research-based journals.9,10 There was no mention of BI in a 45-page report11 discussing pandemics and increases in violence against women and children, and there are scant media reports highlighting BI as a concern for IPV survivors. One report described a woman who was badly beaten into unconsciousness and stabbed in the eye with a piece of glass; a BI was not listed as one of the injuries.12 These examples raise the possibility that while rates of IPV-related BIs are increasing they are still being overlooked by not only the media and research community, but also the medical community. Given the chronicity of the COVD-19 pandemic, women will likely remain at a heightened risk for IPV-related BI.
IPV-related BI is often repetitive and associated with cognitive, psychological, and neural connectivity outcomes. Though limited, a growing literature links the number, recency and severity of IPV-related BIs to a range of negative outcomes. When assessed among women who experience IPV, the majority of BIs have been mild in severity, but Valera and colleagues13 found that 10% of their sample (that included only women who had experienced at least one instance of physical IPV) sustained at least one moderate to severe BI and 3% sustained repetitive moderate to severe BIs from IPV. These percentages are much lower than the 74 and 51% respective figures for at least one or repetitive mild BIs reported in that same sample. These data underscore the importance of recognizing that although mild BIs are most common, more severe BIs also occur. Guided by this knowledge Valera and colleagues13 used a BI score based on number and recency of self-reported BIs and whether a woman had sustained a moderate to severe IPV-related BI, to examine cognitive and psychological outcomes. Higher BI scores were associated with lower learning and memory scores and poorer performance on a test of cognitive flexibility. The team confirmed that these associations were not merely the result of IPV severity or measures of psychological distress. Furthermore, higher BI scores were associated with higher levels of depression, worry, anxiety and posttraumatic stress symptoms.
More recently, Valera and colleagues used neuroimaging to examine associations between BI scores and both structural and functional neural connectivity.14,15 The team put women in a magnetic resonance imaging (MRI) scanner and had women simply lay there and stay awake. First, they used scans to measure the degree to which certain brain regions were communicating with one another to assess resting-state functional connectivity between the Salience and Default networks.14 Communication between these networks is important for efficient cognitive functioning. The team found that the greater the BI score a woman had, the less positively certain regions, namely the right anterior insula and posterior cingulate cortex/precuneus of these two networks, communicated with each other. More importantly, the less positively these two regions communicated with one another, the more poorly women tended to perform on a test of learning and memory. Later, Valera and colleagues examined the effects of repetitive mild BIs on structural connectivity by examining water diffusion in the axons of certain white matter brain regions that have been implicated in repetitive mild traumatic BIs.15 Akin to findings on repetitive BIs in football players, Valera and colleagues found an association between BI scores and water diffusion in two of the three regions examined, the posterior and superior corona radiata. In combination with the aforementioned frequency of IPV-related BIs among women in the United States, these collective findings demonstrating associations of the BI score with cognitive, psychological and neural connectivity data suggest that BIs from IPV are having a host of negative effects on the lives of millions of women in the United States alone.
Strangulation can result in IPV-related BI and is associated with poor cognitive and psychological outcomes.
Valera and colleagues recently examined the effects of strangulation-related BIs independent of IPV-related traumatic BIs to understand the potentially unique contribution of strangulation-related acquired BIs to negative cognitive and psychological outcomes.16 They compared women who had and had not experienced an alteration in consciousness from being strangled while controlling for IPV-related BIs. Results indicated that, women who experienced alteration in consciousness demonstrated poorer working and long-term memory scores and higher levels of depression and posttraumatic stress disorder symptoms. As no other published studies have used neuropsychological measures to assess the cognitive impact of strangulation-related alterations in consciousness, these data represent a first step in understanding the outcomes of strangulation in women who have experienced IPV.
Immediate recognition and intervention for IPV-related BI is critically needed. Here I have presented some of the data that has most directly linked IPV-related BI with a range of negative outcomes. Despite these and other data, there is little research and infrastructure to support recognition and intervention for IPV-related BI. Failure to recognize the occurrence of BIs in women who have experienced IPV can result in misunderstandings, misdiagnoses, and inadequate treatment.9 For example, law enforcement or medical personnel responding to IPV incidents may misattribute disorientation or confusion as intoxication rather than indications of a partner-inflicted BI if the right questions are not asked or considered. Rather than getting proper medical attention, such a misattribution could result in an arrest or dismissal of abuse allegations. The time has come to aggressively address this global public health issue.
- Stöckl H, Devries K, Rotstein A, et al. The global prevalence of intimate partner homicide: A systematic review. Lancet. 2013;382(9895):859-865. doi:10.1016/S0140-6736(13)61030-2
- Devries KM, Mak JYT, Garcia-Moreno C, et al. The global prevalence of intimate partner violence against women. Science (80- ). 2013;340(6140):1527-1528. doi:10.1126/science.1240937
- Breiding MJ, Chen J, Black MC. Intimate Partner Violence in the United States — 2010.; 2014.
- American Cancer Society. About Breast Cancer. American Cancer Society. Published 2021. Accessed December 14, 2021. http://www.cancer.org/cancer/breast-cancer/about/what-is-breast-cancer.html
- Schumacher JA, Coffey SF, Norris FH, Tracy M, Clements K, Galea S. Intimate partner violence and Hurricane Katrina: Predictors and associated mental health outcomes. Violence Vict. 2010;25(5):588-603. doi:10.1891/0886-6708.25.5.588
- Schneider D, Harknett K, McLanahan S. Intimate partner violence in the Great Recession. Demography. 2016;53(2):471-505. doi:10.1007/s13524-016-0462-1
- Gosangi B, Park H, Thomas R, et al. Exacerbation of physical intimate partner violence during COVID-19 lockdown. Radiology. 2020;298(1):E38-E45. doi:10.1148/radiol.2020202866
- Grierson J. Domestic abuse killings “more than double” amid Covid-19 lockdown. The Guardian. April 15, 2020. Accessed December 14, 2021. https://www.theguardian.com/society/2020/apr/15/domestic-abuse-killings-more-than-double-amid-covid-19-lockdown
- Valera EM. When pandemics clash: Gendered violence-related traumatic brain injuries in women since COVID-19. EClinicalMedicine. 2020;24:100423. doi:10.1016/j.eclinm.2020.100423
- Saleem GT, Fitzpatrick JM, Haider MN, Valera EM. COVID-19-induced surge in the severity of gender-based violence might increase the risk for acquired brain injuries. SAGE Open Med. 2021;9. doi:10.1177/20503121211050197
- Peterman A, Potts A, Donnell MO, et al. Pandemics and violence against women and children. Center for Global Development Working Paper, 528. Published 2020. Accessed December 14, 2021. https://www.cgdev.org/publication/pandemics-and-violence-against-women-and-children
- Donovan L. A transport ban in Uganda means women are trapped at home with their abusers. CNN. Published May 15, 2020. Accessed December 14, 2021 https://edition.cnn.com/2020/05/15/africa/uganda-domestic-violence-as-equals-intl/index.html.
- Valera EM, Berenbaum H. Brain injury in battered women. J Consult Clin Psychol. 2003;71(4):797-804. doi:10.1037/0022-006X.71.4.797
- Valera E, Kucyi A. Brain injury in women experiencing intimate partner-violence: neural mechanistic evidence of an “invisible” trauma. Brain Imaging Behav. 2017;11(6):1664-1677. doi:10.1007/s11682-016-9643-1
- Valera EM, Cao A, Pasternak O, et al. White matter correlates of mild traumatic brain injuries in women subjected to intimate-partner violence: A preliminary study. J Neurotrauma. 2019;36(5):661-668. doi:10.1089/neu.2018.5734
- Valera E.M., Daugherty J.C., Scott O. BH. Strangulation as an acquired brain injury in intimate-partner violence and its relationship to cognitive and psychological functioning: A preliminary study. J Head Trauma Rehabil. 2022;37(1):15-23.doi:10.1097/HTR.0000000000000755.