Traumatic Brain Injury (TBI) is a significant and largely hidden public health issue. It results in an approximated 373,000 hospitalizations each year in the United States with 99,000 survivors classified as disabled and costs an estimated 48.3 billion US dollars with most experts agreeing that these figures are underestimates of the true problem.
TBI has gotten increased media attention over the past several years because of the increasing amount of data demonstrating the role that contact sports, particularly football, may play in acquiring TBI and the chronic and degenerative outcome of repeated head injury, chronic traumatic encephalopathy (CTE). Currently, over 100 former NFL players have been posthumously diagnosed with CTE and a study by the Mayo Clinic found CTE in 32% of men who played contact sports at an amateur level but found no traces in the brains of men who did not. Even President Obama has weighed in on the impact of football on TBI stating in an interview that football will likely need to become less violent over the coming years in light of the evidence of the long-term impact on players.
The increased media attention around TBI has meant that we are getting better at identifying and understanding the causes and outcomes of TBI in sports and other obvious risk scenarios like car crashes, but there is a significant and important population who is being left out of the discussion- victims of domestic violence. We know that domestic violence is a widespread problem in America and it is estimated that around 3 million couples engage in some form of physical violence and one in four married women are struck by their spouse at some time in their marriage. There is a distinct lack of evidence around the health impact of domestic violence, but it is estimated that between 3-21% of female victims need medical care after an incident of domestic violence and between 22-35% of all women’s visits to emergency care are a direct result of domestic violence.
We know that head injuries are one of the most common reported injuries for victims of domestic violence, that women are more prone to developing a post-concussive syndrome after a head injury and that women also have worse outcomes than men in 85% of TBI indicators. We also know that survivors of a mild TBI resulting from assault experience worse post-concussive syndrome than survivors of other types of brain injuries. All of these elements point to increased risk of long-term disability for female survivors of domestic violence. This is important because it is very likely that we are significantly underestimating TBI in domestic violence cases. Up to 20% of brain injuries are never reported, hospitalization for TBI is infrequent, the majority of domestic violence victims who show signs of TBI never receive a formal diagnosis and emergency rooms do not routinely screen for it. Further, victims of domestic violence may not report violence for fear of legal involvement, insurance loss, shame related to being a victim of domestic violence, fear of further violence or simply because they may not be able to remember the full extent of the assault, particularly where it led to a loss of consciousness.
All of this points to a sizable and already marginalized group of women who may have widespread and significant disability that is going undetected and untreated by the medical and legal community. Some of the symptoms of TBI such as aggression, poor memory, mood swings may be manifesting in female domestic violence victims in other ways. For example, 64% of all women who have been psychiatrically hospitalized have a history of domestic violence, how many of these women were institutionalized because of undiagnosed and untreated TBI? We cannot know because there have been no studies to explore persistent impairments or disabilities secondary to domestic violence.
Our medical and legal systems need to do better. We can provide training for police and emergency medical personnel around the risk factors for TBI in domestic violence situations, particularly for women, and systematically screening female emergency attendees for signs of domestic violence could increase the identification of TBI. Understanding of symptoms of TBI in victims of domestic violence could help courts and police to more effectively and empathetically question victims of domestic violence who may have memory lapses due to their condition. Identification of TBI in domestic violence victims could lead to more appropriate criminal sentencing of those who act violently in the home taking into account the full range of harm that they have inflicted on their partners. Better understanding of the prevalence of TBI in domestic violence victims could raise awareness in the broader community and help generate appropriate ways to assist those who are suffering from a TBI disability. Just as we are looking at how to mitigate risks for TBI as a society in contact sports such as football, we need to look at ways to identify and mitigate risks for victims of domestic violence.