Shedding Light on the Shadow Brain Pandemic: The Devastating Effects of Gendered Violence-Related Acquired Brain Injury

COMMENTARY

Violence against women, which often results in traumatic brain injury (TBI) and other acquired brain injuries (ABIs), has intensified during the COVID pandemic. Violence against women is a clear violation of human rights and a legal and moral failure of society. It likewise contributes to the brain health gap as well as presents as a major economic problem. As the world struggles to emerge from COVID-induced health and economic decline, women are a major key to the economic recovery. A comprehensive and long-term strategy is required to shed light on and address this dire issue and to ensure the mental well-being women as well as unlock the power of women to drive the economic recovery.

During July 2021, social media influencer Gabby Petito, aged 22, and her fiancé Brian Laundrie, aged 23, embarked from New York on a cross-country road trip captured on Instagram and YouTube.¹ In September, Brian returned early from the trip—and alone. Weeks later, Gabby’s remains were found. It was determined that Gabby died from strangulation, and her case opened a national conversation about intimate partner violence (IPV).²

Tragically, Gabby’s case is just one of many. There has been an increase in IPV, illuminating a shadow pandemic within the COVID-19 pandemic.^3,4 Even before COVID-19, 1 in 3 women (approximately 1.27 billion individuals out of the 3.82 billion women in the world) are estimated to have experienced IPV.⁵ Further, more than one-third (30,000) of the women killed in 2017 were killed by their current or former intimate partner.⁶ COVID-19 has escalated the rates of IPV. Calls to helplines have increased five-fold in some countries in 2020.4In numerous countries, there has been a 300% increase in police reports of IPV, likely fueled by COVID-19 mitigation strategies.⁴ UN Women had projected that an additional 15 million women would be affected by IPV for every 3 months of lockdown.⁷

Although this increase in violence will have multipronged effects, the neurological effects and IPV-related acquired brain injury (ABI), including Traumatic Brain Injury (TBI), is particularly devastating. Despite the increasing attention in the last 10 years paid to sports-related TBI, little attention has been paid to TBI resulting from IPV.⁸ Up to 90% of survivors of IPV report head, neck, and face injuries, many of which result in TBI.^9,10 One study examining brain injury in women who experienced IPV found that 74% of the women sustained at least one IPV-related TBI and 51% sustained repetitive IPV-related TBIs.11 Moreover, the study found a higher brain injury score from IPV was negatively associated with memory, learning, and cognitive flexibility and positively associated with a number of measures of psychological distress.¹¹

IPV-related ABI also includes nontraumatic brain injuries. Research has shown that 1 out of 10 women have been strangled by an intimate partner,¹² which can cause a multitude of neurological problems, including hypoxic-anoxic brain injury, with long-term implications. As Gabby’s case emphasized, strangulation can result not just in hypoxic-anoxic brain injury but also in death. Indeed, prior non-fatal strangulation has been found to be associated with greater than 6-fold odds of becoming a victim of attempted homicide, and more than 7-fold odds of becoming a victim of completed homicide.¹³ The high-profile fatal strangulation murder of Gabby underscores femicide in IPV, which devastatingly remains commonplace.²

In addition to TBI, hypoxic-anoxic brain injury, and other forms of acquired brain injury, women who experience IPV also are more likely to suffer from anxiety, depression, posttraumatic stress disorder, suicidal ideation, and many other health problems that can last even after the violence has ended, potentially detaching them from the labor market.^4,14

There is also a growing concern that women who experience repeated TBIs from IPV may develop chronic traumatic encephalopathy (CTE), a progressive and fatal neurodegenerative disease that cannot be diagnosed until postmortem.^8,15-18 Unfortunately, the literature tells their tales. For instance, a report from 1990 identified a case of a women who apparently developed CTE from partner abuse.¹⁹ In 2021, during a postmortem examination of a woman aged 29 who died following a domestic violence incident, immunohistochemical staining for phosphor-tau revealed evidence of CTE-type pathology.²⁰ This marked the first case of CTE pathology in a young woman who experienced IPV. However, there remains a lack of research investigating the long-term neurological consequences for women who have experienced IPV; research is needed to understand the potential for misdiagnosis, nondiagnosis, or the development of dementia and Alzheimer disease as a result of IPV.¹⁵ The latter is especially important since TBI has been identified as a modifiable risk factor for dementia.²¹ Thus, more research is needed to evaluate IPV as a potential risk factor for dementia.

The neurological effects of IPV extend to the entire family and remain under researched. A recent Brain Injury Australia report of the country’s first research into domestic and family violence (DFV) and ABI found that, out of the 16,000 survivors of family violence attending Victoria hospitals over a decade’s time, 2 in every 5 survivors had sustained brain injury.²³ Further, nearly 1 in 3 of the survivors of family violence were children and, of those, 1 in every 4 had sustained a brain injury. Because this was not a study of IPV but instead a study of hospitalizations, it likely represents the tip of the iceberg. Similarly, a study of more than 100 clients of 5 domestic abuse shelters in Arizona found 9 in every 10 individuals reported a head injury with loss of consciousness from family violence in the preceding 12 months.24 Of those, 9 in every 10 reported “too many head injuries to quantify.” Yet only 1 in every 5 ever sought medical attention. Thus, community rates of IPV ABI remain radically under researched.

Currently, most domestic violence shelters and emergency department settings do not assess for TBI, non-fatal strangulation, or other brain injuries from IPV, despite the significant number of studies that demonstrate brain trauma among IPV survivors as well as those that show non-fatal strangulation as an important risk factor for homicide of women.^13,15,25 Additionally, many women do not seek medical care for their IPV-related ABI.²⁶ However, even when women do interact with social workers, physicians, or domestic violence advocates and shelter staff, there is a lack of training in these professions to adequately screen for and address IPV-related ABI.^7,23

Further, when developing criminal justice policy, histories of abuse and brain injury should be addressed. A study of women in prison found that 78% had significant head injury; 84% of these women had experienced repeated head injury largely as a result of domestic abuse that had occurred over many years.²⁷ Yet screening and care for brain injury is not adequately accounted for in criminal justice. The staggering statistics of the number of women who have experienced abuse and are now in prison also further necessitates the development of a trauma-informed criminal justice system.

IPV-related ABI add yet another injustice to the Brain Health Gap, which highlights and frames the sex and gender gap in outcomes for brain health disorders across the lifespan, with strikingly negative outcomes for women.^28,29 To address the Brain Health Gap, research institutions are calling for more women participants in preclinical development of medications, clinical trials, and clinical practice, as well as the expansion of research designed to focus on culturally relevant experiences specific to individuals who identify as female. This will enable more robust and representative data to be collected. Big data, real world evidence, and precision medicine approaches should be the tools used to respond to the call to action above. Furthermore, investing in leaders in health care and public health efforts is imperative to translate these data and perspectives into action. Women remain underrepresented in health care leadership, underlining the lack of gendered consideration in care. These efforts and initiatives are especially important for research, clinical care, and training related to IPV. The Brain Health Gap must address issues related to IPV-related ABIs.

Likewise, we have previously noted that the world is suffering a global brain capital collapse.^30-32 Brain Capital is a novel econometric asset that puts a premium on brain health and brain skills in our brain economy.^30,31 Brain Capital is a form of capital relevant to a complex, interconnected, and fragile global economy. Brain Capital needs to be integral to a new narrative of growth and progress that puts people and their well-being, health, interaction with others, and psychological resilience at the center of our economic system. Female empowerment—which includes preventing and addressing violence against women and better identifying and caring for the neurological effects in survivors—is a public and brain health imperative as well as the most effective way to build Brain Capital globally.

Addressing gendered violence and related ABIs can be remedied by integrating the social, medical, political, policy, and diplomatic levels. Taking sex and gender into account—including structural and social determinants—is critical for equality in brain health and precision medicine. The Organisation for Economic Co-Operation and Development (OECD) New Approaches to Economic Challenges (NAEC) Unit’s Neuroscience-inspired Policy Initiative (NIPI) seeks to tackle this issue.^30,31,33 We aim to find new ways to reconceptualize and revitalize the economy and how it works, laying the groundwork to identify relevant metrics while building a transdisciplinary network of stakeholders. The effort draws on experts from medicine, neuroscience, gender analysis, economic policy, philanthropy, and business. The Initiative will rapidly refine and advance women’s brain health via a series of research projects, seminars, and clear policy analyses and recommendations. In doing so, we hope to address the Brain Health Gap, leading to greater health justice for all people and a new era of innovation and progress. We hope to help build a future where both men and women are equipped with the support, resources, and care they need to thrive and in turn build more a resilient society and world.

Ms Smith is an Atlantic Fellow for Equity in Brain Health at the Global Brain Health Institute (GBHI) (at the University of California, San Francisco (UCSF) and Trinity College Dublin), a Thiel Fellow at Stanford University and Steering Committee member for NIPI ( OECD, Meadows Mental Health Policy Institute (MMHPI) and the PRODEO Institute). Mr Rushworth is the CEO of Brain Injury Australia. Dr Valera is an associate professor in psychiatry at Harvard Medical School and a research scientist at Massachusetts General Hospital. Dr Chadha is head stakeholder, Engagement Alzheimer's disease at Biogen and Pro Bono CEO and Co-founder of the Women's Brain Project. Dr Hynes is head of the OECD New Approaches to Economic Challenges Unit, Senior Advisor to the OECD Secretary General and co-lead of OECD NIPI.Ms Kawaguchi is advisor to the chief of staff and gender advisor at OECD. Dr Wolfe is a Senior Clinical Advisor for Cohen Veterans Bioscience’s Trauma Research Programs. She serves as Strategic Advisor co-leading CVB’s Suicide Strategy Initiative. Dr Eyre is co-lead of OECD NIPI, strategic advisor to the HEKA Fund (Newfund Capital and Fondation FondaMental), steering committee member for the Brain Health Nexus at Cohen Veterans Bioscience, and holds adjuncts roles with IMPACT at Deakin University, GBHI and Baylor College of Medicine.

References

1. Rosman K. How the case of Gabrielle Petito galvanized the internet. The New York Times. October 20, 2021. Accessed November 20, 2021. https://www.nytimes.com/2021/09/20/style/gabby-petito-case-tiktok-social-media.html

2. Santucci J. Gabby Petito was strangled. Experts say such an assault is a red flag for intimate partner homicides. USA Today. October 12, 2021. Accessed November 20, 2021. https://www.usatoday.com/story/news/nation/2021/10/12/gabby-petito-strangled-experts-say-its-common-intimate-partner-violence/8426282002/

3. Evans ML, Lindauer M, Farrell ME. A Pandemic within a Pandemic - Intimate Partner Violence during Covid-19. N Engl J Med. 2020;383(24):2302-2304.

4. Valera EM. When pandemics clash: Gendered violence-related traumatic brain injuries in women since COVID-19. EClinicalMedicine. 2020;24:100423. Published 2020 Jun 27.

5. Breiding MJ, Smith SG, Basile KC, et al. Prevalence and characteristics of sexual violence, stalking, and intimate partner violence victimization--national intimate partner and sexual violence survey, United States, 2011. MMWR Surveill Summ. 2014;63(8):1-18.

6.United Nations Office on Drugs and Crime. Global study on homicide: Gender-related killing of women and girls. 2018. Accessed November 20, 2021. https://www.unodc.org/documents/data-and-analysis/GSH2018/GSH18_Gender-related_killing_of_women_and_girls.pdf

7. Mlambo-Ngcuka P. Gender-based violence: We must flatten the curve of this shadow pandemic. November-December 2020. Accessed November 20, 2021. https://www.un.org/africarenewal/magazine/november-december-2020/gender-based-violence-we-must-flatten-curve-shadow-pandemic

8.Pandaram J. Concussion in sport: Domestic violence victims show same brain injury trauma as athletes with CTE. The Daily Telegraph. April 18, 2021.

9. St Ivany A, Schminkey D. Intimate Partner Violence and Traumatic Brain Injury: State of the Science and Next Steps. Fam Community Health. 2016;39(2):129-137

10.Liu LY, Bush WS, Koyutürk M, Karakurt G. Interplay between traumatic brain injury and intimate partner violence: data driven analysis utilizing electronic health records. BMC Womens Health. 2020;20(1):269. Published 2020 Dec 7.

11.Valera EM, Berenbaum H. Brain injury in battered women. J Consult Clin Psychol. 2003;71(4):797-804.

12.Monahan, K., A. Purushotham, and A. Biegon, Neurological implications of nonfatal strangulation and intimate partner violence. Future Medicine. 2019. 14(3).

13. Glass N, Laughon K, Campbell J, et al. Non-fatal strangulation is an important risk factor for homicide of women. J Emerg Med. 2008;35(3):329-335..

14. Lagdon S, Armour C, Stringer M. Adult experience of mental health outcomes as a result of intimate partner violence victimisation: a systematic review. Eur J Psychotraumatol. 2014;5:10.3402/ejpt.v5.24794. Published 2014 Sep 12.

15. Monahan K. Intimate Partner Violence, Traumatic Brain Injury, and Social Work: Moving Forward. Soc Work. 2018;63(2):179-181.

16. Monahan K. Intimate partner violence and traumatic brain injury: a public health issue. J Neurol Neuromed. 2018; 3(3): 3-6.

17. Stern RA, Daneshvar DH, Baugh CM, et al. Clinical presentation of chronic traumatic encephalopathy. Neurology. 2013;81(13):1122-1129.

18. Baugh CM, Stamm JM, Riley DO, et al. Chronic traumatic encephalopathy: neurodegeneration following repetitive concussive and subconcussive brain trauma. Brain Imaging Behav. 2012;6(2):244-254.

19. Roberts GW, Whitwell HL, Acland PR, Bruton CJ. Dementia in a punch-drunk wife. Lancet. 1990;335(8694):918-919.

20. Danielsen T, Hauch C, Kelly L, White CL. Chronic Traumatic Encephalopathy (CTE)-Type Neuropathology in a Young Victim of Domestic Abuse. J Neuropathol Exp Neurol. 2021;80(6):624-627.

21. Livingston G, Huntley J, Sommerlad A, et al. Dementia prevention, intervention, and care: 2020 report of the Lancet Commission. Lancet. 2020;396(10248):413-446.

22. Leung FH, Thompson K, Weaver DF. Evaluating spousal abuse as a potential risk factor for Alzheimer's disease: rationale, needs and challenges. Neuroepidemiology. 2006;27(1):13-16.

23. Brain Injury Australia Consortium. The prevalence of acquired brain injury among victims and perpetrators of family violence. 2018. Accessed November 20, 2021. https://www.braininjuryaustralia.org.au/wp-content/uploads/BRAININJURYAUSTRALIAfamilyviolencebraininjuryFINAL.pdf

24. Zieman G, Bridwell A, Cárdenas JF. Traumatic Brain Injury in Domestic Violence Victims: A Retrospective Study at the Barrow Neurological Institute. J Neurotrauma. 2017;34(4):876-880.

25. Meyer JE, Jammula V, Arnett PA. Head Trauma in a Community-Based Sample of Victims of Intimate Partner Violence: Prevalence, Mechanisms of Injury and Symptom Presentation [published online ahead of print, 2021 May 15]. J Interpers Violence. 2021;8862605211016362.

26. 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.

27. McMillan TM, Aslam H, Crowe E, et al. Associations between significant head injury and persisting disability and violent crime in women in prison in Scotland, UK: a cross-sectional study. Lancet Psychiatry. 2021;8(6):512-520.

28. Aragam GG, Kawaguchi N, Hynes W, et al, Highlighting brain-based inequalities for women: from bedside and boardroom to policy. Psychiatric Times. May 5, 2021. Accessed November 20, 2021. https://www.psychiatrictimes.com/view/brain-based-inequalities-women

29. Smith E, Kawaguchi N, Chapman SB, et al. Closing the brain health gap: addressing women’s inequalities. Oxford University Press Blog. August 21, 2021. Accessed November 20, 2021. https://blog.oup.com/2021/08/closing-the-brain-health-gap-addressing-womens-inequalities/

30. Smith E, Ali D, Wilkerson B, et al. A Brain Capital Grand Strategy: toward economic reimagination. Mol Psychiatry. 2021;26(1):3-22.

31. Eyre HA, Ayadi R, Ellsworth W, et al. Building brain capital. Neuron. 2021;109(9):1430-1432.

32.Ellsworth W, Smith E, Champman SB, et al. Move over data, brain capital is the new oil. Psychiatric Times. 2021. Accessed November 20, 2021. https://www.psychiatrictimes.com/view/move-over-data-brain-capital-is-the-new-oil

33. OECD. Neuroscience-inspired policy Initiative. January 13, 2021. Accessed November 20, 2021. https://www.oecd.org/naec/brain-capital/