Issue 28: Traumatic Brain Injury & Violence Against Women
This Issue will:
- Examine the prevalence of IPV-related TBI
- Share how a TBI can be recognized
- Highlight how barriers complicate help-seeking
- Provide resources that support women’s individual and collective resilience
Traumatic Brain Injury (TBI) is “an injury which disrupts the normal functioning of the brain. The result of such disruption may include changes in physical, cognitive and/or emotional wellbeing.” It is one of the leading causes of long-term disability.
TBI can be the result of violence including being hit in the head (e.g. punched, shoved into a wall or floor, hit by an object), arduous shaking, and non-fatal strangulation. The lingering symptoms of TBI (e.g. headache, sleeping problems, irritability, memory problems) are also referred to as post-concussive syndrome.
Head injuries and/or probable TBI is prevalent in women experiencing violence, including Intimate Partner Violence (IPV):
- In a 2017 U.S. study with 225 women whose IPV experiences were reported to law enforcement, 56% screened positive for TBI
- In a 2018 study with 65 women and transgender women engaged in sex work in the U.S. and Canada, 61% sustained head injuries during sex work
- In a 2018 U.S. study with a convenience sample of 901 women of African American descent, 50% of women with lived experience of IPV reported probable TBI
The high percentage of probable TBIs for women with lived experience of IPV is likely related to high rates of non-fatal strangulation and hits to the face, neck, and head that women experience. Data on the results of TBIs is, however, constrained due to limited research, lack of screening, and possible misdiagnosis or missed diagnosis.
There are a number of ways that TBI in the context of violence against women can be distinguished from TBI in other contexts:
- Women experiencing violence may endure frequent and cumulative incidents of abuse without time for recovery which may cause multiple TBIs, longer recovery times, and more severe impacts
- Resources and support for TBI sustained through violence are sparse as professionals are less likely to recognize TBI in the IPV context
- The effects of TBI may be mistaken as the impacts of psychological abuse (e.g. Post Traumatic Stress Disorder)
- Presence of a TBI may impact a women’s ability to stay safe (e.g. find employment and housing, leave an abusive partner) and may increase the possibility of revictimization
The focus of this Issue will be on women’s, including transgender women’s, experiences of TBI.
The Issue takes an intersectional approach to examining how privilege and disadvantage affects the lives of different women, and how these impact their various experiences of TBI and violence.
Prevalence of Violence Against Women Causing TBI
IPV-related TBI is prevalent amoung women. Since intimate partner violence typically occurs over time, there is an increased chance that women experiencing IPV may experience multiple TBIs. A preliminary study of 20 women who experienced IPV found that all participants reported at least one probable partner-related TBI and 75% reported multiple probable TBIs.
Cumulative TBIs are dangerous as they increase the risk of serious and permanent injury.
Rates of TBI are likely to be higher for women who have experienced multiple forms of violence (e.g. sexual violence, child maltreatment). A small qualitative study conducted with women, including transgender women, sex workers in Toronto found that 9 out of 10 of participants reported obtaining TBIs throughout their life course. The reported causes of these injuries ranged from child maltreatment to experiences of violence from intimate partners, friends, clients, and strangers.
Women with disabilities and D/deaf women face disproportionately high rates of violence in Canada which puts them at increased risk of TBIs. The presence of a TBI may also amplify a woman’s vulnerability and increase the likelihood of further victimization experiences.
Learn more: Click here for our Issue on Women with Disabilities and D/deaf Women, Housing, and Violence.
Violence Against Children & TBI
Children living with IPV are at risk of child abuse which in turn increases the likelihood that they will experience TBI.
7 in 10 children who witnessed violence by their parent or guardian against another adult reported that they had experienced childhood physical and/or sexual abuse.
Studies have found that there is an association between adverse childhood experiences and TBI. In particular, childhood physical abuse and psychological abuse were found to increase risk of a TBI.
Abuse-inflicted head injury is “the most common cause of death and long-term disability as a result of physical child abuse.”
Non-fatal strangulation, and possible subsequent TBI, is underdetected and undertreated.
Non-fatal strangulation may leave visible signs like bruises and petechiae but it is common for signs to be invisible. For example, bruising may be difficult to detect, especially on darker skin. Also, screening may not always be conducted for non-fatal strangulation, especially among same-sex couples.
Learn more: WomenatthecentrE’s A Fresh Breath initiative engaged in a participatory action research project to explore the physical and emotional impact of strangulation on women with lived experience of intimate partner violence. Read their report.
Common symptoms of TBI include:
- Chronic pain
- Loss or reduction of vision and hearing
- Sleeping difficulties
- Motor and balance problems
- Difficulty concentrating
- Decreased alertness
- Incapacity for sustained attention
- Memory loss
- Difficulty with reasoning, planning, and understanding
- Slurred speech
- Intrusive thoughts
Psychological and Emotional
- Emotional sensitivity
- Exacerbation of PTSD symptoms
Maria sought refuge at a domestic violence shelter after arriving in Canada and leaving her partner. While at the shelter, she expressed a desire to work and engaged in activities to seek employment.
Staff assisted her in setting up interviews for a variety of positions. Staff began to get frustrated when Maria missed her appointments. Maria had trouble keeping track of all the appointments and even when she remembered, she had difficulty waking up and reading the map to find the appointment location. When talking to staff about the appointments, Maria was perceived as aggressive and told them that “my head has been off since he hit me with a bat and I woke up in the hospital!”
What possible indicators are there that Maria experienced a TBI? What kinds of other factors should we consider in trying to understand Maria’s experience in seeking support (e.g. racism)?
What is the Relationship between PTSD and TBI?
The lists below illustrates the overlap in symptoms between TBI and Post-Traumatic Stress Disorder (PTSD). Due to this overlap, IPV-related TBI are often undetected. Unlike with TBI, the association between PTSD and IPV is widely recognized.
- Difficulty concentrating
- Sleep disturbance
- Memory difficulties
- Problems with concentration
- Sleep disturbance
- Dissociative amnesia
- Irritable behavior and angry outbursts
Women’s experiences of PTSD and TBI may frequently co-occur as impacts of violence.
Barriers Complicating Help-Seeking
A study of 208 women in shelter found that out of 88% of women living with probable TBI, only 21% sought medical care for their injuries. This low number may be due to barriers that compromise women’s ability to access resources, some of which are addressed here. Such barriers are compounded for women who experience intersecting oppressions (e.g. racism, colonialism, ableism, audism) that impact access to services.
Fear of Knowing
Some women expressed concern about learning that they have TBI as a result of violence:
“I never really told anybody in the shelter, or went to the doctor’s even though when I went to the shelter they knew about it. They told me I needed to go to the doctor’s right away but I never went because they might tell me something I don’t want to hear because I know there’s something wrong with me. I know I’m not normal after that. I know there’s something wrong with my head or my hearing.”
It is important to note, however, that some women have shared that it was reassuring to know they have a TBI as it explained the symptoms they had been experiencing, opened up new opportunities for support and strategies for coping, and showed how their symptoms were connected to the violence.
Fear of Reprisal
Experiences of abuse and coercive control may hinder women’s ability to seek supports. For instance, women report fear of being killed if they share their experiences of violence and TBI with others:
“If I was just to go out and say look, [my man] did this and this, if I ever did that he would definitely... come back and try to either just get rid of me... I didn’t want the chance that [they would] find me dead in the woods or something like that.”
Lack of Awareness and Research
That violence against women could result in TBI is still not commonly known amongst service providers, first responders, and people living with a TBI. As such, many professionals do not screen for TBI. Research on the connection between violence against women and TBI is likewise limited. In particular, research that explores how intersecting social locations (e.g. race, gender identity, sexual orientation, disability) impact experiences of TBI and care are needed.
Institutional and Organizational Barriers
The environment of services like hospitals, shelters, and detox centres may be difficult for those with TBI due to the amount of light and noises in these spaces. Furthermore, individuals with TBI may have difficulty following the expectations and appointment schedules in those environments due to both the TBI and their life circumstances (e.g. not being able to take time off work). Coping with violence and the stress related to that can also exacerbate the effects of TBI.
Stigma against women with violence related TBI intertwined with systems of sexism, ableism, and audism. It diminishes the perceived competency and capability of women with TBI, and undermines their access to justice, housing, and economic opportunities. Stigma against women with TBI may be exploited by those engaging in abuse, and others, to discredit women’s capacity to care for themselves and their children.
The negative outcomes of this stigma can be compounded for those who are socially marginalized in other ways as well. For instance, women and transgender women sex workers expressed how widespread stigma and oppression negatively impacted their ability to seek support and justice:
“If I have to go to the hospital, I’d lie and say I was drunk and fell or something stupid, like I was in a fight, drinking even though I wasn’t. If I got punched in the mouth from a date, I’d just say, you know, ‘I was drunk and got in a fight.’ I wouldn’t tell the whole truth.”
Narratives throughout this issue are used with permission. We are grateful to the researchers and the women who shared their experiences.
How can Experiences of TBI Compound Difficulties in Securing Safe and Accessible Employment and Housing?
Securing employment and housing that is safe, secure, and accessible can be difficult for women living with violence and TBI. Their options for jobs maybe limited by a lack of accessible work environments (e.g. bright lighting, loud noises, no time for breaks, no workplace harassment policy, no paid leave). Without employment, women may face income insecurity even if they are able to obtain social assistance.
Similarly, finding housing that is affordable and accessible can be difficult in urban areas due to costs and in rural settings due to availability. A study of TBI for those experiencing homelessness in Toronto found that there was a high prevalence of TBI in the women participants (42%). The study also found that first experiences of TBI often occurred at a young age and before a person’s first experience of homelessness, suggesting that TBI may contribute to homelessness, although future research is needed.
Learn more: More than a Footnote: A Research Report on Women and Girls with Disabilities in Canada by the DisAbled Women’s Network of Canada documents the conditions and lived experience of women with disabilities in Canada, including income insecurity and housing precarity.
How can Services be Responsive to the Needs of Women Living with TBI and Violence?
Included here are some suggestions for supporting women who have experienced violence and TBI, however there is no one-size solution as women’s strengths and needs differ.
1. Be Aware
Raising awareness about TBI can help to ensure that women receive the correct screening and diagnosis. This can come in various forms including providing information about TBI and the symptoms that individuals may be experiencing in shelters, hospitals, and sexual assault centres.
Learn more: Access a shareable infographic on Traumatic Brain Injury (TBI) and Intimate Partner Violence (IPV): Supporting Survivors in Shelters.
2. Screen for Potential TBI
Thus far, screening of TBI in the context of violence has been limited. Training is needed for staff members who interact with women experiencing violence to recognize potential signs of TBI and connect women with external professionals for further screening and diagnosis (e.g. forensic nurses).
There is also a need for more appropriate screening tools for TBI in the context of IPV, including the particular means by which a woman may acquire a TBI through violence (e.g. being hit in the head or by an object, strangulation, drowning). Research suggests that women living with violence tend to prefer self-administered questionnaires as they underreport violence face-to-face.
If a woman disclosures a head injury, it is also important to engage in danger assessment as they may be at higher risk of intimate femicide and/or further violence.
The results of screening can aid in connecting women with supports and services. In addition, a medical diagnosis could help women to gain financial assistance for their TBI and could be included in potential abuse charges.
3. Know the Services in Your Community
There are already a number of existing services that offer information, assistance, and treatment for those who are brain injured. In Ontario, the Ontario Brain Injury Association (OBIA) offers:
- An online support group system for individuals which includes a social worker and peer group
- A peer support program that matches mentors and partners based on their similar experiences and interests. This program is also open to family members and caregivers
- A helpline offering confidential emotional support and referrals open from 9:00 a.m. to 5:00 p.m. EST on Monday to Friday: 1-800-263-5404
4. Build TBI-Sensitive Services
In a survey of 19 Toronto-based agencies providing IPV support services, researchers found that training about IPV-related TBI was often lacking but highly desired. While 84% of the agencies reported little or no previous TBI education or training, 88% said they would be willing and able to create TBI inclusive services. Learn more: View a video and read an article about findings from the survey and subsequent workshop conducted on building TBI-sensitive services within the IPV sector.
Below are some suggestions on how to build TBI-sensitive services for women with lived experience of violence:
- Share information about TBI, including how it is acquired and what its possible symptoms are
- Refer women for medical assessment and rehabilitation as possible and desired by women
- Create space with low stimulation (e.g. low light, minimal noise)
- Ensure that meetings are short, paced to match women’s needs, and include regular confirmation that the information presented is accessible
- Engage in ongoing safety planning that takes into consideration the symptoms, needs, and strengths of the woman, including protecting against another TBI (e.g. shielding their head, removing tripping hazards)
- Introduce checklists, daily planners, and journaling so that information, tasks, and activities are written down
- Build relationships with medical staff, brain injury services, disability activists, and others to build awareness of abuse related TBI and how to support women
- Obtain respite services for mothers
- Offer culturally relevant services and trauma- and violence-informed responses. Learn more: Read about Dr. JoLee Sasakamoose’s presentation on an Indigenous framework for understanding TBI and IPV in the Learning Network Knowledge Exchange Summary Report
- Ensure accessible programming and service provision. Learn more: Find training and resources on what organizations need to do to become accessible in the long term as part of OCASI’s Accessibility Initiative
- Institute policy and procedural reform to ensure that housing is accessible to women. Learn more: Read this Learning Network Brief where Doris Rajan shares findings from a focus group with Indigenous, racialized, refugee women and women with intellectual and psychosocial disabilities about their housing needs
5. Promote Individual and Collective Resilience
It is important to recognize the strengths that women already have in themselves and in their community. Supporting women may involve highlighting their own interests (e.g. art-based practice, body work) and supports (e.g. family, friends, companion animals). It may also be recognizing the collective support that some women experience within their faith, culture, race, and other communities. Collective experiences can offer a sense of belonging, identity, and control.
Learn more: Watch our webinar on Traumatic Brain Injury (TBI) and Intimate Partner Violence: Implications of the Co-occurrence of PTSD & TBI with Dr. Akosoa McFadgion. She explores the relationship between TBI and PTSD in the context of IPV through the unique experiences and collective resilience of black women.
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