When pandemics clash: Gendered violence-related traumatic brain injuries in women since COVID-19

Recent articles highlight reports of escalating rates of domestic violence (DV) in numerous countries including, for example, a 300% increase in police reports of intimate-partner violence (IPV) likely fuelled by effects and mitigation strategies of COVID-19.[1]Peterman A. Potts A. O'Donnell M. et al.Pandemics and violence against women and children.Center Global Dev Work Paper. 2020; 528 (DC: Center for Global Development)Google Scholar Left out of these reports is any mention of a possibly coincident surge in one of IPV's most dangerous yet often overlooked consequences, traumatic brain injuries (TBIs). All clinicians need to be aware of this in order to ensure optimal interventions and avoid additional harm. Approximately one in four women experience severe IPV,[2]Breiding M.J. Chen J. Black M.C Intimate partner violence in the United States — 2010.in: GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta2014Google Scholar with most recorded injuries to the neck and higher,[3]Wu V. Huff H. Bhandari M Pattern of physical injury associated with intimate partner violence in women presenting to the emergency department: a systematic review and meta-analysis.Trauma Violence Abuse. 2010; 11: 71-82Crossref PubMed Scopus (143) Google Scholar including frequent high-impact forces to the head.[4]Valera E.M. Kucyi A. Brain injury in women experiencing intimate partner-violence: neural mechanistic evidence of an “invisible” trauma.Brain Imaging Behav. 2017; 11: 1664-1677Crossref PubMed Scopus (80) Google Scholar Data suggest staggeringly high rates of IPV-related TBIs even under “normal” conditions.[4]Valera E.M. Kucyi A. Brain injury in women experiencing intimate partner-violence: neural mechanistic evidence of an “invisible” trauma.Brain Imaging Behav. 2017; 11: 1664-1677Crossref PubMed Scopus (80) Google Scholar, [5]Valera E.M. Berenbaum H. Brain injury in battered women.J Consult Clin Psychol. 2003; 71: 797-804Crossref PubMed Scopus (122) Google Scholar In COVID-19 conditions, as violence escalates, women who may want to escape may not have the option due to mitigation strategies or contamination fears, likely resulting in more severe forms of abuse including TBIs. IPV-related TBIs have been linked to poorer cognitive, psychological, and neural health.[4]Valera E.M. Kucyi A. Brain injury in women experiencing intimate partner-violence: neural mechanistic evidence of an “invisible” trauma.Brain Imaging Behav. 2017; 11: 1664-1677Crossref PubMed Scopus (80) Google Scholar, [5]Valera E.M. Berenbaum H. Brain injury in battered women.J Consult Clin Psychol. 2003; 71: 797-804Crossref PubMed Scopus (122) Google Scholar However, women are often unaware they have sustained TBIs or understand the importance of reporting them. Consequently, post-TBI symptoms – such as depression, anxiety, cognitive, or sleep difficulties - may be misinterpreted as psychological responses to the abuse resulting in misdiagnoses, inappropriate treatment, and unsuccessful outcomes. It is every clinician's responsibility to screen for IPV-related TBI. Couching questions in the context of COVID-19 as a risk factor for violence may reduce stigma associated with being abused. Screening can be as simple as inquiring about partner-related hits, jolts or forces to the head that resulted in an alteration or change in consciousness as indicated by a loss of consciousness (even if very brief), disorientation, confusion, memory loss, dizziness, or seeing stars or spots. If IPV-related TBI appears to be likely, referral to a neurologist or concussion specialist should be made. This will provide women with an opportunity to obtain information about sequelae of TBIs, and understand that problems they may have with anxiety, depression, cognition or sleep, may be related to TBIs rather than merely “psychological stress.” We need to inform women of the dangers of IPV-related TBI and offer them resources. The clash of IPV and COVID-19 has created a perfect storm for an increase in this “invisible trauma.” If we do not act now, we risk facing yet another pandemic of women who are struggling to live with the effects of likely undiagnosed TBIs. Dr. Valera reports grants from National Institutes of Health, grants from Rappaport Fellowship, during the conduct of the study; grants from National Institutes of Health, grants from Rappaport Fellowship, outside the submitted work; Dr. Valera reports grants from National Institutes of Health, grants from Rappaport Fellowship, from Canadian Concussion Centre at The Krembil Neuroscience Centre, from Ontario Brain Injury Association, from Oatley Vigmond Law Firm, from Learning Network at the Centre for Research & Education on Violence Against Women & Children (CREVAWC) and Western University, from Quebec Women's Shelter Association, from Organization for Economic Cooperation and Development, from Santa Clara Superior Court, from NINDS, CNRM, DVBIC, NCMRR, NICHD, and ORWH, from Institute on Violence, Abuse and Trauma, from The CACTIS Foundation, Sojourner centre, University of Arizona College of Medicine, during the conduct of the study; grants from National Institutes of Health, grants from Rappaport Fellowship, from Canadian Concussion Centre at The Krembil Neuroscience Centre, from Ontario Brain Injury Association, from Oatley Vigmond Law Firm, from Learning Network at the Centre for Research & Education on Violence Against Women & Children (CREVAWC) and Western University, from Quebec Women's Shelter Association, from Organization for Economic Cooperation and Development, from Santa Clara Superior Court, from NINDS, CNRM, DVBIC, NCMRR, NICHD, and ORWH, from Institute on Violence, Abuse and Trauma, from The CACTIS Foundation, Sojourner centre, University of Arizona College of Medicine, outside the submitted work; none. 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