AUSTRALIA/ In photos of her face taken the Saturday night she was knocked unconscious, Ashley’s* eye is swollen and purple, a dark bruise spilling from her lashline to her cheekbone. There’s blood dripping from a gash on the bridge of her nose towards her split lip. Her eyes appear red, as if she’s been crying. She looks scared, and sad.
Police had arrived at Ashley’s house that evening in 2021 on a domestic violence callout, after her abuser — an army-trained man much bigger than her — came to her home in Brisbane’s outer suburbs and refused to leave. While they were arguing in the front yard, she says, he whacked her in the head with a metal pole. The next thing she remembers is waking up at the bottom of her driveway, vomiting and in pain.
Later, an emergency doctor at the local hospital would diagnose her with a concussion, several fractures to bones in her nose and a perforated eardrum. But the police, who interviewed Ashley in the back of an ambulance, seemed to regard her unsteadiness and agitation as confirmation of her perpetrator’s account of what happened: he slapped Ashley, with his palm, in self-defenses — and she also had a drinking problem. They applied for a domestic violence order against her, which she says she accepted because she didn’t want to go through a stressful fight in court.
“I think they just got it in their head that, ‘Oh, she’s had a couple of drinks, she’s gotten violent and this is the result’,” says Ashley, who is adamant she had three drinks over about eight hours that day. “The police officers repeatedly accused me of being drunk,” she later said in a statement for the court. “I was not drunk. I was concussed and suffering nausea, vomiting, disorientation and for a while unconsciousness from the blow I had to my head.”
It wasn’t her first brain injury, either. When she was 18, Ashley’s ex-partner, a “very violent” and controlling man, punched her in the head, fracturing her skull and perforating her ear drum. “One more hit to my head, the doctors said, and it would have been game over,” she says. “It took me a long time to get over it. I was very, very scared for my life for a long time.”
Australians are becoming increasingly aware of the risks and ramifications of brain injuries, with concussion in contact sports dominating media coverage and Senate inquiries in any given week. But the links between domestic violence and brain injury remain bafflingly under-discussed and the long-term consequences an invisible crisis — despite evidence suggesting victims are sustaining head injuries at staggering rates.
American and Canadian research suggests as many as three-quarters of female victims of domestic violence have suffered traumatic brain injury (TBI), with some experts estimating up to 20 million women in the US sustain TBIs through partner violence every year — 11 to 12 times the number experienced by athletes and military personnel combined.
And in 2018, the first major Australian study of brain injury and family violence found 40 per cent of victims attending Victorian hospitals over a decade had suffered a brain injury, though researchers said it was likely just “the tip of the iceberg” given how few victims seek medical care.
Still, many domestic violence workers aren’t trained in identifying TBI signs and symptoms, and few frontline services screen victims for potential brain injury — a missed opportunity, experts say, to connect them with medical specialists and improve their chances of recovering. Instead, women across the country are falling through gaping cracks in the health system, unable to access treatment for debilitating chronic symptoms that affect their mental health, their capacity to work and, crucially, their ability to leave abusive relationships.
Some experts also fear victims who experience frequent domestic violence may be at risk of developing dementia or even chronic traumatic encephalopathy (CTE), a degenerative brain disease that has been found in deceased football players, boxers and other athletes. Others find themselves colliding with the criminal justice system or in prison, having struggled to cope with their symptoms.
“I think there’s a lot of conversation about concussion in sport, and there’s been campaigns and … guidelines about when you should return to play,” says Michelle Fitts, a senior research fellow at Western Sydney University. “But we don’t seem to have those conversations about women who’ve experienced concussion repeatedly as a result of violence. We need to raise the profile and visibility of head injury in relationships as well … and educate the community about the potential long-term harm and disability you can cause someone.”
Debbie Hewitt, a solicitor at Women’s Legal Service Queensland who obtained police body-worn camera footage of Ashley’s callout, says the attending officers believed her abuser slapped her in self-defence even though “his story wasn’t credible”. “I think one police officer in particular became more inclined to believe his account … when he put that view to [Ashley] while she was in the back of the ambulance … and she got angry at him. I think that was the turning point; he saw her as belligerent and uncooperative — and then you can see him reframing the whole incident around her being the perpetrator.”
But the officers’ assumption that Ashley was drunk — not concussed — was “pivotal” to their “reframing” of what happened, Ms Hewitt says. “We see a lot of women who are misidentified by police as the perpetrator … it may be because they’re concussed … or there’s hypoxic brain injury from strangulation,” she says. “The trauma of the violence is [also] distressing and may mean they behave differently to how police expect victims to behave. But I would think there are a lot of cases where concussion, head injuries, is exacerbating it.”
Shaken brains
Brain injuries are often described as “invisible” injuries: other people can’t “see” them, but their impacts can be devastating. Usually they’re caused by the brain moving suddenly within or against the skull after a blow to the head or body, in some cases resulting in a loss of consciousness.
The initial impact can cause bruising and swelling, while the forces that shake and stretch the brain can damage neurons, triggering chemical and metabolic cascades and tissue damage over days or weeks. This can disturb the brain’s delicate circuitry and generate symptoms like fatigue, headaches, slowed thinking and difficulty concentrating, noise and light sensitivity, dizziness, insomnia, anxiety and depression.
Until relatively recently, though, less severe brain injuries — particularly concussion, the most common traumatic brain injury — were dismissed as minor mishaps that resolved quickly and without complication. Mounting evidence now shows they can have serious consequences and require careful management, especially for the significant minority of patients who don’t recover within the “typical” few weeks.
For those who sustain multiple brain injuries, the stakes are raised: researchers at the Universities of Oxford and Exeter recently found people who suffered three or more concussions had much poorer cognitive function which got successively worse with each one after that.
Still, it’s unclear how many people in Australia are sustaining brain injuries as a result of domestic violence, a gendered issue experienced by more women, and more severely, than men. Partly it’s because concussions — of which there are an estimated 170,000 every year — are not systematically tracked. And most of the research focuses on sports-related concussion, even though it makes up just 20 per cent of mild TBI, with the majority a result of falls, motor vehicle and bike accidents, and assaults.
Small clues, though, point to a potentially massive problem: A 2021 report on domestic violence-related hospitalisation over nine years found head injuries were the most common injury leading to a hospital stay, with intimate partners responsible for the majority of admissions and women much more likely to be injured than men. And a 2017 case analysis of women and girls hospitalised for assault found 69 per cent were attacked in their home, with the majority of injuries to the head and neck area.
But not everyone goes to hospital, or even to a GP, for diagnosis. “We really don’t know the extent of brain injury as a result of domestic violence in Australia — it’s one of the key things we should be trying to find out,” says Sarah Hellewell, a senior research fellow in neurotrauma at the Perron Institute and Curtin University. “We don’t know how often it’s happening or even what kinds of injuries people are getting.”
We don’t know, for instance, how often hypoxic or anoxic brain injuries from strangulation happen at the same time as TBI, Dr Hellewell says: “But I think we can expect that they happen quite frequently when victims are being choked and hitting their head against something as well.” We also don’t know what victims’ recoveries look like, she says, “particularly whether they’re having ongoing injuries in the context of fear and stress, and how that can influence the pathology and recovery”.
These questions become more urgent in light of several studies showing that women are more susceptible to concussion and take longer to recover than men, for reasons scientists are still trying to understand.
But like many other health issues, women’s experiences of brain injury remain disturbingly understudied — mostly on the basis that female sex hormones can complicate medical research. As Katherine Price Snedaker, the founder and executive director of PINK Concussions, told Forbes in 2019: “If brain injury is the ‘invisible illness’ of our time, then within this invisible injury, women have been the invisible patients.”
The lack of progress in this space has been perplexing Eve Valera for more than 20 years. An associate professor in psychiatry at Harvard Medical School and a research scientist at Massachusetts General Hospital, Dr Valera’s interest in brain injuries and domestic violence was sparked while she was volunteering at a battered women’s shelter during graduate school. There, she noticed many of the symptoms often attributed to the trauma of abuse overlapped with those of brain injury.
“Some of these women are hit in the head with hammers or stomped on with work boots or thrown down stairs and off porches,” she says. “And I was like, they’ve got to be sustaining brain injuries.”
When she discovered there were almost no studies on the issue, she decided to pursue her own. The paper Dr Valera published in 2003 is still cited widely: of 99 women from local shelters she interviewed, three-quarters reported sustaining at least one brain injury as a result of partner violence, including through strangulation, and more than half had sustained multiple.
Yet none of the terrorized women arriving at shelters were being screened for brain injury and referred for medical care — instead, their behavioral and cognitive problems were being put down to “depression” and “PTSD”.
“We have to recognise that women are sustaining brain injuries, that it’s not just all in their head … it’s not psychological,” Dr Valera says. “There are consequences to these brain injuries that women and others need to understand. If you think of the resources shelters provide, they may have a social worker, a therapist, somebody with some legal experience. But there’s no neuro-rehab, no one’s thinking about anything like that. And if, say, 50 per cent of the women going into shelters are experiencing brain injuries, isn’t that a problem?”
It’s one reason why frontline workers need to ask careful questions about head injury and strangulation, Dr Valera says: “Because women won’t necessarily offer it up, they won’t necessarily think it’s important.” It also allows victims to seek a diagnosis, and treatment. “At least in my experience, people find it relieving to be diagnosed with brain injury and given information about their symptoms.”
Some will also have very different life courses if they understand what is at stake: “If you get out of the relationship, if you sustain no more brain injuries, maybe things will [improve] — the brain can heal,” she says. “But … we know that if you continue to sustain brain injuries your brain doesn’t have a chance to heal.”
First Nations women get second rate care
Buried within the research on brain injury in Australia is a startling statistic, from a 2008 study by researchers in Adelaide: Aboriginal women experience head injury — including traumatic brain injury — due to assault at 69 times the rate of non-Indigenous women. Yet almost two decades later, still too few Aboriginal women are getting adequate treatment and, according to Michelle Fitts, not enough is known about their needs.
“Most of the research has been done with metropolitan-based, non-Indigenous patients and … patients who have experienced moderate or severe brain injuries”, not milder injuries like concussion, Dr Fitts says. The research gap is especially confounding considering Aboriginal women experience disproportionately higher rates of violence from men of all cultural backgrounds — and homicide — than non-Indigenous women, and poorer responses from police.
First Nations women in remote communities typically have to travel long distances to access medical services for TBI, Dr Fitts says, while a lack of local specialists means getting a diagnosis is difficult unless women are flown out for emergency care. This can limit the kinds of support they’re able to access and disadvantage legal matters. As one frontline worker in a remote region told Dr Fitts and her colleagues last year:
“You get their medical histories and their police records, and they’ve just been basically pummelled within an inch of their life, for all of their life … and you just look at the totality of it and go, how does this person even function at any level?” But without a diagnosis, they said, “You then have problems … convincing a court that there is a disability at play here which is an important factor to be taken into account when sentencing them or when a determination is made.”
Still, many frontline workers haven’t completed brain injury training or education, Dr Fitts says, and often don’t recognise their signs and symptoms. “I think once people know about it, it’s like a light-bulb moment where they’ll go, ‘Ah ha, I see this now in some of my clients’ — where previously they may have attributed their behaviour to mental health or drugs and alcohol or a combination of those things. It may also be — or it may just be — the traumatic brain injury.”
Compounding the problem is that Aboriginal women often won’t access hospital or support services for complex reasons that can be traced back to settler colonisation. For another recent study, Dr Fitts and her team interviewed dozens of women and frontline workers in Queensland and the Northern Territory to better understand the barriers, which include a lack of awareness of brain injury symptoms, controlling partners stopping women from seeking help, and a fear of the violence escalating if they do.
But the most influential factor is a legitimate fear their children will be removed by protection agencies. As one woman in the study explained: “We won’t report when there is domestic violence. If there is any words that come from the woman that [her] children were there, children are considered at risk and so they are taken.”