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brain injuries a common result of intimate partner violence: research
a ubc professor is working with nurses and advocates for intimate-partner-violence victims to research brain trauma and improve medical responses
9 minute read
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when it comes to concussions, we often think of athletes who get hit in front of witnesses, typically receive fast medical help, and follow strict return-to-play rules.
“most of our concussion tools, protocols, assessments are around sports,” said jen ehirchiou, a nurse practitioner at fraser health’s embrace clinic for victims of interpersonal violence.
but potentially groundbreaking research, involving a university of b.c. professor and data from embrace patients, investigates victims of intimate partner violence suffering concussions after they are hit in the head, strangulated or violently shaken.
unlike most athletes, though, a major challenge with diagnosing and treating abuse victims is finding out about the head injuries in the first place.
“generally speaking, the only witnesses to domestic violence are children,” ehirchiou said grimly.
there is often no one around to document how many times the victims are hit, whether it has happened several times in the past, or if they lose consciousness or have a seizure. and there is rarely prompt treatment or the ability to follow recovery steps, such as staying in a dark room.
“these women can’t not go to work, in many cases they need the finances. they can’t stop looking after their children. all of a sudden, they’ve now moved to shelters where it’s not quiet,” said hannah varto, one of two nurse practitioners who launched embrace in surrey in 2015.
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in the past, varto said, concussion-like symptoms displayed by some victims of violence — headaches, memory loss, stress, blurry vision — were dismissed as emotional or psychological responses to the assaults.
only in the last few years have people began to link these behaviours to brain injuries.
“we know that with sports injury, especially around the research with football players, repeated hits to the head over and over — over years and years and years — can cause early onset dementia,” said varto, a nurse for two decades.
“and suddenly, we’re going: we’re seeing that in people who disclose the history of repeated violence over many years.”
nurse practitioners hannah varto (left) and jen ehirchiou with pads dog levi.
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embrace, the only clinic of its kind in canada to offer specialized followup care to violence victims after they’ve been discharged from an emergency room, has partnered with ubc-okanagan professor paul van donkelaar so researchers can now learn more about interpersonal abuse and head injuries.
embrace “sees people who’ve experienced intimate partner violence sometimes right away, within an hour or two of the experience, and at most within a day or two,” said van donkelaar, co-creator of ubc’s soar, or supporting survivors of abuse and brain injury through research, project.
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“being able to tap into that and collect data on some of their clients, will make it more analogous to the work that’s done in sport-related concussion.”
embrace provided him with years of data with the victims’ ages, types of assault, weapons used, injuries, symptoms and other details, but not names. and the nurses have now expanded the questions they ask based on the requirements of the academic research.
“we’re taking part to better understand how do we better diagnose brain injury in survivors of violence? is there an objective measure?” varto said.
she hopes the ubc research can lead to improved ways to treat concussions in these victims, lead to understanding the forms of assault that lead to brain injuries, and bolster evidence in court that head trauma is an outcome of intimate partner violence.
ideally, ehirchiou added, this will result in health-care providers looking for possible brain injuries in all victims of violence, because concussions take far longer to heal if treatment is not provided in the first 24 to 48 hours.
“the symptoms last longer, they’re more significant, they’re more severe, there’s a lot more disruption in returning to daily functioning, returning to work, returning to some semblance of emotional regulation,” said ehirchiou, a nurse for 23 years who joined embrace in 2019.
karen mason and ubc professor paul van donkelaar co-founded soar.
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like athletes or workers hurt on the job, women with head injuries from partner violence require a “clear pathway of care,” said karen mason, soar’s other co-creator. “there’s nothing like that specifically dedicated to this population. and given the numbers are so high, and the issue is so complex, it’s absolutely needed. so this (research) is like that first, first tiny step toward that.”
statistics canada reported this year that nearly half of women, or 44 per cent, who have had an intimate-partner experienced some form of abuse — psychological, physical or sexual — in their lifetime, which equates to about 6.2 million women aged 15 or older. reports of abuse increased during the pandemic, in part because of requirements to isolate, and many victims said the lack of affordable housing made it difficult to escape.
published studies suggest a very high number — up to 90 per cent — of victims of intimate-partner physical abuse suffer a brain injury, van donkelaar said, but added the exact tally is hard to pin down because not everyone reports the abuse or gets timely medical help, often due to stigma or fear.
soar was founded in 2016 after mason, who was then executive director of the kelowna women’s shelter, saw an article about the possible connection between brain injury and intimate-partner violence — something she had never heard of before despite working with vulnerable women.
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“i had this moment of, ‘oh, my god.’ thinking about women we serve who come across sometimes as oppositional, come across as difficult, forget to do chores in the shelter, forget appointments, seem to get angrier than some others,” said mason. “what if these women have had a brain injury and we don’t know? and are there things we could be doing to serve them better?”
she contacted van donkelaar, a friend who was then studying concussions in athletes, and he discovered very few academics were examining this theory, with the exception of eve valera, a harvard psychiatry professor who studies brain injury from intimate-partner violence. after speaking with valera, van donkelaar began researching this topic, in collaboration with kelowna women’s shelter residents who experienced partner abuse.
around the same time soar was established, fraser health got funding to start embrace. the need was identified by forensic-nurse clinics in hospitals, where violence victims received wraparound care but then often struggled, for various reasons, to get followup help after being discharged.
embrace nurses connect with these patients within 72 hours of leaving hospital, and also provide rapid-access care for victims too scared to go to the emergency room. they document bruises, provide minor wound care, do trauma-informed pelvic exams, and look for signs of strangulation and concussions.
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there is a new “strangulation clinic” within embrace, because this injury is often under-reported but deserves more attention, varto said. when the neck is squeezed, blood vessels are blocked and stop oxygen from flowing to the brain. this can have long-term effects that include brain impairment due to oxygen deprivation, strokes caused by blood clots, and damage to the thyroid and the hyoid bone.
“it’s really only been in the last 10 years that health care and the legal system has started to recognize strangulation as a serious physical aspect of violence,” varto said.
she hopes the strangulation clinic’s blunt name will encourage patients to seek out its services and police to refer victims to it. statistics show more women are coming to embrace, and more of those have been strangulated.
nurse practitioner hannah varto at the embrace clinic.
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in the fiscal year from april 2021 to march 2022, it averaged 28 new patients a month, with one quarter of them reporting strangulation and 15 per cent with brain injuries. between april and august of 2022, new patients increased to 34 per month, with one third strangulated and one quarter with brain injuries.
embrace’s clients are mainly teen girls, women, or people who identify as female, but also include some men, and come from all demographics. they endure many different types of violence, from many different types of people in their lives.
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cole reinbold, 23, who is a member of the executive team of vancouver island university’s student union, was asked by some faculty in the department of women and gender studies to post a video online to change the language around domestic abuse. her youtube message, posted last fall, also told students about helpful resources on campus.
“young people … are often quite naive when it comes to what is healthy. and so we are much more susceptible to abuse if we haven’t had the perfect model, or if we follow pop culture because a lot of pop culture does romanticize abuse,” said reinbold, a member of the b.c. federation of students.
“it’s common to be completely blinded to the fact that abuse is happening, and it won’t be until you and your partner break up that you realize, ‘oh, my gosh, i was definitely being abused.'”
she was not aware that interpersonal violence could cause concussions, but said the implications of abuse permeate all areas of young people’s lives.
“the impact puts barriers against education, their health, their safety,” she said.
cole reinbold of the vancouver island university student union.
clodagh stankard
researching the link between partner violence and brain trauma is crucial, argued ehirchiou, because after each concussion, it takes less-powerful blows to cause the next one. and the more they happen, the greater risk of long-term cognitive impairment.
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soar has now published several studies, including one that concluded concussion-like symptoms in victims who suffered repeated partner violence were generally more severe than those suffered by athletes with concussions diagnosed more quickly.
its research also shows that women who were strangulated, in addition to being hit, had more serious brain trauma because they suffered two injuries — cutting off oxygen supply from the neck and the force to the head.
soar has developed, as well, several resources to train people about possible head injuries in victims of violence, including one for women’s shelter staff as part of the online concussion awareness training tool created by a b.c. children’s hospital doctor. more than 600 women support workers have done this training.
van donkelaar is now collaborating with ubc pathology professor cheryl wellington to develop a simple blood test that could indicate when someone has a concussion or brain injury, based on elements in the blood that intensify shortly after strangulation or a major blow to the head. blood drawn from embrace patients will be used for this project.
“that’ll be the first really direct evidence … that will give us more confidence in saying these people have experienced brain injuries,” he said.
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it never occurred to the domestic abuse survivors who participated in soar’s research that their brains might have been damaged, mason said.
“they’re accustomed to waking up in the morning and feeling really dizzy, they’re accustomed to the fact that they forget things all the time, or that they have problems regulating their emotions,” she said, adding that perception is finally starting to change as this research continues.
“a lot of them have expressed a sense of validation, to be able to put a label to this thing that was creating incredible challenges for them. and to also know that it’s not their fault.”
embrace clinic appointments can be made by phone or text 604-807-5406, or email embraceclinic@fraserhealth.ca. if outside business hours or you’re in a crisis, visit an emergency room or call 911. more info at fraserhealth.ca/embraceclinic
nurse practitioner jen ehirchiou with tools she uses at the embrace clinic.
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