New report from NCIWR on link between intimate partner violence and traumatic brain injury

National Collective of Independent Women’s Refuges | Ngā Whare Whakaruruhau o Aotearoa (NCIWR) have released a new report, Traumatic Brain Injury and Intimate Partner Violence in Aotearoa, that examines the unseen traumatic brain injuries (TBI) in women who have been physically assaulted by their partners or ex-partners. It highlights the high prevalence of brain injuries for intimate partner violence (IPV) victims and associated challenges with safety and recovery. The report is part of their wider multi-phase research project, Safer When, Safety How?.

NCIWR surveyed 1707 women and non-binary victims about their experiences of IPV and help-seeking. The majority (1328) had been physically assaulted by their partners, 10 percent (138) of whom reported having a known TBI caused by their partner’s use of violence. IPV-inflicted TBI is often undiagnosed, so NCIWR estimates the actual prevalence amongst the report’s sample is likely far higher. To explore how those with TBI experienced risk, support, and safety, the report compares responses from those with a known TBI with responses from respondents overall. As well as survey data, the report also draws upon risk data gathered from clients engaging with Women’s Refuge services.

The report found victims with a TBI experienced amplified and extended risks and harms associated with IPV, both during the relationship and after separation. Dr Ang Jury, CEO of NCIWR, said in the report’s media release:

“It is clear from this report that the likelihood of women sustaining a TBI from their partners’ abuse is much higher than we had thought. And this is not a bruise that heals quickly – these consequences last days, weeks and even years and have serious impacts on how a victim can function day to day and the type of support they receive.”

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Prevalence of IPV-inflicted TBI

Women’s Refuge risk data gathered from 1250 new clients in 2024 shows 77.5% have been physically assaulted by their abusers. Of those:

• 57% are hit or punched in the head by their abusers,
• 69.8% are pushed or shoved by their abusers, and
• 39.8% are strangled or suffocated.

Of those hit or punched in the head:

• 26.7% lost consciousness,
• 36.7% experienced physical symptoms like head/neck pain, fatigue, unsteadiness, or problems hearing or seeing in the days afterwards, and
• 30.4% experienced new difficulties with concentration, memory, or emotion regulation in the days afterwards.

Prevalence of TBI amongst IPV victims is high, but under-identification of it complicates prevalence estimates. The report notes that victims are often unable to seek medical care,  including assessment, diagnosis, or treatment for TBI.

Dr Ang Jury said:

“Because the connection between family violence and TBI is not widely understood, many women will not have TBI diagnosed by their GPs and may not even know what is happening themselves. Additionally, many will never even get the opportunity – over a quarter of women reported that their access to medical care was blocked by their abuser.”

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Key conclusions

The report draws key conclusions that should inform best practice when working with victims of IPV and those with TBI. It makes recommendations for specialist agencies involved because of IPV, healthcare services, services that determine and enable access to resources after an injury, and services involved with victims.

Intimate partner violence and traumatic brain injury are experienced in tandem

Victims with TBI reported worse impacts and worse outcomes in every measurable way compared with the overall group of respondents. Their comments underlined the immense toll that IPV-inflicted TBI took on their health, lives, and futures.

The report states: “In these victims’ lives, TBI and IPV do not simply co-exist; they are mechanised by one another and ultimately service abusers’ interests. It is therefore essential to name the abuser as the origin point for both, and as the instigator of the costs and consequences that IPV and TBI in tandem accrue within the victim’s life.”

Effective support must account for both the violence and the TBI

The presence of IPV affects how someone might recover from a TBI. Treatment must be designed for an IPV context, accounting for all challenges a victim faces, and may need to be more comprehensive or intensive to achieve recovery.

Healthcare providers must proactively enquire about head injury even when it is not the main concern victims are presenting with. Likewise, those responding to the violence must facilitate timely healthcare access after the disclosure of any assault involving the head, face, neck, or spine.

As IPV is the leading cause of TBI for women, the report says that failure to recognise and respond to IPV-inflicted TBI “perpetuates the gendered inequity of treatment… In short, the current landscape of TBI identification and treatment in Aotearoa, and internationally, appears oriented to the context of men’s TBI”.

Services can work better for women with IPV-inflicted TBI

Services need to identify IPV-inflicted TBI when it occurs and link the injury to the violence a victim experiences. They should advocate for and resource victims while addressing both the TBI and the IPV in empathetic, comprehensive, and sustainable ways. Some of the recommendations include:

• Specialist agencies responding to IPV can facilitate victim access to TBI healthcare and can support them by explaining the backdrop of IPV to healthcare providers.
• Health services can ask about assault and TBI, even when there are other possible explanations for a victim’s emotional or physical symptoms.
• After-injury support services can enable access to compensation, in-home support, funding for childcare, and rehabilitative pathways.
• Services involved with victims can help by modifying their agency’s approach to make it as feasible, easy, and sustainable for victims as possible.

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Traumatic brain injuries in te ao Māori

NCIWR’s report notes that wāhine Māori with a TBI reported feeling less connected to whānau, whakapapa, reo, tikanga, and/or culture than they did before the abuse started, at higher rates than overall Māori respondents.

For discussion on traumatic brain injuries from a te ao Māori perspective, see the following research from Dr Hinemoa Elder and colleagues:

• Elder, H. (2012). ‘Tuku iho, he tapu te upoko - From our ancestors, the head is sacred’: Indigenous theory building and therapeutic framework development for Māori children and adolescents with traumatic brain injury [Doctoral dissertation, Massey University]
• Elder, H. (2012): An examination of Māori tamariki (child) and taiohi (adolescent) traumatic brain injury within a global cultural context. Australasian Psychiatry, 20(1), 20-23 – Abstract only
• Elder, H., & Kersten, P. (2015). Whakawhiti kōrero, a method for the development of a cultural assessment tool, Te Waka Kuaka, in Māori traumatic brain injury. Behavioural Neurology, 2015(1), 137402

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Other NZ and Australian research on IPV and TBI

An article from King. et. al. (2023) - Intimate partner violence reporting and assessment of traumatic brain injuries and strangulation by a New Zealand hospital health service examines TBI assessments for IPV victims in an NZ hospital. It finds that less than 1% of IPV survivors had a TBI assessment, only 0.6% had a strangulation assessment, and only 0.5% had a referral for brain injury rehabilitation services. Reported loss of consciousness and strangulations caused by IPV were high in this hospital setting, yet they were rarely assessed, and Māori had the highest incidence per ethnic population of partner-inflicted TBI presenting to the hospital at 81.8 per 100,000 population.

An evidence brief from Women’s Health New South Wales - Non-fatal strangulation and acquired brain injury in the context of sexual violence (2024) - states: “Women’s brain injuries do not get the attention they deserve”. It discusses how brain injuries are popularly understood as injuries sustained by men during contact sports, which overlooks women’s injuries and experiences. The report focuses on non-fatal strangulation as part of a pattern of escalating IPV causing brain injury and its co-occurrence with other forms of physical IPV. It notes strangulation is both a potentially fatal act of violence and a key marker of escalating risk for further serious harm.

A qualitative study from Wills, E. and Fitts, M.: Listening to the Voices of Aboriginal and Torres Strait Islander Women in Regional and Remote Australia About Traumatic Brain Injury from Family Violence looks at the IPV and TBI experiences of Indigenous women in Australia and finds a range of gaps in healthcare and housing supports, highlighting the significant investment needed to develop responsive and appropriate pathways of care in regional and remote areas.

A factsheet from Tahū o te Ture | Ministry of Justice: Non-fatal strangulation/suffocation in New Zealand (2024) promotes understanding of the severity of non-fatal strangulation/suffocation (NFSS) and its links to intimate partner violence. It uses New Zealand data from risk assessments, case studies, and population surveys as well as some Australian data to report some measures of NFSS prevalence.