Traumatic Brain Injury in Female Intimate Partner Violence Survivors: Incidence,Sociodemographic Disparities,and Clinical Outcomes

Abstract

Intimate partner violence (IPV) represents a public health crisis in the United States. Experiencing IPV is associated with various adverse health outcomes and injuries, including traumatic brain injury (TBI). Improving screening and care for individuals affected by concurrent IPV and traumatic brain injury (IPV-TBI) requires understanding its incidence, sociodemographics, risk factors, and clinical outcomes. Using standardized multicenter data from the US National Trauma Data Bank years 2018 to 2022, this study aimed to answer the following questions: (a) What is the incidence of IPV-TBI among female patients treated for TBI at US trauma facilities? (b) Are there sociodemographic and clinical differences between female IPV-TBI and female non-IPV-TBI patients? (c) What hospital outcomes (length of stay [LOS], emergency department discharge disposition, hospital discharge disposition) are associated with IPV-TBI, based on TBI severity. Statistical differences were examined using Welch’s t-test and analysis of variance, Pearson’s chi-squared test with post hoc Bonferroni-corrected z-tests, and multivariate logistic and linear regressions. Our findings indicate that most female trauma center patients with assault-related TBI experienced IPV (76.8%), often inflicted by male partners (97.9%). Compared to those with non-IPV TBI, IPV survivors who experienced TBI were younger (mean 37.9 ± 12.5 years vs. non-IPV: 48.0 ± 12.4; p < .001) and more commonly insured by Medicaid (47.0% vs. 36.5%, p < .001). IPV-TBI was associated with significantly higher odds of discharge to home in female patients (aOR = 1.31 [95% CI: 1.01, 1.69]), and IPV-TBI patients were likely to have shorter hospital LOS than those with TBI from non-IPV assault (4.3 ± 6.8 days vs. 5.9 ± 9.8; p < .001). Our findings underscore the critical importance of screening TBI patients for IPV, given that the social and medicolegal contexts surrounding their injury and recovery may be substantially different from TBI patients without IPV, and being discharged home may present significant safety risks.

Keywords

traumatic brain injury (TBI)intimate partner violence intimate partner violence–traumatic brain injury (IPV-TBI)screening hospitalization national trauma data bank

Introduction

Intimate partner violence (IPV) remains an urgent public health crisis and pervasive social issue. Defined as “abuse or aggression that occurs in a romantic relationship,” IPV manifests in various forms, including physical violence, sexual violence, psychological aggression, and stalking (Centers for Disease Control and Prevention, 2022). IPV disproportionately affects women; in the United States, 47% of women have experienced contact sexual violence, physical violence, and/or stalking by an intimate partner in their lifetime (Leemis et al., 2022).

Violence in intimate partner relationships, which is rooted in gender inequality and problematic community and social norms, is about power and control (Dixon & Graham-Kevan, 2011). Partner abuse is widely believed to be cyclical, with four stages that repeat: (a) tension-building, (b) the incident of abuse, (c) reconciliation, and (d) calm (Walker, 1979). People tend to cohabitate with their intimate partners, meaning they face ongoing risk of experiencing physical IPV and other types of violence.

Experiencing IPV is associated with an array of adverse health outcomes in the short and long term (Coker et al., 2002; World Health Organization, 2013). These outcomes include an increased risk of mental health problems (e.g., post-traumatic stress disorder, anxiety, depression) (Lagdon et al., 2014), substance use disorders (Ogden et al., 2022), noncommunicable diseases (e.g., diabetes) (Goldberg et al., 2021), sexual and reproductive health conditions (e.g., unwanted pregnancy, STIs, gynecological problems) (Hutchinson et al., 2023), and physical injuries (Leemis et al., 2022), among others (Coker et al., 2002; World Health Organization, 2013).

While the most severe outcome of physical IPV is death, another significant and debilitating adverse health outcome is traumatic brain injury (TBI), hereby referred to as IPV-TBI (Campbell et al., 2022; Chiou et al., 2023). The Centers for Disease Control and Prevention (CDC) define TBI as a disruption in the normal function of the brain, typically caused by an impact, blow, or jolt to the head, or penetrating head injury (Centers for Disease Control and Prevention, 2024a). TBI can result from bodily injuries, specifically when direct force is applied to the head, face, and neck, or through strangulation (Kwako et al., 2011; Lindsey et al., 2023). These injuries confer many immediate and long-term neurological and psychological consequences.

IPV-TBI has been shown to cause structural brain alterations (Daugherty et al., 2022). Given that survivors of IPV often live with their perpetrator, they are at higher risk of repetitive injury than those who experience other forms of violence. Compared to women with no history of IPV-TBI, women with repetitive IPV-TBI have been shown to experience greater cognitive concerns, lower verbal learning, delayed memory test scores, and reduced fluid cognition from estimated premorbid functioning. This group also exhibits greater neurobehavioral, post-traumatic, depressive, and anxiety-related symptom severity, along with worse pain intensity, greater social isolation, and less emotional support (Karr et al., 2024). IPV-TBI with persistent symptoms is associated with worse insomnia, depression, and physical health over time (Iverson et al., 2017).

Head injuries with associated loss of consciousness have been linked to a higher prevalence of disability in mobility and work productivity (Schneider, Wang, et al., 2021). Head injury has also been shown to increase the 25-year risk of dementia, with stronger associations among female patients (Schneider, Selvin, et al., 2021). TBI is also linked with both neuropsychiatric complaints, including depression and anxiety, and neuropsychological problems, such as cognitive decline (Raskin et al., 2024; Silver et al., 2009). Moderate and severe TBIs can lead to long-term or life-long health problems, including disability (Centers for Disease Control and Prevention, 2024b; Kwako et al., 2011). Even mild TBI where no acute intracranial pathologies are detected on a head CT scan can result in a range of negative sequelae, including PTSD, changes in memory/attention, and behavioral impairments (Madhok et al., 2022; Nelson et al., 2019), with nearly one in five patients with mild TBI being unable to return to work a year after the injury (Gaudette et al., 2022).

In the United States, between 2002 and 2015, female patients visited emergency departments (EDs) an estimated 2.57 million times for IPV-related events, with the proportion of these visits increasing during that time (Mariscal et al., 2020). Nationally representative data reveal that 14.6% of women (approximately 6.2 million people) reported losing consciousness after being hit, slammed against an object or choked as a result of rape, stalking, or physical violence by an intimate partner (Breiding et al., 2014). The consequences of IPV are profound and wide-ranging for women and their children. Qualitative research has also shown that women experiencing IPV who have had a TBI are often afraid to seek medical treatment because they are afraid of the abuser’s actions, but also of judgment from health care workers (St. Ivany & Schminkey, 2016).

TBI among survivors of IPV is often overlooked or missed (Campbell et al., 2024; Rajaram et al., 2021), which may complicate the recovery of survivors, given the myriad of debilitating consequences incurred by IPV-TBI (Ramesh et al., 2024). Women who have screened positive for IPV-TBI are particularly more likely to report headaches, dizziness, sensitivity to noise, numbness in limbs, lack of balance, anxiety, and difficulty with memory (Chiou et al., 2023). While sustaining an IPV-TBI is a serious injury in itself for all of the aforementioned health consequences, it can also exacerbate other common medical, psychiatric, and behavioral IPV symptoms (Chiou et al., 2023).

Surgical professional societies recommend universal screening for IPV in patients presenting with traumatic injuries (Statement on Intimate Partner Violence, 2018). Acute care settings may be appropriate places to identify people experiencing IPV because of the high prevalence of IPV among women seeking care in EDs and trauma facilities (Downie et al., 2021; Melhado et al., 2024). However, IPV screening is not consistently applied among trauma patients, with clinicians often citing challenges such as limited time and the absence of culturally and linguistically appropriate screening tools (Melhado et al., 2024).

Screening for IPV is especially crucial for patients presenting with TBI to trauma settings, per the recommendations of national organizations such as the American College of Surgeons (Statement on Intimate Partner Violence, 2018). Several IPV screening questionnaires have been developed for healthcare settings, and three have been identified as having strong psychometric values (Arkins et al., 2016a, 2016b; Brown et al., 2000; McFarlane et al., 2001; Rabin et al., 2009; Sohal et al., 2007). IPV screening is also important in primary care settings and across various subspecialities due to its significant health, education, and financial consequences (Melhado et al., 2024).

Various screening tools have been developed to identify and assess IPV-TBI in clinical, community, and research settings (Clarke et al., 2024). Screening at domestic violence agencies is crucial to refer survivors to necessary health services to mitigate some of the adverse outcomes associated with IPV-TBI (Saleem et al., 2022). Evidence demonstrates that using a screening tool designed for determining brain injury severity levels in IPV survivors, such as BISA (7), may be more effective than using non-IPV-specific tools such as the widely used Sports Concussion Assessment Tool (SCAT5) (Smirl et al., 2019). Technology to measure the levels of Glial fibrillary acidic protein (GFAP) and breakdown products (GFAP-BDP) using blood tests to diagnose TBI hold promise for more accurate TBI diagnosis in clinical settings (Korley et al., 2022; Okonkwo et al., 2013).

Research on the prevalence of IPV-TBI has been conducted with small cohorts (Adhikari et al., 2024; Meyer et al., 2022), in specific populations (Anderson et al., 2015; Iverson et al., 2017), and/or in particular settings (Linton & Perrin, 2017; Zieman et al., 2017), but there are inconsistencies in the reported prevalence rates (Haag et al., 2022). Considering the high prevalence of IPV in the United States, coupled with the long-term negative sequelae of TBI, further investigation into the incidence of IPV-TBI and associated outcomes is warranted (Monahan, 2018). In our study, utilizing multicenter, retrospective data from the US National Trauma Data Bank (NTDB) from 2018 to 2022, we aimed to (a) evaluate the incidence and mechanisms of IPV-TBI among female patients seen at U.S. trauma facilities, (b) identify sociodemographic and clinical differences between female TBI patients who experienced IPV and non-IPV assault, and (c) characterize hospital outcomes associated with IPV-TBI, stratified by injury severity. This study contributes to the literature by presenting findings on IPV-TBI derived from the largest standardized U.S. trauma registry data to date (National Trauma Data Bank, 2025), offering insights from a diverse sample of patients across numerous trauma centers and states.

Methods

Data Source

The NTDB constitutes the largest standardized collection of data from U.S. trauma facilities. NTDB data entries record millions of incident encounters annually, providing patient demographic and clinical variables from over 800 trauma centers distributed across the United States. This wide geographic coverage offers critical variability in patient demographics, injury types, and care practices. NTDB Trauma Quality Programs Participant Use Files from 2018 to 2022 were queried for all adult female patients (age ≥18-years) presenting with a primary or secondary TBI diagnosis attributed to assault using International Classification of Diseases, Tenth Revision (ICD-10), diagnosis and external cause codes (Supplemental Tables S1, S2). This cohort was divided into IPV and non-IPV groups based on the recorded identity of the assault perpetrator using ICD-10 external cause codes. External cause codes indicating mechanism of assault were extracted where available. We analyzed sociodemographic, injury severity score (ISS), hospital length of stay (LOS), and discharge disposition variables.

Variable Coding

Age, sex, race, and ethnicity (Hispanic or non-Hispanic) were obtained from the NTDB. Insurance status was categorized based on the primary payment method, with all non-Medicare or Medicaid governmental payment methods combined into a single “Other” category due to the inability to specify exact payment types. ED disposition outcomes were classified as home, hospital ward, intensive care unit (ICU), operating room, transfer to another hospital, death, and other (including jail, institutional care, and mental health facility). Hospital discharge outcomes were classified into the following categories: acute inpatient rehabilitation facility, skilled nursing facility, home, death, and other (including unspecified cases or court/law enforcement).

For IPV-TBI patients, Glasgow Coma Scale (GCS) score ranges were used to dichotomize TBI severity into mild (GCS = 13–15) and moderate to severe (GCS = 3–12) categories due to the small number of patients with moderate TBI (N = 25). GCS scores are used clinically to assess a patient’s level of consciousness based on the individual’s ability to open their eyes, respond verbally, and move their extremities to different levels of stimulation; scores range from 3 (no eye opening, verbal, or motor response to noxious stimuli) to 15 (eyes open spontaneously, oriented, and conversant, following commands for motor movement), with lower scores indicating more severe impairment.

Several types of TBI were identified and evaluated: skull fracture, cerebral contusion, epidural hemorrhage, subdural hemorrhage, subarachnoid hemorrhage, and cerebral edema. For individuals with intracranial injuries (i.e., cerebral contusion and epidural, subdural, or subarachnoid hemorrhage), the number of concomitant lesion types was also recorded: 1, 2, or 3+.

Statistical Analysis

Sociodemographic (age, sex, race, ethnicity, insurance) and clinical variables (ISS, LOS, ED disposition, discharge disposition, mortality) were compared between the IPV-TBI and non-IPV TBI groups. Statistical differences were assessed with Welch’s t-test and analysis of variance (ANOVA) for continuous variables, and Pearson’s chi-squared test with post hoc Bonferroni-corrected z-tests for independent proportions for categorical variables. Statistical significance was determined for all comparisons using p < .05 given the exploratory nature of our analyses. Candidate variables were entered into multivariable logistic and linear regression to predict odds of discharge to home and length of hospital stay, respectively. Adjusted odds ratios (aORs) and beta coefficients with 95% confidence intervals (CI) were reported. All analyses were performed using R (version 4.3.1; https://www.r-project.org/about.html), an integrated suite of software facilities for data manipulation, calculation and graphical display available as free software.

Results

Our final analytic cohort included 1,718 females with assault-related TBI between 2018 and 2022. Of these encounters, 1,319 (76.8%) were caused by IPV and the remaining 399 (23.2%) were attributed to non-IPV violence.

Incidence of Female IPV and Non-IPV TBI From 2018 to 2022

The proportion of all NTDB encounters involving Female IPV-TBI remained largely consistent during the studied years, ranging from 0.022% (226/1,043,736) in 2018 to 0.020% (245/1,232,956) in 2022 (Figure 1). Similarly, the proportion of female non-IPV TBI encounters varied from 0.006% in 2018 (60/1,043,736) to 0.007% in 2022 (82/1,232,956).

Figure 1.

Female IPV and non-IPV assault TBI encounters in NTDB from 2018 to 2022.

Mechanism of Female IPV and Non-IPV TBI Assault

Most assaults for female patients presenting to trauma centers with IPV-TBI were due to bodily force (n = 726; 55.0%), followed by unspecified means (341; 25.9%), blunt objects (134; 10.2%), and firearms (46; 3.5%) (Table 1).

Table 1.

Mechanism of Female IPV and Non-IPV TBI Assault.

Mechanism of assault, N (%)	IPV TBI(N = 1,319)	Non-IPV TBI(N = 399)
Bodily force	726 (55.0)	192 (48.1)
Blunt object	134 (10.2)	46 (11.5)
Firearm	46 (3.5)	19 (4.8)
Sharp object	43 (3.3)	25 (6.3)
Pushing from high place	15 (1.1)	4 (1.0)
Motor vehicle	13 (1.0)	7 (1.8)
Pushing in front of moving object	1 (0.1)	2 (0.5)
Steam, hot vapors, hot objects	0 (0.0)	1 (0.3)
Unspecified	341 (25.9)	103 (25.8)

Note. IPV = intimate partner violence; TBI = traumatic brain injury.

Perpetrators of Female IPV and Non-IPV TBI

The majority of assaults causing Female IPV-TBI were perpetrated by patients’ husbands (72.0%) and male partners (25.9%; Table 2). The remaining encounters were perpetrated by female partners (1.8%) and wives (0.2%).

Table 2.

Perpetrators of Female IPV.

Perpetrator	Frequency, N (%)
Husband	950 (72.0)
Male partner	342 (25.9)
Female partner	24 (1.8)
Wife	3 (0.2)

Note. IPV = intimate partner violence.

Sociodemographic Differences Between Female IPV and Non-IPV TBI Encounters

Female IPV-TBI patients were, on average, younger than non-IPV TBI patients (IPV: 37.9 ± 12.5 years versus non-IPV: 48.0 ± 12.4; p < .001; Table 3). The IPV-TBI group also had a lower proportion of Asian/Pacific-Islander (API) patients (1.5% vs. 4.6%; p = .003). No significant difference was seen in Hispanic ethnicity (p = .287) between the two groups. The IPV-TBI group was more likely to be insured by Medicaid (47.0% vs 36.5%; p < .001) and less likely to be insured by Medicare (7.5% vs. 24.0%; p < .001).

Table 3.

Demographic and Clinical Characteristics of Female IPV TBI and Non-IPV Assault TBI.

Variable	IPV TBI (N = 1,319)	Non-IPV TBI (N = 399)	Sig. (p)
Age (Mean ± SD)	37.9 ± 12.5	48.0 ± 12.4	<.001
Race, N (%)			.003
White	672 (51.6)	202 (51.5)
Black	410 (31.5)	119 (30.4)
Asian/Pacific Islander	20 (1.5)	18 (4.6)	*
American Indian	62 (4.8)	23 (5.9)
Other	138 (10.6)	30 (7.7)
Hispanic ethnicity, N (%)	205 (15.7)	52 (13.0)	.287
Insurance, N (%)			<.001
Medicaid	605 (47.0)	143 (36.5)	*
Private/commercial	311 (24.2)	82 (20.9)
Self-Pay	191 (14.9)	56 (14.3)
Medicare	96 (7.5)	94 (24.0)	*
Other	83 (6.5)	17 (4.3)
Presenting GCS, N (%)			.110
GCS: 13–15	942 (74.3)	267 (69.0)
GCS: 9–12	25 (2.0)	12 (3.1)
GCS: 3–8	301 (23.7)	108 (27.9)
ISS (Mean ± SD)	9.6 ± 7.4	11.3 ± 9.3	<.001
Length of stay (LOS) (Days) (Mean ± SD)	4.3 ± 6.8	5.9 ± 9.8	.002
Emergency department (ED) discharge disposition, N (%)			.002
Home	246 (19.2)	63 (16.0)
Hospital ward	643 (50.3)	177 (44.9)
Intensive care unit	294 (23.0)	110 (27.9)
Operating room	56 (4.4)	30 (7.6)
Transferred	24 (1.9)	6 (1.5)
Deceased	4 (0.3)	7 (1.8)	*
Other	11 (0.9)	1 (0.3)
Hospital discharge disposition, N (%)			<.001
Home	894 (86.5)	235 (73.0)	*
Post-acute care facility	91 (8.8)	63 (19.6)	*
Deceased	26 (2.5)	19 (5.9)	*
Other	23 (2.2)	5 (1.6)

Note. IPV = intimate partner violence; TBI = traumatic brain injury.

Denotes a statistically significant difference between the IPV TBI and non-IPV TBI groups.

Clinical Differences Between Female IPV and Non-IPV TBI Encounters

The distribution of TBI severity did not vary significantly between the IPV and non-IPV TBI groups (p = .110); most patients in both groups presented with GCS 13–15 (IPV: 74.3% vs. non-IPV: 69.0%). Mean ISS was lower for the IPV group than for those with non-IPV TBI (9.6 ± 7.4 vs. 11.3 ± 9.3; p < .001).

The average LOS was lower for the IPV-TBI group (4.3 ± 6.8 days vs. 5.9 ± 9.8; p < .001). Female patients with IPV-TBI were more likely to be discharged home following their hospital stay than the non-IPV TBI cohort (86.5% vs. 73.0%; p < .001). Patients with non-IPV TBI were more likely to die in the ED (1.8% vs. 0.3%; p = .002), be discharged to a post-acute care facility (19.6% vs. 8.8%; p < .001), and expire or discharge to hospice (5.9% vs. 2.5%; p < .001).

Sociodemographic and Clinical Differences Across TBI Severities in Female IPV TBI Encounters

Most female patients with IPV-TBI presented with mild TBI (n = 942; 74.3%) (Table 4). Compared to those with mild TBI, patients with moderate–severe TBI were more likely to be Hispanic (moderate–severe: 19.6% vs. mild: 13.8%; p = .012) and to be insured by non-Medicare or Medicaid governmental sources (12.0% vs. 7.5%; p = .039). Age (p = .116) and race (p = .175) did not vary significantly between the two groups.

Table 4.

Demographic and Clinical Characteristics of Female IPV-TBI Patients by Severity.

Variable	(GCS: 3–12) (N = 326)	(GCS: 13–15) (N = 942)	Sig. (p)
Age (Mean ± SD)	38.9 ± 13.4	37.6 ± 12.2	.116
Race, N (%)			.175
White	168 (52.5)	474 (50.9)
Black	89 (27.8)	303 (32.5)
Asian/Pacific Islander	8 (2.5)	12 (1.3)
American Indian	13 (4.1)	47 (5.0)
Other	42 (13.1)	95 (10.2)
Hispanic ethnicity, N (%)	64 (19.6)	130 (13.8)	.012
Insurance, N (%)			.039
Medicaid	156 (47.9)	429 (45.5)
Private/commercial	66 (20.2)	233 (24.7)
Self-Pay	39 (12.0)	144 (15.3)
Medicare	26 (8.0)	65 (6.9)
Other	39 (12.0)	71 (7.5)	*
ISS (Mean ± SD)	12.7 ± 9.6	8.6 ± 6.2	<.001
TBI injury type			<.001
Concussion	91 (20.9)	351 (36.5)	*
Skull fracture	100 (23.0)	258 (26.8)
Cerebral contusion	37 (8.5)	47 (4.9)
Epidural hemorrhage	8 (1.8)	7 (0.7)
Subdural hemorrhage	101 (23.2)	173 (18.0)
Subarachnoid hemorrhage	74 (17.0)	112 (11.6)	*
Cerebral edema	24 (5.5)	14 (1.5)	*
Intracranial lesion types^†			<.001
1	88 (59.9)	244 (84.1)	*
2	41 (27.9)	39 (13.4)	*
3+	18 (12.2)	7 (2.4)	*
LOS (Days) (Mean ± SD)	6.4 ± 10.5	3.6 ± 4.7	<.001
ED discharge disposition, N (%)			<.001
Home	48 (15.0)	193 (21.2)
Hospital ward	125 (39.2)	494 (54.2)	*
Operating room	24 (7.5)	27 (3.0)	*
Transferred	8 (2.5)	15 (1.6)
Deceased	3 (0.9)	1 (0.1)
Other	2 (0.6)	8 (0.9)
Hospital discharge disposition, N (%)			<.001
Home	196 (74.0)	652 (93.3)	*
Post-acute care facility	42 (15.8)	46 (6.6)	*
Deceased	23 (8.7)	0 (0.0)	*
Other	4 (1.5)	1 (0.1)	*

Note. IPV = intimate partner violence; TBI = traumatic brain injury.

Denotes a statistically significant difference between the IPV TBI and non-IPV TBI groups.

†

Cerebral contusion, epidural, subdural, and subarachnoid hemorrhage were considered intracranial lesions.

Mean ISS was higher among the moderate–severe TBI patients (12.7 ± 9.6 vs. 8.6 ± 6.2; p < .001). The GCS 13–15 group had a higher proportion of patients with concussions (36.5% vs. 20.9%; p < .001) while the GCS 3–12 group had more frequent subarachnoid hemorrhages (17.0% vs. 11.6%; p < .001) and cerebral edema (5.5% vs. 1.5%; p < .001). Most patients in both groups had one intracranial lesion type, though this finding was more common in those with mild TBI (84.1% vs. 59.9%; p < .001). Patients with moderate–severe TBI were significantly more likely to have 2 (27.9% vs. 13.4%; p < .001) or ≥3 concurrent lesion types (12.2% vs. 2.4%; p < .001).

Mean LOS was greater for the moderate–severe TBI group (6.4 ± 10.5 days vs. 3.6 ± 4.7; p < .001). The GCS 13–15 patients were more likely to be admitted to non-ICU wards (54.2% vs. 39.3%; p < .001) and to be discharged home following hospitalization (93.3% vs. 74.0%; p < .001). The moderate–severe TBI group was more likely to be admitted to the ICU (34.2% vs. 19.0%; p < .001), to be taken to the OR from the ED (7.5% vs. 3.0%; p < .001), to discharge to a post-acute care facility following hospitalization (15.8% vs. 6.6%; p < .001), and to pass away during their hospitalization or discharge to hospice (8.7% vs. 0.0%, p < .001).

Predictors of Discharge to Home in Female TBI Encounters

TBI from IPV was associated with significantly increased odds of discharge to home in female patients (aOR = 1.31 [95% CI: 1.01, 1.69]) (Figure 2). Black (0.73 [0.57, 0.94]) and American Indian patients (0.58 [0.36, 0.94]) were less likely to be discharged home than White patients. Lower GCS scores also predicted lower odds of discharge to home; patients with GCS 9–12 (0.42 [0.23, 0.85]) and GCS 3–8 (0.60 [0.47, 0.76]) were less likely to be discharged home than those with GCS 13–15.

Figure 2.

Multivariable logistic regression for predictors of discharge to home in female assault-related TBI patients.

Predictors of Hospital Length of Stay in Female TBI Encounters

Female IPV-TBI patients were likely to have shorter hospital stays than those with TBI from non-IPV assault (Coeff = −0.96 [95% CI: −1.83, −0.89]) (Figure 3). Older age was a significant predictor of longer hospital stays (0.06 per-year [0.03, 0.09]). Higher GCS scores were also associated with higher length of stay; patients with GCS 9–12 (4.59 [2.20, 6.98]) and GCS 3–8 (2.14 [1.32, 2.96]) were likely to stay longer than those with GCS 13–15.

Figure 3.

Multivariable linear regression for predictors of hospital in female assault-related TBI patients.

Discussion

Improving care for individuals affected by IPV-TBI requires a comprehensive understanding of its incidence, the sociodemographic characteristics of people who experience it, and their clinical outcomes. The findings of this study highlight how most female patients who sought care at trauma centers for assault-related TBI had experienced IPV (as opposed to non-IPV violence), with husbands and male partners reported as the most common perpetrators. Overall, patients who had experienced their TBI from IPV were younger and more likely to be insured by Medicaid than those whose TBI resulted from another type of violence. Mild TBI was the most common type among IPV survivors presenting to trauma centers and resulted from a range of injuries. Over half of our sample experienced IPV-TBI from bodily force.

Range of Risks Associated with IPV-TBI

Overall, 2.1% of our sample of IPV-TBI patients died either in the ED or during their hospitalization. The same mechanisms that indicate TBI have also been found to be associated with female intimate partner homicide (Campbell et al., 2022), underscoring the importance of intervening early to prevent the escalation of violence. Based on these findings and previous work conducted by our team in this area (Ramesh et al., 2024), we know that a small percentage of people will pass away during their hospitalization as a result of IPV-TBI. However, the large majority of IPV survivors seeking care at trauma centers in our sample received TBI diagnoses resulting from more insidious mild TBI. Even after mild TBI, people experience serious adverse health outcomes (Madhok et al., 2022; Nelson et al., 2019), underscoring the need for timely clinical intervention.

Social Impacts of IPV-TBI

Beyond the deleterious health impacts of IPV-TBI, it also impacts employment outcomes, affecting people’s ability to return to work, and economic outcomes (Gaudette et al., 2022), and productivity (Silverberg et al., 2018). Most of the patients in our sample who suffered from IPV-TBI (74.3%) experienced mild TBI. In the short term, mild TBI has serious consequences on employment: One study found that 59% of participants reported not working two weeks after the injury (Gaudette et al., 2022). However, one year after injury and a mild TBI diagnosis, the same study showed that 17% of participants were not working and 21% reported an income decline in the year after their mild TBI. Mild TBI is associated with people exiting the workforce even four years after its occurrence, with one study showing that 17.3% of people who were employed before their mild TBI had exited the workforce or reduced their working hours (for reasons other than retirement or pursuing education), while 15.5% reported work limitations because of their injury (Theadom et al., 2017). In our sample, as compared to the non-IPV group, the IPV-TBI group was more likely to be insured by Medicaid, indicating that a large part of the sample qualified as low income (Centers for Medicare & Medicaid Services, n.d.). This may be associated with financial dependence on partners, which could be complicated by the short-term and long-term employment outcomes among TBI patients.

The Importance of IPV and IPV-TBI Screening

To ensure the early detection of both IPV among TBI patients and TBI among IPV survivors, it is essential to utilize the appropriate tools across a range of settings to increase the number of opportunities for individuals to be screened for these conditions. While our findings do not have direct implications for IPV and TBI screening because our sample consisted of patients with identified IPV-TBI, it is critical that IPV survivors are screened for TBI to ensure that they are connected to appropriate care. Survivors who have not sought health care may need to be screened in settings such as domestic violence shelters or NGOs. Early recognition and accurate diagnosis of neurological injuries among IPV victim-survivors during initial assessments are essential for providing timely medical treatment and rehabilitation (Clarke et al., 2024). While the patients in our sample had already sought care at a trauma center, many IPV survivors have undetected TBI as they are not screened for these injuries (Saleem et al., 2022; St. Ivany & Schminkey, 2016). NTDB also likely underestimates IPV-TBI as it relies on ER coding (Haider et al., 2012; Robles et al., 2019). Furthermore, patients may have nebulous symptoms and not specifically endorse a blow to the head, and many imaging-negative TBI patients are probably missed as well. Further research is warranted to determine the clinical validity and reliability of available tools to improve the identification of IPV brain injury (Esopenko et al., 2024).

Discharge and Safety

Many women in our sample were admitted to either a hospital ward or ICU from the ER. Even short hospital stays likely disrupt many areas of people’s lives (work, childcare, school, etc.). TBI from IPV was associated with significantly increased odds of discharge to home in female patients and IPV-TBI patients were likely to have shorter hospital stays than those with TBI from non-IPV assault. Studies have found that patients with mild TBI are largely not provided with sufficient education on their injury at discharge and less than half receive follow-up within 3 months (Seabury et al., 2018). When patients are eventually discharged to go home, there need to be specific considerations for those who have experienced IPV-TBI compared with other types of assault. Research has shown that some IPV patients who seek care in the ED are not discharged with a safety plan and most are not discharged to shelters (Clery et al., 2023). In our sample, the majority of patients who had experienced mild and moderate–severe TBI were discharged from the ED to a hospital ward, and from the hospital, most people were discharged home. IPV-TBI is different from TBI resulting from other types of violence because IPV-TBI survivors are much more likely to cohabitate with the perpetrator of IPV, who in our sample was most likely to be a husband or partner. This means that they may need safety planning, including finding alternative, which is often delivered by a social worker (Clery et al., 2023).

Implications for Education

Beyond clinical utility, the demographic and injury profiles identified in this study provide a data-driven framework to supplement interdisciplinary education. In medical curricula, the statistics presented here can be used to heighten diagnostic suspicion for IPV-TBI. Educators can reinforce the need for a mental screening reflex prompting clinicians to ask questions about IPV when TBI is diagnosed, and conversely, to assess for TBI in patients presenting after intimate partner assault. Similarly, in nonmedical settings, such as law enforcement or social work training, these findings offer a basis for identifying vulnerable populations and recognizing the long-lasting, multi-faceted, and uniquely repetitive consequences of IPV to better support survivors.

Limitations

In this study, we focus on people who sought medical care, but many people do not receive treatment for TBIs or they are not detected when individuals do seek care (Rajaram et al., 2021). One limitation of the NTDB is that information on the mechanisms of TBI assault for both IPV patients and non-IPV patients is incomplete. Furthermore, the registry’s classification of ethnicity is limited to a binary categorization of Hispanic versus non-Hispanic, which may obscure more nuanced demographic differences within the patient population. A few of the NTDB’s other limitations are the lack of longitudinal outcomes, the inability to identify recurrent visits, and that reporting by trauma centers to the NTDB is voluntary, meaning it is not entirely representative of all trauma centers in the United States (Haider et al., 2012). Specifically, the voluntary nature of reporting may lead to variable participation by region and contribute to an overrepresentation of larger, urban, and/or academic sites compared with that of smaller rural hospitals. As a result, rural populations, geographically isolated groups, and Native American and tribal communities may be underrepresented by the NTDB, limiting the generalizability of our results to these groups. Given that this is convenience sample (Haider et al., 2012), further research with more trauma centers is needed, as well as research with people who suffer TBIs and do not seek care in trauma centers. Another important note is that NTDB does not include other dimensions of diversity relevant to research on IPV, including sexual orientation, zip code, income, and disability status, restricting our ability to analyze how intersectional identities shape IPV exposure and outcomes.

Conclusion

This study shows that IPV is a common underlying cause of traumatic brain injury among women seeking care at trauma centers in the United States. Mild TBI was the most common type of IPV-TBI, which is associated with debilitating health and social impacts in both the short and long terms. IPV screening among TBI patients is critical, given the different social and medicolegal contexts surrounding their injuries. Given the context, the possibility of recurrent injury are likely to be different from those of a non-IPV TBI patient, and being discharged home may present significant safety risks and potential harm.

Supplemental Material

sj-docx-1-jiv-10.1177_08862605261441201 – Supplemental material for Original ResearchTraumatic Brain Injury in Female Intimate Partner Violence Survivors: Incidence, Sociodemographic Disparities, and Clinical Outcomes

Supplemental material, sj-docx-1-jiv-10.1177_08862605261441201 for Original ResearchTraumatic Brain Injury in Female Intimate Partner Violence Survivors: Incidence, Sociodemographic Disparities, and Clinical Outcomes by Sophie M. Morse, Rithvik Ramesh, John K. Yue, Geoffrey T. Manley, Phiroz E. Tarapore and Anthony M. DiGiorgio in Journal of Interpersonal Violence

Supplemental Material

sj-docx-2-jiv-10.1177_08862605261441201 – Supplemental material for Original ResearchTraumatic Brain Injury in Female Intimate Partner Violence Survivors: Incidence, Sociodemographic Disparities, and Clinical Outcomes

Supplemental material, sj-docx-2-jiv-10.1177_08862605261441201 for Original ResearchTraumatic Brain Injury in Female Intimate Partner Violence Survivors: Incidence, Sociodemographic Disparities, and Clinical Outcomes by Sophie M. Morse, Rithvik Ramesh, John K. Yue, Geoffrey T. Manley, Phiroz E. Tarapore and Anthony M. DiGiorgio in Journal of Interpersonal Violence

Footnotes

Acknowledgements

Committee on Trauma, American College of Surgeons. Trauma Quality Programs (TQP) Participant Use Files (PUF) Admission Years 2018 to 2022, Chicago, IL, 2022. The content reproduced from the TQP PUF remains the full and exclusive copyrighted property of the American College of Surgeons. The American College of Surgeons is not responsible for any claims arising from works based on the original data, text, tables, or figures.

ORCID iDs

Sophie M. Morse

Rithvik Ramesh

John K. Yue

Phiroz E. Tarapore

Ethical Considerations

Since the National Trauma Data Bank (NTDB) is deidentified and does not report any of the 18 Federal Health Insurance Portability and Accountability Act identifiers, our study received exemption status from the institutional review board of record at the University of California, San Francisco.

Funding

The authors disclosed receipt of the following financial support for the research and/or authorship of this article: Dr. Morse was supported by a grant from the Agency for Healthcare Research and Quality (T32HS022241; Rodriguez, PI).

Declaration of Conflicting Interests

The authors declared no potential conflicts of interests with respect to the authorship and/or publication of this article.

Data Availability Statement

No datasets were generated during the current study.

Supplemental Material

Supplemental material for this article is available online.

Author Biographies

Sophie M. Morse, PhD is a Postdoctoral Scholar at the Philip R. Institute for Health Policy Studies at the University of California, San Francisco and a women’s health and health policy researcher. Her work focuses on gender-based violence, sexual and reproductive health policy and care, maternal health and health inequities in the US and globally, with the central aim of improving health services and access to care for women and young adults.

Rithvik Ramesh, BA is a medical student and researcher at the University of California, San Francisco. He conducts research focused on neurological disorders and neurosurgical outcomes, with particular interests in traumatic and cerebrovascular brain injury, clinical outcomes, and patient-reported measures in neurological care

John K. Yue, MD is Assistant Professor of Neurological Surgery, Affiliate Faculty of Institute of Health Policy, and Clinician-Scientist at the Weill Institute for Neurosciences at University of California, San Francisco. His expertise is in neurotrauma, neurocritical care, intracranial physiology, injury biomarkers, prognostic tools, best practices, and efficacy of care pathways. He is dedicated to national efforts to improve traumatic brain injury classification and care.

Geoffrey T. Manley, MD, PhD is Professor and Vice Chair of Neurological Surgery at University of California, San Francisco, Chief of Neurosurgery at Zuckerberg San Francisco General Hospital and Trauma Center, Co-Director of the UCSF Brain and Spinal Injury Center, and Lead PI of the TRACK-TBI Consortium. His transformative work focuses on traumatic brain injury, neurocritical care, and the repair of central nervous system injury.

Phiroz E. Tarapore, MD is a Professor in the Department of Neurological Surgery at the University of California, San Francisco and a member of the Brain and Spinal Injury Center. His research focuses on brain injury, neurosurgical innovation, and improving patient outcomes, and he has a strong research interest in functional imaging and presurgical mapping with Transcranial Magnetic Stimulation (TMS).

Anthony M. DiGiorgio, MD is an Assistant Professor in the Department of Neurological Surgery at the University of California, San Francisco and he serves as Director of Spinal Neurotrauma at Zuckerberg San Francisco General Hospital and Trauma Center. His clinical and research interests include traumatic brain injury, neurotrauma, and spinal cord injury and minimally invasive spine surgery. He also studies health care policy and health care disparities.

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