How hidden brain injuries, strangulation laws, and medical evidence expose a major gap in domestic violence protection.

Intimate partner violence (IPV) is a widespread social and public health crisis with serious physical, psychological, and legal consequences. While public attention has long focused on emotional trauma, chronic stress, and visible injuries, one outcome has remained dangerously under-recognized: traumatic brain injury (TBI). Survivors of IPV frequently endure repeated blows to the head or attempted strangulation – both of which can cause mild to severe TBIs. Unlike injuries sustained in sports or combat, IPV-related TBIs are often cumulative, invisible, and untreated. As a result, survivors may live with long-term neurological and psychological harm while their injuries go unacknowledged in both healthcare and legal systems.

This creates a profound gap between medical evidence and legal response. Symptoms such as headaches, dizziness, memory loss, and depression are commonly attributed only to emotional trauma rather than understood as possible signs of brain injury. Without screening or diagnosis, survivors are left without proper treatment and without documentation that could protect them in court.

Understanding IPV-Related TBI

Research shows that IPV-related TBI is both common and distinct from other forms of brain injury. Kwako et al. (2011) provide one of the earliest comprehensive reviews of TBI in the context of IPV. Across multiple studies, 30% – 74% of women seeking shelter or emergency services for IPV reported head injuries consistent with TBI, yet fewer than 40% received medical treatment (p. 117). Many survivors experienced repeated injuries over years of abuse, and more than half reported attempted strangulation (p. 117). Common symptoms – including headaches, dizziness, and depression – were often misdiagnosed as mental health disorders rather than neurological injury (pp. 116 – 117). The authors argue that IPV-related TBI is fundamentally different from athletic or military TBI because it is typically chronic and untreated, requiring systematic screening and medical – legal integration (p. 122). This distinction is critical because ongoing abuse, combined with fear and secrecy, makes detection and follow-up far more difficult than in other injury contexts.

Under-Recognition in Medical Settings

Costello and Greenwald (2022) estimate that IPV-related TBIs may occur at rates 11 – 12 times higher than TBIs among athletes and military personnel combined (p. 2). Yet 72% of domestic violence patients with TBI are not identified in emergency departments (p. 7). Neurological symptoms are often mistaken for intoxication or emotional instability, preventing survivors from receiving proper care (p. 7). The authors call for standardized IPV – TBI screening tools and interprofessional collaboration (pp. 8 – 10). These findings show that the first medical encounter can determine whether survivors are believed and treated, shaping both clinical outcomes and their credibility in legal proceedings.

The Hidden Injury of Repetitive Trauma

Baxter and Hellewell (2019) focus on repetitive and sometimes subconcussive trauma common in IPV. They emphasize diffuse axonal injury (DAI) – microscopic damage that often does not appear on standard imaging but leads to lasting impairment (p. 663). Survivors showed deficits in attention, memory, and executive function, and women with IPV-related TBI were six times more likely to experience PTSD than other TBI patients (p. 668). Fear of retaliation and clinician neglect further contribute to underdiagnosis (pp. 669 – 670). Although tools such as the HELPS screening instrument show promise, they remain underused without institutional support (p. 670). This research demonstrates how repeated injuries – even when they appear minor – can significantly disrupt daily functioning.

When Documentation Helps – and When It Can Harm

As clinical recognition has increased, new ethical and legal challenges have emerged. Boyle et al. (2022) explain that while screening can validate survivors and open access to services, it can also be misused in custody disputes when “brain injury” is framed as incapacity (pp. 2 – 4). They identify low legal literacy about IPV-related brain injury and difficulties proving causation in court (pp. 9 – 10). To address these risks, they recommend physician – lawyer collaboration and survivor-centered screening practices (pp. 11 – 13). This reveals a troubling paradox: documentation intended to protect survivors can sometimes be used against them when legal systems are not equipped to interpret it properly.

Chan et al. (2024) confirm that routine screening remains rare. Only about 10% of primary care clinicians screen new patients for IPV, and rates are even lower in brain-injury clinics (p. 3). While tools such as HITS and WAST exist, they are not validated for IPV-related TBI (p. 5). Emerging tools like. Brain Injury Screening Questionnaire IPV (BISQ-IPV) show promise but are not widely implemented (p. 10). Patchwork mandatory-reporting laws can further discourage disclosure (p. 7). Together, these findings illustrate how medical and legal systems often work at cross-purposes, leaving survivors trapped between the need for care and fear of legal consequences.

Nonfatal Strangulation: A Lethal but Invisible Assault

Monahan et al. (2020) identify nonfatal strangulation as one of the strongest predictors of homicide: survivors are over seven times more likely to be killed by partners later (p. 82). Yet up to 40% of fatal strangulations leave no external marks (p. 80). Medically, strangulation can cause hypoxic brain injury and vascular damage (p. 76), while symptoms such as memory loss and vision problems overlap with PTSD (pp. 79 – 80).

Recognizing this danger, Tennessee law treats strangulation as aggravated assault. Under Tennessee Code Annotated § 39–13–102, a person commits aggravated assault if the assault “involved strangulation or attempted strangulation,” defined as intentionally impeding normal breathing or circulation of blood by applying pressure to the throat or neck or blocking the victim’s nose or mouth, even if no visible injury is present.

Douglas and Fitzgerald (2014) demonstrate that this issue extends beyond the United States. In Queensland, strangulation appeared in 6.4% of protection order applications but provided no greater protection (pp. 246 – 247). In Canada, prosecutions rely on general assault statutes that rarely succeed (pp. 238 – 239). In Australia, broad assault statutes obscure the lethality of strangulation when visible injury is absent (p. 240). The authors conclude that judicial education and clear statutes are essential (pp. 239 – 240).

Structural Blind Spots: Military and Global Contexts

Hinton (2020) highlights unintended harms of laws designed to protect veterans. Military spouses caring for veterans with PTSD or TBI face elevated IPV risk, yet leaving an abusive dependent can trigger neglect charges (p. 220). Courts may interpret leaving as abandonment in custody disputes (p. 220). Hinton recommends trauma-informed training and statutory exemptions for IPV survivors from caregiver liability (p. 222).

Maas et al. (2022) broaden the lens globally, noting that 50 – 60 million TBIs occur annually and describing TBI as a chronic disease (p. 1005). Although over 90% of TBIs are classified as mild, half of patients never return to baseline after six months (p. 1004). Gender disparities and unequal access to rehabilitation mirror the barriers faced by IPV survivors (p. 1006). These findings emphasize that IPV-related TBI is not only a medical and legal problem, but also a matter of structural justice.

Early Evidence That Shaped the Field

Corrigan et al. (2003) found that among women in emergency departments, 30% reported loss of consciousness and 67%had lingering symptoms consistent with postconcussive syndrome (pp. S73 – S74). They stress early screening and referral to prevent worsening depression, anxiety, and substance use (pp. S74 – S75). Iverson et al. (2017) later found that 28.1%of women veterans had a history of IPV-related TBI and 12.5% had ongoing symptoms (p. 81). These survivors were nearly six times more likely to screen positive for PTSD and met all DSM-5 symptom clusters (p. 85). They recommend integrated care that addresses PTSD and TBI together (p. 85).

Policy Implications: Learning from Strangulation Law

States have already shown that domestic violence laws can evolve when medical evidence makes clear that certain forms of violence are especially dangerous. Tennessee’s aggravated assault statute (§ 39–13–102) recognizes that strangulation is a grave offense – even without visible injury – because the act itself threatens life and brain function.

A similar approach is urgently needed for traumatic brain injuries caused by IPV. When a victim reports being struck in the head, slammed against objects, or losing consciousness, that injury should trigger a mandatory medical evaluation to determine whether a concussion or other brain injury has occurred. Head trauma should never be treated as minor – it can affect memory, judgment, emotional regulation, and long-term neurological health. Implementing a standardized brain injury screening tool (such as the HELPS brain injury screening tool) in emergency care settings would help clinicians identify symptoms that are often overlooked, ensure consistent documentation, and reduce the risk that neurological injury is mistaken for intoxication or emotional distress. Such screening would improve early detection, guide appropriate treatment, and provide clear medical evidence that can support survivor safety and accountability within the legal system.

Once a physician confirms that a concussion or other brain injury has occurred, that assault should be treated as aggravated assault, just as strangulation is. The reasoning is consistent: both strangulation and blunt-force head trauma involve injury to the brain, both may leave little or no visible evidence, and both carry a high risk of long-term harm or death. Treating IPV-related brain injury as aggravated assault would strengthen accountability, improve legal recognition of neurological harm, and ensure that survivors are not dismissed as merely experiencing emotional distress.

Tennessee’s statute demonstrates that when lawmakers take medical evidence seriously, legal standards can be raised to reflect real risk. Extending this logic to traumatic brain injury would close a major gap in domestic violence protection and align criminal law with modern neuroscience. Recognizing IPV-related TBI as serious bodily injury is not about expanding punishment; it is about ensuring justice, safety, and meaningful protection for survivors whose injuries are too often invisible.

Conclusion

IPV-related traumatic brain injury is a hidden epidemic. Screening remains inconsistent. Legal recognition is uneven. Survivors are sometimes harmed by the very documentation meant to protect them. Unless medical practices and criminal statutes catch up to neuroscience, survivors will continue to fall through the cracks.

Tennessee’s strangulation law shows that reform is possible. Extending that same legal logic to traumatic brain injury would close a critical gap in domestic violence protection and help fulfill the promise of justice for survivors whose injuries are invisible – but life-altering.

References

Baxter, K., & Hellewell, S. C. (2019). Traumatic brain injury within domestic relationships: Complications, consequences and contributing factors. Journal of Aggression, Maltreatment & Trauma, 28(6), 660 – 676. https://doi.org/10.1002/jts.22421

Chan, J. P., Harris, K. A., Berkowitz, A., Ferber, A., Greenwald, B. D., & Valera, E. M. (2024). Experiences of domestic violence in adult patients with brain injury: A selective overview of screening, reporting, and next steps. Brain Sciences, 14(7), Article 716. https://doi.org/10.3390/brainsci14070716

Corrigan, J. D., Wolfe, M., Mysiw, W. J., Jackson, R. D., & Bogner, J. A. (2003). Early identification of mild traumatic brain injury in female survivors of domestic violence. Journal of Head Trauma Rehabilitation, 18(4), 272 – 284. https://www.ajog.org/action/showPdf?pii=S0002-9378%2803%2900358-2

Costello, O. K., & Greenwald, B. D. (2022). Update on domestic violence and traumatic brain injury: A narrative review. Brain Sciences, 12(1), Article 122. https://doi.org/10.3390/brainsci12010122

Douglas, H., & Fitzgerald, R. (2014). Strangulation, domestic violence and the legal response. Sydney Law Review, 36(2), 231 – 254.

Hinton, R. (2020). Military caregiving, intimate partner violence, and the law: Unintended consequences of protective statutes. Family Court Review, 58(1), 218 – 225. https://doi.org/10.1111/fcre.12450

Iverson, K. M., Dardis, C. M., & Pogoda, T. K. (2017). Traumatic brain injury and PTSD symptoms in female veterans: Associations with intimate partner violence. Psychological Trauma, 9(1), 74 – 81.

Kwako, L. E., Glass, N., Campbell, J., Melvin, K. C., Barr, T., & Gill, J. M. (2011). Traumatic brain injury in intimate partner violence: A critical review of outcomes and mechanisms. Trauma, Violence, & Abuse, 12(3), 115 – 126. https://doi.org/10.1177/1524838011404251

Maas, A. I. R., Menon, D. K., Manley, G. T., Abrams, M., Åkerlund, C., Andelic, N., Aries, M., & Bashford, T. (2022). Traumatic brain injury: Progress and challenges in prevention, clinical care, and research. The Lancet Neurology, 21(11), 1004 – 1060. https://doi.org/10.1016/S1474-4422(22)00309-X

Monahan, K., Bannon, S., & Dams-O’Connor, K. (2022). Nonfatal strangulation (NFS) and intimate partner violence: A brief overview. Journal of Family Violence, 37, 75 – 86. https://doi.org/10.1007/s10896-020-00208-7

Quinn Boyle, J., Illes, J., Simonetto, D., & van Donkelaar, P. (2022). Ethicolegal considerations of screening for brain injury in women who have experienced intimate partner violence. Journal of Law and the Biosciences, 9(2), lsac023. https://doi.org/10.1093/jlb/lsac023

Tennessee Code Annotated § 39–13–102 (2024). Aggravated assault. https://law.justia.com/codes/tennessee/title-39/chapter-13/part-1/section-39-13-102/