Two women who endured decades of intimate partner violence including dozens of brutal assaults and head injuries before they died have been diagnosed with chronic traumatic encephalopathy — the first cases of CTE in victims of domestic violence in Australia and two of just a handful globally.
The grim findings, published today in the journal Acta Neuropathologica, were made by a group of pathologists from several states and territories who teamed up to understand whether the degenerative brain disease found mostly in deceased male football players and boxers is also prevalent among abused women with histories of repetitive head injury.
The women, aged in their 30s and 40s, died from blunt force injuries and impact trauma — one in an alleged assault and the other after being struck by a car.
The pathologists examined their brains after reviewing their clinical records and learning they had at least 70 assault-related medical presentations and 35 documented head injuries related to partner violence between them.
One was found to have stage I CTE and the other stage II, the earliest, mildest forms of the disease.
Though CTE is likely to be found only in the most extreme examples of domestic violence, experts say the discovery of these new cases underscores the importance of screening victims for the disease at autopsy — and the urgency of supporting women to leave violent relationships.
It is also a confronting reminder of the overlooked risks of brain trauma for abused women, a group that has long been neglected in research despite suffering physical abuse and brain injuries at staggering rates.
“I was a bit shocked that in this first-world country with supposedly world-class public health care that these sorts of histories were popping up through the women’s exposure to violence,” said Michael Buckland, head of the Department of Neuropathology at the Royal Prince Alfred Hospital in Sydney, director of the Australian Sports Brain Bank and one of the new paper’s authors.
“The pathology we found in these cases is identical to what we find in contact sports players — this abnormal deposition of tau protein in the cortex of the brain where you do most of your thinking, most of your planning, and where most of your impulse control comes from … and the fact that we’ve found it in women in their 30s and 40s is quite striking.”
The difference between contact sports players and domestic violence victims, Dr Buckland added, “is that contact sports players choose to participate, whereas obviously these women did not choose to be hit in the head a lot”.
Screening for CTE in victims of abuse
First identified as “punch-drunk syndrome” in boxers in the 1920s, CTE is a progressive brain disease that has been found mostly in athletes and military veterans who have typically suffered hundreds or thousands of concussions and sub-concussive hits.
Its symptoms can include memory loss and confusion, poor impulse control, severe depression and suicidality, though some people seemingly show no signs of illness at all. It can only be diagnosed post-mortem.
CTE was first linked with domestic violence in 1990, when a British doctor described findings of the disease in a 76-year-old woman who had a history of stroke, dementia and years of abuse by her husband.
Two other cases have since been documented using modern diagnostic criteria: in 2021, in a 29-year-old woman who was killed by her abusive fiancé following years of violence in Colorado, and last year, in a 69-year-old woman from California who suffered decades of abuse by her husband.
Having found CTE in several footballers and a small number of autopsy brains in the general population, Dr Buckland believed it was only a matter of time before more diagnoses were made in victims of domestic violence.
It’s why he has argued that deceased victims of abuse with histories of repetitive head injury should routinely be examined for CTE.
“Forensic pathologists and coroners have a unique role to play in disease identification and public health measures,” said Dr Buckland.
“And really, I think for any person who has a history of domestic violence that goes to a coroner, consideration should be given to screening their brain for CTE.
“That’s the only way we’re going to understand how common the problem is in this population.”
Severity of abuse ‘more shocking’ than CTE
More than one in four women in Australia have experienced physical and or sexual violence by a partner or family member since the age of 15, with a 2018 study finding about 40 per cent of family violence victims attending Victorian hospitals over a decade had sustained a brain injury.
The statistics are particularly alarming for First Nations women, who suffer head injury due to assault at 69 times the rate of non-Indigenous women.
Yet head trauma in women remains disturbingly understudied, despite evidence suggesting that women are more susceptible to brain injury and take longer to recover than men.
Linda Iles, head of forensic pathology at the Victorian Institute of Forensic Medicine, has screened for CTE in five victims of family violence who had signs of chronic head trauma or documented histories of long-term partner violence.
In some cases, the victim’s relatives specifically raised concerns they might have CTE.
To date, she has found no evidence of the disease.
“But it’s early days,” she said, “and we still need to keep looking for it”.
As for the two new cases of CTE, Dr Iles said they likely represented “a very extreme end of chronic repetitive head trauma in the setting of family violence”.
What is most shocking about the discovery, she said, is the severity of the abuse the women suffered.
“I think the extent of the chronic violence experienced just by these two individuals should shock people and should refocus attention on this issue,” Dr Iles said.
“Whether there’s low stage CTE is really important and something we need to explore.
“But I think it’s important to focus on the bigger picture” — the many other potential health impacts of persistent violence.
It’s a long and harrowing list.
Last year the largest brain autopsy study of women who had experienced partner violence found substantial vascular and white matter damage as well as cardiovascular and cerebrovascular disease.
The researchers, from the Brain Injury Research Center of Mount Sinai in New York, found Alzheimer’s disease in one case but no CTE in any — though there was a lack of evidence the women had endured long-term repetitive head injury, a crucial factor in the development of CTE.
“We were astounded by the burden of health comorbidity carried by the women in this series,” said Kristen Dams-O’Connor, the study’s lead author.
Approximately half had epilepsy, and chronic diseases such as diabetes, hypertension, substance use and HIV were common, she said.
“The findings clearly indicate that we should be casting a much wider net when it comes to characterising the neuropathology of partner violence-related brain injury and post-traumatic neurodegeneration.”
Spotting the signs of brain injury
As for how the risks of brain trauma from domestic violence can be addressed is an open question, though many experts believe the first step is raising awareness that it’s a major problem in the first instance.
In the sporting realm, education is a crucial strategy for preventing CTE, Dr Buckland said.
“So people should be thinking of exposure to contact sports like we think of exposure to the summer sun, in that you should be aware of the amount of exposure you’ve had — your dosage — and then modify your behaviour so you can still enjoy the sun, but also reduce your overall exposure.”
But that is not always possible for victims of intimate partner violence, who are often prevented from leaving by their abusers or circumstance — and sometimes because they’re unable to think strategically as a result of the brain injuries they’ve sustained.
Tania Farha, chief executive of Safe and Equal, the peak body for family violence organisations in Victoria, said there was a common assumption that repetitive head trauma was primarily a problem for men who play contact sports like football, largely because mainstream media tends to report closely on concussion and CTE among players.
The discovery of two new cases of CTE in victims of domestic violence, then, “really goes to the heart of the fact that this stuff is happening probably more commonly in family violence situations,” she said.
“Lately we’ve been hearing a lot about the deaths of women who have experienced family violence which is really critical … but I also think we have to remember that there’s a lot of injury and harm being done outside of homicide.”
To that end, governments need to invest in campaigns to educate communities about the potential long-term harms of brain injury, Ms Farha said.
“We also need education and training for frontline specialists, so the family violence workforce and the health sector more broadly can recognise when someone is presenting with signs or symptoms that may indicate brain injury and provide long-term support, particularly if they’re in an ongoing [abusive] relationship.”
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