This Thing of Darkness

We all walk the earth in egg-shell armour at the whim of Nature. There is little of any of us that will not break if chaos strikes, or heal without a scar. You’d think that, given our fragility, we would opt for conciliation or compromise, and yet more often we challenge those who are not us, and seek to conquer those we cannot otherwise convince to join. It has become a point of honour not to yield, and so we glorify those who suffer grievous injury for causes dear to us, and our stories magnify their deeds, and exploit their hardships. We call them heroes…

But not all who suffer are our heroes, even though they may also have demonstrated equal courage for their positions, or found themselves inadvertently damaged in the crossfire of our wrath. We call them victims -if we notice them at all -and often deny guilt, even if we do.

Despite Steven Pinker’s contention in his The Better Angels of Our Nature that violence has been diminishing ‘over long stretches of time’ and that ‘today we may be living in the most peaceable era in our species’ existence’, I am still troubled by the violence that continues around us. Of course he may be correct in pointing out a lack of current, or at least, local internecine wars that would affect our daily lives, and suggesting that our improved communication systems highlight and magnify our knowledge of more distant conflicts without our having to experience the trauma ourselves. So, is it our arguably decreasing experience of violence that makes something like domestic cruelty stand out? At any rate, when this form of abuse seems all too apparent around us, it is impossible to ignore. Immoral to accept.

And often hidden beneath the more obvious traumatic injuries are the long-term effects. Of course we have all read about the ramifications of continuing abuse, and about how difficult it is to know whether the injuries are purposefully inflicted or the accidents they are often claimed to be, but what about the often more subtle and cumulative effects of traumatic brain injury?

Two articles caught my eye when I was trying to learn more about the subject. The first was an op-ed in the Los Angeles Times of a few years ago: ‘In recent years, medical science has uncovered the high risk and devastating effects of traumatic brain injury, or TBI, among U.S. combat soldiers and athletes, especially football and hockey players. What if a vastly greater population were also suffering these effects: women and children living with the consequences of domestic violence?’

At that time, ‘There [were] few empirical studies on the prevalence of TBI among women and children affected by domestic violence. But evidence so far strongly indicates a silent epidemic, with major public health ramifications. A 2001 study found that 67% of women seeking emergency medical support for injuries stemming from domestic violence had symptoms related to TBI, and 30% reported loss of consciousness.’

A more recent article, with links to this op-ed was in the online Conversation: ‘The statistics are terrifying: In Canada, one woman is killed every week by her partner, globally, one third of women will suffer violence at the hands of someone they love in their lifetime.’

The article was written by Paul van Donkelaar, a professor in the Faculty of Health and Social Development and a neuroscientist at the University of British Columbia. He goes on to ask, ‘But what if survivors […] are also dealing with the effects of a traumatic brain injury along with the fear and trauma of finally having escaped a long-term abusive relationship? […] the impacts of this injury can be devastating — ranging from headaches, double vision and nausea to difficulty concentrating, remembering things and completing simple tasks. It’s also clear the effects tend to be worse when the trauma occurs repeatedly over time, with symptoms lasting for months to years.’

And, ‘Unlike athletes who have suffered a sport-related concussion, survivors of intimate partner violence also quite often experience emotional difficulties such as post-traumatic stress disorder (PTSD), depression and anxiety.’

‘[…]the U.S. Centers for Disease Control and Prevention, reports each year, 2.3 per cent of women over the age of 18 experience severe physical violence including “being slammed against something” or “being hit with a fist or something hard.” Furthermore, up to 90 percent of survivors of intimate partner violence report head, neck and face injuries at least once and typically on multiple occasions.’

Although I’d like to hope that we live in somewhat different conditions from our neighbours to the south, ‘Assuming similar percentages in Canada, this translates into approximately 276,000 women per year who will suffer a traumatic brain injury as a result of intimate partner violence.’

One of the many disturbing things about this trauma is the possibility of subsequent cognitive deficits -some of which may be severe, and because they may have occurred years before, difficult to remedy, let alone reliably assign attribution. As the author of that op-ed in the L. A. Times, Maria Garay-Serratos, wrote of her mother: ‘For as long as I can remember, my mother took aspirin every day, complaining of unbearable headaches. Sometimes she locked herself in the bedroom with the lights off, asking me to take my siblings outside because she couldn’t tolerate the noise. As she got older, her naps grew longer and her sensitivity to light and noise intensified. By her 50s, her memory had begun to fail.

‘On the day she finally asked me to take her away from my father, I found her in a worse state than I had ever seen her. She could barely stand. She was crawling from room to room while my father ignored her. […] When all the tests were finished, the neurologist told us my mother was suffering from moderate to severe Alzheimer’s disease. The head trauma had been so great and so consistent that there was little they could do.’

Unfortunately, it’s all too easy to focus on simply treating the physical symptoms -and, of course, rescuing the victim from further harm. This is obviously important, and yet woefully insufficient; there is also a need to be alert to problems that seem temporally unrelated. The link to head trauma may be more evident with events like automobile and athletic or combat injuries, but less so in a woman who escaped from an abusive relationship years ago.

Maybe Pinker really has spotted an inexorable trend towards less violence in our society. In the meantime, however, I think ongoing surveillance and counselling for the effects of head trauma might help the abused victims to live a better life while we await an actual treatment for what we now call CTE (Chronic Traumatic Encephalopathy). Oh, and an effective prevention strategy, too -in case those better angels lose their jobs…












Violence Against Women

According to a recent meta-analysis by the World Health Organization, one in three women worldwide are subject to intimate partner violence (IPV) . And it’s not just a third world problem either, as we Canadians with our often parochial outlook would no doubt like to believe. True, some countries seem to be over-represented: ‘East Asia having the lowest incidence, at 16.30% (range, 8.9% – 23.7%), and Central Sub-Saharan Africa having the highest incidence, at 65.64% (range, 53.6% – 77.71)’, but we in Canada are certainly not immune.

Recognizing this, there has been a move to screen women for IPV in hopes of decreasing the violence or improving the outcomes for the victims. However, in a review published in the May 13 edition of the British Medical Journal, the lead author, Dr. Lorna O’Doherty from the University of Melbourne ‘Did not detect a decrease in rates of violence in women’s lives as a result of screening nor did it find improved mental and physical health outcomes for women.’

I have to admit that I had hoped that screening would have had more of an effect than is reported, but maybe on closer examination there are readily identifiable reasons for this. The whole issue seems to involve a complex algorithm with a lot of contextual conditions that have to be considered. First of all, the woman may not yet be ready to admit abuse is taking place; she may not actually see it as ‘abuse’ and so is unlikely to report it as such, even if asked. Or, perhaps she has thought about it, but isn’t yet ready to address or admit the issue –especially to others because of the stigma. There are phases through which she needs to progress in accepting and addressing the abuse. And yet, even if she is ready, her ability to admit it to someone else is going to be predicated on several factors -the WHO report again (and I quote an article in Medscape for the summary):

The report points out that certain healthcare settings (eg, antenatal clinics and HIV screening clinics) offer good opportunities to spot problems and intervene.

However, to be effective in such situations, the recommendations say, certain minimum standards need to be in place. Those include that:

  • providers need to be trained on how to ask about violence,
  • standard operating procedures need to be in place,
  • consultations need to take place in private settings,
  • confidentiality needs to be guaranteed,
  • referral arrangements need to established and maintained, and
  • providers need to be properly equipped to handle the physical and mental consequences of sexual assault.

This sounds reasonable; our obstetrical delivery unit provides universal IPV screening, but I am disappointed with the finding in that study published in the British Medical Journal that even so, the mental and physical outcomes for those women were not improved. And although we are probably missing the vast majority of women who suffer from abuse (and in some cases men as well -but more likely detected in a different venue), one would still like to hope that for those we have found, discovering the problem would be a step towards its solution.

But I think that public recognition of the problem is an equally important, if preliminary step. I sometimes wonder if we inadvertently stigmatize IPV because we, as a society, simply do not acknowledge it. It is something we’d rather not think about, or if we do, we do so judgementally. So, despite various professionals attempting to detect it and thereby (it was hoped) ameliorate the consequences, the victims remain reluctant to admit it is even happening. They, like the rest of us, see it as shameful and perhaps reflecting on their own choices, their own self-worth…

I’m reminded of our Canadian disgrace: the seeming indifference to the disappearance and violence against our Aboriginal women. There is, of course, lip service acknowledgement by the government that there might be a problem, but a rather indignant assurance that they are taking steps to resolve the issue seems to be all they have to offer. One could be forgiven for wondering whether they simply didn’t want any more public attention drawn to the problem.

I see the problem of violence against women differently. I think that the more it is publicized, the more it will be recognized, and the more will be society’s demand that the hitherto secret norm of violence will be seen to be inappropriate –no, not inappropriate, wrong. Think of the changing (I’d like to say changed but I suspect it would be premature) attitude to drinking and driving. As a society, we are realizing it is something to be condemned, not tolerated. Something that can be, and should be, discussed in the open. Something that is no longer acceptable…

It is possible to alter behaviour we have always viewed as undesirable, yet secretly condoned by our unwillingness to confront it. We need to acknowledge and tackle it as a society –and we need confront it often, publically, rationally, doggedly. I am reminded of something Lucretius wrote: The drops of rain make a hole in the stone, not by violence, but by oft falling.