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Nonfatal Strangulation as Part of Domestic Violence: A Review of Research
Abstract
This article reviews recent scholarship around the issue of nonfatal strangulation in cases of domestic violence. In the mid-1990s, the San Diego City Attorney's Office began a systematic study of attempted strangulation among 300 domestic violence cases, becoming one of the first systematic research studies to specifically examine the prevalence of attempted strangulation as a form of injury associated with ongoing domestic violence. Prior to this time, most of the research into strangulation was conducted postmortem, and little was known about the injuries and signs of attempted strangulation among surviving victims. This article reviews the research that has since been conducted around strangulation in domestic violence cases, highlighting topics that are more or less developed in the areas of criminology, forensic science, law, and medicine, and makes recommendations for future research and practice.
... Open access serious future harm by 7.48 times above victim-survivors who do not experience NFS. 8 Several reviews have documented the prevalence and type of visible and psychological strangulation injuries. [11][12][13] However, there is a cumulative evidence that having few or no injuries visible to the naked eye is common following NFS. 2 11 The implications of this are not only problematic for healthcare, but can make the prosecution of NFS as a result of domestic violence more difficult. This is particularly true among jurisdictions that rely on evidence that the assault occurred beyond the testimony of the complainant and where this evidence can lend additional credibility to the complainant. ...
... Evidence that was recommended as useful for prosecutors were any diagnostic testing; photographic images and medical records of any visible injuries such as contusions, scratches, ligature marks or defensive wounds related to the assault; and records of other clinical symptoms related to the assault, neck pain, loss of consciousness or incontinence. 12 for prosecution evidence gathering than the same observations recorded by law enforcement. Importantly, a lack of external injury was discussed across all articles, with three remarking that arguments that absence of injury are consistent with the occurrence of strangulation is ambiguous, 37 or potentially misleading 31 Open access hand, the use of coordinated evidence collection using questioning provided broader corroborating evidence that did not rely solely on the presence of external injury. ...
... 12 38 The overall quality of medical evidence was discussed as a central factor in prosecuting NFS cases. 12 This was reiterated by data finding that cases were 40% more likely to be filed when NFS victim-survivors were examined using procedural collection of evidence through forensic nurses, compared with cases where a forensic examination did not take place. 36 ...
ABSTRACT
Objectives: Non-fatal strangulation (NFS) is a serious form
of gendered violence that is fast becoming an offence in
many jurisdictions worldwide. However, it often leaves
little or no externally visible injuries making prosecution
challenging. This review aimed to provide an overview
of how health professionals can support the prosecution
of criminal charges of NFS as part of regular practice,
particularly when externally visible injuries are absent.
Method: Eleven databases were searched with terms
related to NFS and medical evidence in health sciences
and legal databases. Eligible articles were English
language and peer reviewed, published before 30 June
2021; sample over 18 years that had primarily survived a
strangulation attempt and included medical investigations
of NFS injuries, clinical documentation of NFS or medical
evidence related to NFS prosecution.
Results: Searches found 25 articles that were included
for review. Alternate light sources appeared to be the most
effective tool for finding evidence of intradermal injury
among NFS survivors that were not otherwise visible.
However, there was only one article that examined the
utility of this tool. Other common diagnostic imaging
was less effective at detection, but were sought after
by prosecutors, particularly MRIs of the head and neck.
Recording injuries and other aspects of the assault using
standardised tools specific for NFS were suggested for
documenting evidence. Other documentation included
writing verbatim quotes of the experience of the assault
and taking good quality photographs that could assist
with corroborating a survivor’s story and proving intent, if
relevant for the jurisdiction.
Conclusion: Clinical responses to NFS should include
investigation and standardised documentation of internal
and external injuries, subjective complaints and the
experience of the assault. These records can assist in
providing corroborating evidence of the assault, reducing
the need for survivor testimony in court proceedings and
increasing the likelihood of a guilty plea.
... Women's nondisclosure of mechanism of injury or minimization of injuries was reported, and multiple physical and psychological outcomes were recorded. Pritchard et al. (2017), USA Nonfatal strangulation literature across the areas of criminology/domestic violence, forensic science, law and medicine. 49 reviewed articles , looking at research on nonfatal strangulation in the following four areas; criminology, forensic science, law and medicine Strangulation injuries may be more serious and less visible than previously understood. ...
... For example, victims may not consider NFS to be significant or worthy of reporting and therefore may be unaware of its symptoms, sequalae or associated risks (Monahan et al., 2020;Patch et al., 2018Patch et al., , 2021, and thus may not seek health care or disclose their experiences. NFS can occur without any obvious signs of symptoms being present or with delayed symptoms (Monahan et al., 2020;Patch et al., 2018), and when other traumas or violent acts are experienced at the same time, they may overshadow strangulation (MacDonald et al., 2021;Pritchard et al., 2017). Additionally, victims may not have the language to disclose NFS (e.g. using terms like choke and strangle to mean different things) or its sequalae (Pritchard et al., 2017). ...
... NFS can occur without any obvious signs of symptoms being present or with delayed symptoms (Monahan et al., 2020;Patch et al., 2018), and when other traumas or violent acts are experienced at the same time, they may overshadow strangulation (MacDonald et al., 2021;Pritchard et al., 2017). Additionally, victims may not have the language to disclose NFS (e.g. using terms like choke and strangle to mean different things) or its sequalae (Pritchard et al., 2017). Finally, even if disclosure does occur, victims may conceal the mechanism of injury, and/ or injuries may be minimized . ...
Aim
The aim of this study was to determine how front‐line health professionals identify and manage nonfatal strangulation events.
Design
Integrative review with narrative synthesis was conducted.
Data Sources
A comprehensive database search was conducted in six electronic databases (CINAHL, Wed of Science, DISCOVER, SCOPUS, PubMed and Scholar) resulting in 49 potentially eligible full texts, reduced to 10 articles for inclusion after exclusion criteria were applied.
Review Methods
An integrative review was undertaken in accordance with Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) Statement guidelines. Data were extracted, and a narrative synthesis using Whittemore and Knafl (2005) framework was undertaken to determine how front‐line health professionals identify and manage nonfatal strangulation events.
Results
The findings identified three main themes: an overall failure by health professionals to recognize nonfatal strangulation, a failure to report the event and a failure to follow up on victims after the event. Stigma and predetermined beliefs around nonfatal strangulation, along with a lack of knowledge about signs and symptoms, were the salient features in the literature.
Conclusion
Lack of training and fear of not knowing what to do next are barriers to providing care to victims of strangulation. Failure to detect, manage and support victims will continue the cycle of harm through the long‐term health effects of strangulation. Early detection and management of strangulation are essential to prevent health complications, particularly when the victims are exposed to such behaviours repeatedly.
Impact
This review appears to be the first to explore how health professionals identify and manage nonfatal strangulation. It identified the significant need for education and robust and consistent screening and discharge policies to assist health providers of services where victims of nonfatal strangulation attend.
No Patient or Public Contribution
This review contains no patient or public contribution since it was examining health professionals' knowledge of identifying nonfatal strangulation and the screening and assessment tools used in clinical practice.
... Non-fatal strangulation (NFS), defined as "the external compression of a person's neck and/or upper torso in a manner that inhibits that person's airway or the flow of blood into or out of the head," [1] (p. 410), has garnered recent attention as a potentially lethal type of violence [2][3][4] used in domestic violence situations to exert control over a victim [1,5]. ...
... Non-fatal strangulation (NFS), defined as "the external compression of a person's neck and/or upper torso in a manner that inhibits that person's airway or the flow of blood into or out of the head," [1] (p. 410), has garnered recent attention as a potentially lethal type of violence [2][3][4] used in domestic violence situations to exert control over a victim [1,5]. NFS "is essentially a live demonstration of power and control over another individual's life or death" [1] (p. 1). ...
... Along with the realization of the seriousness of NFS came statutory changes making NFS a felonious assault in most states [1], though holding offenders accountable under these statutes is challenging with lack of corroborating evidence that is typical of NFS cases [20,22]. With medical evaluation and documentation viewed as "powerful ways to substantiate the survivor's account of the incident" [11] (p. 45), it is essential for NFS victims to have a complete medical examination [10] including a forensic assessment to not only mitigate any serious health consequences of NFS [2] but also to collect valuable evidence to aid prosecution efforts [11,[23][24][25][26]. ...
The purpose of this study is to examine forensic documentation of non-fatal strangulation (NFS) in domestic violence cases. Research has pointed to the importance of forensic evidence in the prosecution of strangulation offenders. However, limited research has examined the type of evidence that is gathered during a forensic examination for NFS that occurs during a domestic violence situation. To address this gap in the literature, this study analyzed 63 NFS forensic examination records and body sketches for victims who were referred by police during a domestic violence incident. Results reflect the seriousness of NFS with multiple strangulation attacks in the current incident recorded in 52% of the reports, loss of consciousness recorded in 13.1% of the reports, and a history of strangulation in the relationship recorded in 60% of the reports. It is argued that a forensic exam is essential to identify and mitigate serious symptoms and injuries, as well as to collect valuable evidence that can be used during legal proceedings. Implications for practice and policy are discussed.
... Despite an elevated risk of fatality, most victims will survive a strangulation incident. Nonfatal strangulation (NFS) is an issue that has received increasing attention from scholars over the last two decades and emerging research has broadened our knowledge of NFS in a domestic context (Armstrong & Strack, 2016;Bendlin & Sheridan, 2019;Pritchard et al., 2015;Strack et al., 2001). Yet, current research remains inadequate, mainly due to methodological issues, making comparisons across studies difficult (Pritchard et al., 2015), a challenge also facing DV research more generally (Bender, 2016). ...
... Nonfatal strangulation (NFS) is an issue that has received increasing attention from scholars over the last two decades and emerging research has broadened our knowledge of NFS in a domestic context (Armstrong & Strack, 2016;Bendlin & Sheridan, 2019;Pritchard et al., 2015;Strack et al., 2001). Yet, current research remains inadequate, mainly due to methodological issues, making comparisons across studies difficult (Pritchard et al., 2015), a challenge also facing DV research more generally (Bender, 2016). As a result, determining the prevalence of NFS can be problematic and varies substantially depending on the nature and size of the sample (Bendlin & Sheridan, 2019;Black et al., 2011;Glass et al., 2008;Marks et al., 2020;Pritchard et al., 2015;Shields et al., 2010;Sorenson et al., 2014;Wilbur et al., 2001). ...
... Yet, current research remains inadequate, mainly due to methodological issues, making comparisons across studies difficult (Pritchard et al., 2015), a challenge also facing DV research more generally (Bender, 2016). As a result, determining the prevalence of NFS can be problematic and varies substantially depending on the nature and size of the sample (Bendlin & Sheridan, 2019;Black et al., 2011;Glass et al., 2008;Marks et al., 2020;Pritchard et al., 2015;Shields et al., 2010;Sorenson et al., 2014;Wilbur et al., 2001). Population-based samples report a lower prevalence of NFS (3%-9.7%) ...
Nonfatal strangulation (NFS) is a common form of domestic violence (DV) that frequently leaves no visible signs of injury and can be a portent for future fatality. A validated text mining approach was used to analyze a police dataset of 182,949 DV events for the presence of NFS. Results confirmed NFS within intimate partner relationships is a gendered form of violence. The presence of injury and/or other (non-NFS) forms of physical abuse, emotional/verbal/social abuse, and the perpetrator threatening to kill the victim, were associated with significantly higher odds of NFS perpetration. Police data contain rich information that can be accessed using automated methodologies such as text mining to add to our understanding of this pressing public health issue.
... Emerging evidence suggests that perpetrators use NFS/S as a mechanism of coercive control to instill compliance and dependency over time through a pattern of malevolent conduct (Nemeth et al., 2012;Pritchard et al., 2017;Stansfield & Williams, 2018;Stark, 2007;Thomas et al., 2014;Vella et al., 2017). Much of what is known about survivors' perception of NFS/S, however, has come from studies using retrospective designs of small samples of women from domestic violence (DV) shelters (Joshi et al., 2012;Thomas et al., 2014;Vella et al., 2017;Wilbur et al., 2001) or jail phone call recordings between suspects and victims (Bonomi et al., 2011;Nemeth et al., 2012). ...
... Technically, choking is an accidental event that inhibits airflow internally when the trachea (i.e., windpipe) is blocked by a foreign object (Strack & Agnew, 2013;Strack & Gwinn, 2011). Conversely, strangulation occurs intentionally (Strack & Agnew, 2013, emphasis added) when external pressure on the neck and/or torso disrupts normal breathing patterns and/or circulation of blood in and out of the brain (Pritchard et al., 2017). 1 Despite popular misperceptions of strangulation involving a ligature (Strack & McClane, 1999), most perpetrators use their hands and/or their forearm (e.g., choke hold; Mcquown et al., 2016;Pritchard et al., 2018;Strack et al., 2001). Regardless, strangulation is among the most lethal forms of DV, where serious injury and/or death can occur within minutes. ...
... Existing accounts of the lived experiences of survivors have provided a wealth of baseline insight into the dynamics, motives, and impact of NFS/S on victims' health and autonomy (Joshi et al., 2012;Nemeth et al., 2012;Thomas et al., 2014;Vella et al., 2017;Wilbur et al., 2001), fueling an ongoing debate as to whether NFS/S is more a malicious tactic used to reinstate power and control over victims versus an unsuccessful murder attempt (Laughon et al., 2009;Thomas et al., 2014). To date, much of the evidence centers on NFS/S as a mechanism of coercive control, whereby aggressors instill compliance and dependency over time through a pattern of malicious physical and nonphysical conduct (e.g., gaslighting, threats of suicide, humiliation; Nemeth et al., 2012;Pritchard et al., 2017;Stansfield & Williams, 2018;Stark, 2007;Thomas et al., 2014;Vella et al., 2017). While definitions vary, Stark (2012) defined coercive control as "a strategic course of oppressive conduct that is typically characterized by frequent, but low-level physical abuse and sexual coercion in combination with tactics to intimidate, degrade, isolate, and control victims" (p. ...
Holding perpetrators accountable for family violence is challenged when survivors are reluctant to testify. In light of recent Supreme Court precedents limiting the admissibility of statements to law enforcement in victimless prosecutions, the current study examined 130 cases of nonfatal strangulation (NFS) to determine whether case characteristics and themes across survivors' on-scene statements can help prosecutors combat common legal defenses raised when victims are unavailable for trial. The history of prior violence and how only 6% of perpetrators stopped strangling victims on their own suggests that NFS complaints should be investigated as an attempted homicide until evidence suggests otherwise.
... Statutory changes have made nonfatal strangulation, a potentially life-threatening assault, a felony offense in 1 University of Central Florida, Orlando, USA many states across the United States . These statutory changes emerged as awareness grew regarding the serious consequences of strangulation, including, but not limited to, miscarriage, loss of consciousness, and even delayed death (Funk & Schuppel, 2003;Glass et al., 2008;Iserson, 1984;McClane et al., 2001;Messing et al., 2018;Plattner et al., 2005;Pritchard et al., 2017;Smith et al., 2001;Stanley & Hanson, 1983;Strack et al., 2001). Research also indicates that strangulation commonly occurs multiple times during the course of a violent relationship (5.3 times on average; Wilbur et al., 2001), and multiple attacks on separate occasions results in an increased frequency of strangulation injuries (Messing et al., 2018;Smith et al., 2001). ...
... Furthermore, victims with visible injuries are more easily identified and are taken more seriously when reporting (Thomas et al., 2014), whereas those without visible injuries may struggle more to convince the court of their assault (Joshi et al., 2012;Pritchard et al., 2017). Nonfatal strangulation can also result in delayed presentation of injuries, making injuries difficult to identify and document as corroborating evidence for prosecution (Funk & Schuppel, 2003;Joshi et al., 2012;Strack et al., 2001). ...
... Over the years, medical professionals, hospital staff, and physicians have dramatically increased screening for domestic violence among patients (Weeks et al., 2008), yet research indicates that a lack of strangulation-specific training results in the underevaluation by medical personnel of many nonfatal strangulation victims who present without apparent serious injury . While many victims of nonfatal strangulation do not present with any visible injuries or present with only minor injuries, delay in treating these victims may have severe health consequences, including death due to serious internal injuries (Glass et al., 2008;Iserson, 1984;Pritchard et al., 2017;Smith et al., 2001). ...
Many states’ laws now classify nonfatal strangulation as part of domestic violence as a felony offense, but prosecution of offenders remains challenging due to the nature of this type of violent offense. This study evaluates a coordinated effort designed to improve one county’s response to nonfatal strangulation. The impact of law enforcement training and specialized forensic medical examinations on facilitating evidence-based prosecution of nonfatal strangulation offenders is examined. Preliminary support is found for the effectiveness of the coordinated effort, highlighting the importance of comprehensive law enforcement training and detailed medical evidence in facilitating evidence-based prosecution.
... A s many as 1 in 10 women report experiencing nonfatal strangulation by an intimate partner in her lifetime (Black et al. 2011). Strangulation is defined differently depending on specific state laws, but, in general, it is a form of assault, and, in this article, is examined as a specific tactic of partner abuse (Dunn and Smock 2017;Pritchard et al. 2017). Nonfatal strangulation can result in a wide range of injuries depending on the amount of pressure applied to the throat and the length of time of the strangulation (Dunn and Smock 2017; Training Institute on Strangulation Prevention 2018). ...
... Research suggests that nonfatal strangulation is experienced by many partner violence victims, and that many victims experience nonfatal strangulation repeatedly (Messing et al. 2014;Pritchard et al. 2017). Understanding nonfatal strangulation experiences both before and after a PO is obtained can help inform safety planning and legal protections. ...
... (2) about one in eight women experienced nonfatal strangulation after the PO and both nonfatal strangulation and death threats in the year before the PO were associated with nonfatal strangulation experiences after the PO; (3) although nonfatal strangulation was associated with depression, PTSD, and SUD at the bivariate level, nonfatal strangulation experiences do not appear to be uniquely associated with mental 98 LOGAN health status at follow-up when controlling for other abuse experiences and baseline mental health status; and, (4) those with nonfatal strangulation experiences may have more difficulty initiating or maintaining separating from abusive partners as indicated by more separation attempts and more who reconciled with the PO partner after the PO; and, consistent with prior research, the current study found that nonfatal strangulation was a relatively common experience among partner abuse victims who obtained a PO, with about 61% indicating their abusive (ex)partner had ever strangled them (Malek et al. 2000;Messing et al. 2018;Pritchard et al. 2017;Wilbur et al. 2001). Of those who had ever experienced nonfatal strangulation by their abusive (ex)partner, the vast majority (84%) had experienced it in the year before obtaining a PO. ...
Nonfatal strangulation is associated with significant physical harm and lethal violence. The overall objective of this study was to examine relationship and abuse tactics for women with (n = 369) and without (n = 276) nonfatal strangulation experiences the year before, and the year after, a civil protective order (PO) against an abusive (ex)partner was obtained. Furthermore, this study sought to examine which abuse tactics, including nonfatal strangulation, were associated with mental health status at follow-up. In the year before the PO, 57% of women experienced nonfatal strangulation and 12.4% experienced nonfatal strangulation in the year after the PO by their abusive (ex)partner. Those with nonfatal strangulation experiences in the year before the PO were 3.5 times more likely to experience nonfatal strangulation after the PO. Additionally, death threats in the year before the PO as well as having spent any time in the relationship with the abuser after the PO were uniquely associated with post-PO nonfatal strangulation. Furthermore, abuser control tactics and severe violence after the PO were significantly associated with mental health status at follow-up after controlling for baseline mental health status. Study results also suggest that those with nonfatal strangulation experiences may have an especially difficult time initiating and maintaining separation from abusive partners. Results suggest that there are specific risk factors to consider in tailoring PO protections, safety supports, and resources for those with prior nonfatal strangulation experiences.
... NFS is a particularly insidious and lethal form of brain injury sustained by IPV survivors (Goldin et al. 2016;Mcquown et al. 2016;Mechanic et al. 2008;Pritchard et al. 2017;Wilbur et al. 2001). In a study of abused women seeking services, 68% reported a history of NFS, with 5.3 NFS experiences on average (Wilbur et al. 2001). ...
... Choking refers to the internal blockage or constriction of the airway (O'Toole 2017). Pritchard et al. (2017) define NFS as "the external compression of a person's neck and/or upper torso in a manner that inhibits that person's airway or the flow of blood into or out of the head," (pg. 410). ...
... As mentioned, those experiencing NFS are over 7 times more likely to be killed by their romantic partners (Campbell et al. 2007;Glass et al. 2008;Reckdenwald et al. 2017). Invisible physical injuries and cognitive or psychological deficits, often delayed, impede criminal prosecution Pritchard et al. 2017). Accordingly, criminal statutes in many states make the distinction between NFS as attempted murder from other forms of IPV, considered domestic assault. ...
Approximately 1.3 million women in the United States will experience various forms of aggression by an intimate partner, per year. The clinical implications of “choke-holds” and lethal outcomes have recently garnered national attention. Nonfatal strangulation (NFS) and blows to the head or face resulting in traumatic brain injury (TBI) represent forms of aggression that create short and long-term sequelae for the victim. The aim of this paper is to provide an overview for health care providers, mental health clinicians and advocates regarding the physical, neurological and psychological sequelae following NFS, post-Intimate Partner Violence. A search of databases (Google Scholar, PubMed, PsychINFO, SocIndex, Scopus, ScienceDirect, and Web of Science) was conducted regarding the clinical, physical, neurological, and legal issues for women who have experienced NFS and IPV. The authors identified 55 research, mental health, and clinical articles as well as legal reviews, addressing the short-term and long-term outcomes of NFS in IPV. The current manuscript discusses the primary sequelae and challenges facing those who experience NFS. Many health care practitioners will interface with IPV survivors who have experienced NFS; it is a high priority to identify, assess, and intervene. Universal screening methods, safety and referral resources for IPV/NFS survivors, and legal considerations are primary components of successful intervention and treatment with this population.
... Traumatic brain injury (TBI) is defined as "an alteration in brain function, or other evidence of brain pathology, caused by an external force that may result in cognitive impairment" (Menon et al., 2010). Strangulation is defined as the interference of blood or airflow by any "external compression of a person's neck and/or upper torso in a manner to inhibit that person's airway or the flow of blood into or out of the head" (Pritchard et al., 2017). During strangulation a victim may experience difficulty breathing, dizziness and severe pain, and/or a loss of consciousness which can result in an ABI (Hammond et al., 2016). ...
... However, even more disturbing was that 0.6% of IPV survivors had a documented strangulation assessment. In samples of convenience, high rates (e.g., 27% to 89% (Pritchard et al., 2017) of strangulation have been found in females who have experienced IPV. Other data have indicated that many exclusively female survivors (Toccalino et al., 2023). ...
To determine intimate partner violence (IPV) incidence reported by a hospital health service and the proportion of patients who received a traumatic brain injury (TBI) or strangulation assessment.
This retrospective review utilised IPV, TBI and strangulation screening data from one New Zealand hospital healthcare service between 01/01/2018 and 30/12/2021.
Over four years, 660 IPV reports showed an average incidence of 44.2 (95% CI: 37.5 to 52.2) per 100,000 population. New Zealand Māori had the highest incidence 81.8 (95% CI: 70.9 to 94.3) per 100,000 population. Nearly half (n = 328; 49.7%) of IPV survivors reportedly had been “choked” and over a third (n = 252; 38.2%) reportedly “knocked out”. Less than 1% of IPV survivors had a recorded TBI (n = 5; 0.8%) or strangulation (n = 4; 0.6%) assessment. Less than a quarter (24.2%) of IPV reports were completed by doctors and nurses, with social workers completing the most assessments (49.2%).
Reported loss of consciousness and strangulations caused by IPV were high in this hospital setting, yet they were rarely assessed. New Zealand Māori had the highest incidence per ethnic population of partner inflicted TBI presenting to the hospital. There is a risk of potential TBIs being missed due to lack of assessment by registered medical and nursing professionals given the majority of reports were provided by allied health workers such as social workers. These data underscore the critical need for healthcare provider education and training in understanding, recognizing, and treating brain injuries in females who present to medical facilities with IPV.
... (DV) or felony assault statutes to include clear legislative language describing the unique definitions, intent, and penalties for NFS (Laughon et al., 2009;Pritchard et al., 2017). ...
... Despite the wave of legislative reform, strangulation statutes comprise unique elements related to asphyxia, with few mandating training for first responders . While statutes vary state-to-state, arrests and convictions for NFS generally require evidence that perpetrators impeded the victims' blood circulation or normal breathing (Laughon et al., 2009;Pritchard et al., 2017). Without specialized training, however, limited information exists to aid officers and prosecutors on how to corroborate evidence of these unique elements. ...
The reliance on external injuries for justice is misguided given that assault injuries may be less visible among victims of color due to increased melanin in the skin. To date, however, less is known whether racial/ethnic disparities extend to officers' identification of signs of nonfatal strangulation (NFS). The current study estimates the extent of NFS indicators identified by officers who completed a standardized strangulation assessment in 133 family violence complaints. Breathing difficulties were the most common symptoms identified by officers (98%), followed by external signs (89%), and symptoms of impeded blood circulation (87%). Compared to cases involving White/Asian survivors, officers were less likely to identify external injuries on Black survivors' neck, chin, and chest/shoulders. While racial/ethnic differences did not emerge for symptoms of disrupted airflow, Hispanic survivors were twice as likely to report losing control of bodily functions. Implications for policy and practice are discussed.
... [1][2][3] Approximately 25% of women who experience IPV experience repeat strangulations. [6][7][8] Despite the burden of ABI for some women who experience strangulation, little prospective longitudinal data exist that capture the acute phase of injury through an extended period of follow-up after an IPV strangulation event. 4 Such data are critical given that it may allow clinicians to predict which patients may experience persisting symptoms and lead to early intervention and individualized care. ...
... Current recommendations for clinical evaluations do not fully assess the extent of strangulation-associated neuropsychological and functional deficits nor the symptom burden among women experiencing IPV. [8][9][10] Understanding the neuropsychological and functional outcomes of women victimized by strangulation associated with IPV is necessary for future development of evidencebased protocols for the assessment and treatment of ABI in women experiencing IPV. ...
Intimate partner violence (IPV) is a public health crisis that results in acute and long-term health consequences for women, including potential acquired brain injury (ABI) from non-fatal strangulation. Despite existing evidence on the neuropsychological sequelae experienced by women after experiencing IPV-related assault, limited evidence-based treatment protocols exist for these women. This 14-month study sought to, 1) assess the feasibility and acceptability of recruiting women who experienced strangulation associated with IPV within 7 days of the event and retaining them throughout a three-month follow-up period; and 2) examine preliminary data from neuropsychological, balance and symptom assessments. Inclusion criteria were: reported strangulation by an intimate partner in the prior seven days, female, 18 to 60 years of age, English-speaking, and able to consent. Neuropsychological, balance, and symptom assessments were administered at the first time point and again three months later. Participants also completed a standardized daily symptom inventory. Eight participants (73%) were recruited and completed daily inventories and the baseline assessment; four (36%) completed the baseline and three-month assessments. Of the four participants who completed the three-month assessment, none reported symptom resolution. Only balance returned to values consistent with normative values. Our results demonstrate the ability to recruit women who have experienced IPV-related strangulation during the post-acute phase of injury with less success retaining participants for a 90-day period for follow-up study. This pilot research protocol demonstrated the feasibility of recruitment from the ED and systematic evaluation of neuropsychological and functional symptoms in women who experienced strangulation in the context of IPV.
... Research has also been crucial in identifying the symptoms and signs of non-fatal strangulation, which is defined as external compression of a person's neck and/or upper torso in a manner that inhibits that person's airway or the flow of blood into or out of the head [18]. This research has informed the development of non-fatal strangulation toolkits and reference guides for forensic clinicians, investigators, and prosecutors on the 'red-flag' symptoms and signs of non-fatal strangulation [19,20]. ...
... In cases where symptoms do occur the time of onset, and delays in presentations to healthcare services or police, is a further complicating factor. The development of non-fatal strangulation symptoms and signs may be subtle or delayed by many days [18], making it difficult for the healthcare provider or forensic clinician to identify an injury, particularly, if the patient was assessed immediately following the incident. In cases where the patients themselves do not immediately present to a healthcare service or to police, any symptoms and signs may have resolved before a forensic medical assessment is performed. ...
Emerging evidence suggests that an onset or escalation of interpersonal violence has been occurring during the COVID-19 pandemic, particularly among persons in intimate or familial relationships. Strangulation (or neck compression) is a common form of interpersonal violence and can result in serious adverse health outcomes, including death. The identification and attribution of injuries from non-fatal strangulation are complex, as there may be an absence of external signs of injury and their appearance may be delayed by many days. There is a heavy reliance on clinician identification of ‘red flag’ symptoms and signs, the presence of which necessitates urgent further assessment. Additional challenges arise when acute non-fatal strangulation symptoms and signs are shared with other clinical conditions. In such cases, differentiating between the conditions based on the symptoms and signs alone is problematic. We present the diagnostic challenges faced when conducting forensic assessments of COVID-19-positive and suspected COVID-19 (S/COVID) patients following allegations of non-fatal strangulation in the setting of physical and sexual assaults. The implications of shared symptoms and signs, for forensic clinicians, primary healthcare, and emergency practitioners, as well as other frontline service providers, are discussed.
... In some cases, attempted murder may be an option, but it may be difficult to prove intent to cause serious harm or death (Douglas and Fitzgerald, 2014). In response to research highlighting the serious harms and risks associated with NFS and to the perceived undercharging of it, many American states established discrete offences of non-fatal strangulation throughout the 2000s (Pritchard et al., 2017). Most Australian jurisdictions, Canada and New Zealand have subsequently followed their lead, introducing discrete offences of NFS (Edwards and Douglas, 2021). 1 England and Wales have also introduced a non-fatal strangulation offence in 2021 (Domestic Abuse Act 2021 (England and Wales), s. 75A). ...
... In a review of 300 NFS cases, Strack et al. (2001) found that only 50 per cent of strangulation survivors had any visible injuries and only 15 per cent of those with visible injuries had an injury that was severe or clear enough to be photographed for evidential purposes. Subsequent studies have similarly identified that it is common for victims of NFS to have no visible injuries (Joshi et al., 2012;Matusz et al., 2020;Pritchard et al., 2017). Where victims have darker skin, it may be more difficult to see injuries (Baker and Sommers, 2008). ...
Non-fatal strangulation is recognised as a common form of coercive control in violent relationships. Overwhelmingly it is perpetrated by men against women. It is dangerous both because of the immediate and serious injuries it can cause, and the risk of future violence associated with it. A discrete offence of non-fatal strangulation has been introduced in many countries. Queensland, Australia introduced a discrete non-fatal strangulation offence in 2016. While the offence is charged often, around half the non-fatal strangulation charges laid by police do not proceed. We spoke to prosecution and defence lawyers to better understand the evidential obstacles to successful prosecution. We found that the prosecution of the offence faces challenges common to family violence offences more broadly, despite it being a discrete physical act. Specifically, we found that the willingness of the victim to testify and the perception of the victim's credibility were key to successful prosecution.
... BI can also result from hypoxic or anoxic events; strangulation can cause hypoxia and anoxia, when the oxygen supply to the brain is restricted or completely cut off, leading to brain tissue damage and/or death which can occur in a short period of time in IPV-related violence (Pritchard et al., 2015(Pritchard et al., , 2018E. M. Valera et al., 2019). ...
... Using the HELP screen tool criteria (Gagnon & DePrince, 2017;Pritchard et al., 2015), about 58% of women tested "positive" for a possible BI. This is similar to another study that found 56% of IPV survivors screened, tested "positive" for a possible BI using the HELP tool criteria (Gagnon & DePrince, 2017). ...
The study examined rates of possible brain injury among survivors of intimate partner violence. Of the 171 women screened, 91% indicated they had been hit in the head or strangled, and 31% reported it happened more than six times in their life. Only 35% of women who were hit in the head or strangled received medical treatment, and 64% reported losing consciousness or experienced a period of being dazed and confused. Organizations serving intimate partner violence survivors should routinely screen survivors for brain injury so they can obtain timely referrals for neurorehabilitation services to improve their quality of life.
... Non-fatal strangulation was associated with death threats and victims' fear of dying. In this vein, Pritchard et al. (2017) define overt death threats and non-fatal strangulation as a live demonstration of power and control over women's life or death. Indeed, according to these authors, the act of strangulation may be designed to demonstrate to a victim that the perpetrator can end their life whenever he chooses. ...
Purpose Intimate partner violence against women is a major source of morbidity and mortality among women worldwide. In
this study, 131 testimonies of female victims of intimate partner violence (IPV) are examined to study the factors associated
with victims’ decision to seek social support (formal and informal).
Method Semi-structured interviews were conducted with female victims of IPV in Spain. The IRaMuTeQ 7 software was
used to analyze the discourses. A total of 10,845 words with 1183 different forms were examined.
Results The analysis identified six clusters. Cluster 1 (18% of the total content) reflects the emotional component of aggression (fear of death). Cluster 2 (13.1%) describes psychological aggression (threatening), and Cluster 3 (17.2%) refers to the
use of power within relationships (control). Cluster 6 (13.8%) includes different types of physical aggression (hitting); and
Clusters 4 (21%) and 5 (16.9%) refer to formal (judging) and informal (friends) social support.
Conclusions Results indicated a strong association between emotions (e.g., fear of dying) and physical and psychological aggression. Non-fatal strangulation represented an extreme form of physical violence that was used to control women
increasing the risk of violence becoming lethal. Women tended to seek more support when the violence increased, and they
perceived a greater risk to their children. There was an association between suffering violence, power, control, and seeking
formal and informal social support. Results have significant implications to interrupt coercive control processes and to motivate help seeking behaviors in victims of IPV.
... Risk identification and assessment practices tailored to the patterns of family violence experienced by children and young people must ensure that full visibility is given to the range of family violence behaviours that may be experienced -and how they impact the level of risk posed. Additionally, while adult victimsurvivor experiences of non-fatal strangulation have garnered significant attention in recent years (see, inter alia, Pritchard, Reckdenwald & Nordham, 2017;Monahan, Bannon & Dams-O'Connor, 2020;Sharman, Douglas & Fitzgerald, 2021), there has been minimal research examining non-fatal strangulation among children and young people. Further research is needed to understand the contexts, nature and impacts of non-fatal strangulation among young victim-survivors. ...
This study provides an analysis of young Victorians’ (aged 16 to 20 years) self-reported experiences of gender-identity abuse, LGBTIQ+ identity abuse, and the cultural impacts of family violence victimisation. It forms part of a wider study contracted by Family Safety Victoria (FSV) to support the development of the Child and Young Person-focused MARAM practice guidance and tools. This report presents the key findings – including quantitative and qualitative analysis – from a Victorian based study of children and young people’s experiences of LGBTIQ+ identity abuse, gender identity abuse and experiences of family violence that result in cultural impacts. The report presents details about the study design and the broader national data set upon which this project draws.
... It has been well-established that IPV victimization leads to negative mental health consequences for many survivors (Ahmadabadi et al., 2020;Beydoun et al., 2012;Chandan et al., 2020;Trevillion et al., 2012). Survivors are also at increased risk of long-term injuries and other physical health problems (Pritchard et al., 2017;Valera, 2018). Only in recent years has IPV victimization been established as a major contributor to housing instability and homelessness (Broll & Huey, 2020;Chan et al., 2021;Dillon et al., 2016;Pavao et al., 2007). ...
Intimate partner violence (IPV) is a widespread and devastating phenomenon resulting in a myriad of long-term consequences for survivors and their children. IPV victimization not only has negative health and economic consequences, it has also been linked to homelessness and housing instability. In response, the Domestic Violence Housing First (DVHF) model is being used in some domestic violence (DV) agencies to help survivors attain safe and stable housing. The model includes using individualized advocacy and/or flexible funding to help survivors meet these goals. Using a longitudinal, quasi-experimental design, the current study involved conducting interviews with survivors and examining agency records to investigate the effectiveness of this model. We hypothesized that survivors who received DVHF would experience less re-abuse and greater housing stability over 12 months compared to those who received services as usual (SAU). The sample included 345 IPV survivors who had been homeless or unstably housed when they approached one of five DV programs for help. Interviews were spaced 6 months apart (when survivors first sought services as well as 6 months and 12 months later). Longitudinal analyses showed that survivors who received the DVHF model reported greater improvements in housing stability at both the 6-month and 12-month time points compared to those receiving SAU. At the 12-month time point, survivors who had received DVHF reported decreased physical, psychological, and economic abuse, as well as the use of their children against them as a form of abuse. This study adds to a growing body of evidence supporting this model’s effectiveness and adds to our understanding of factors impacting the long-term housing stability and safety for IPV survivors.
... By exerting physical control over their victims, offenders show them they are willing to kill. Indeed, some authors (e.g., Pritchard et al. 2017) argue that strangling is often a prelude to homicide. Even when it is not lethal, it has severe, and sometimes irreversible, consequences for victims' health. ...
Domestic violence is a serious problem in Portugal, affecting mainly women. The significant number of femicides in the context of intimate partner violence has been showing not only the severity of the crime, but also the necessity to reinforce strategies to prevent and combat it. Although several studies were developed in the last decades to portray domestic violence, research on the threat of death and attempted femicide is scarce. This study aims to characterize death threats and attempts of femicide, in the light of the professionals’ perspectives from the Portugal National Support Network for Victims of Domestic Violence, contributing to informing best practices of risk assessment. Seventy-one professionals, 62 female (87.3%) and 9 male (12.7%), at an average age of 37.69 years, filled a questionnaire survey. Results suggest weaknesses in the application of current legislation and the adoption of effective measures in situations where victims experience death threats and attempted murders. Although there are criminal proceedings before these episodes, this does not seem to have effective consequences in terms of protection and security, whereby the development of strategies that safeguard victims from tragic endings such as femicide are necessary.
... While depictions of choking in pornography can lead viewers to believe that choking a sexual partner is pleasurable and safe (Wright et al., 2021), choking is commonly considered to be a rough sex behavior that may increase the risk of injury in a sexual encounter (Herbenick et al., 2019). Being choked by a sexual partner was often described as a scary experience in a populationbased probability survey of Americans between 14 and 60 years old (Herbenick et al., 2019), and strangulation is a common component of intimate partner violence (IPV) against women (McQuown et al., 2016;Pritchard et al., 2017). Strangulation, even with non-fatal intentions, carries inherent health risks. ...
Being strangled, or “choked,” by a sexual partner has emerged as a prevalent, often wanted and consensual sexual behavior among adolescent and young adult women, yet the neurological consequences of repeated exposure to this behavior are unknown. The objective of the study was to examine the association between a history of repeated, recent choking/strangling episodes during sex and fMRI activation during working memory tasks in young adult women. This case-control study involved young adult women (18–30 years old) at a large, public university, and consisted of two study groups: a choking group consisting of participants who were recently and frequently choked/strangled during sex by a partner (≥4 times in the past 30 days) and a choking-naïve (control) group who had never been choked/strangled during sex. Participants completed two variations of the N-back (0-back, 1-back, and 2-back) working memory task during functional magnetic resonance imaging (fMRI): verbal and visual N-back tasks. Data from 20 participants per group were available for analysis. Between-group differences for accuracy and reaction time were not significant for either variation of the N-back task. Significant differences in fMRI activation patterns were detected between the choking and the choking-naïve groups for the three contrasts of interest (1-back > 0-back, 2-back > 0-back, and 2-back > 1-back). The choking group exhibited increased activation in multiple clusters relative to the choking-naïve group for the contrasts between the 1-back and 2-back conditions compared to the 0-back conditions (e.g., superior frontal gyrus, corpus callosum). However, the choking-naïve group exhibited increased activation relative to the choking group in several clusters for the 2-back > 1 back contrast (e.g., splenium, middle frontal gyrus). These data indicate that recent, frequent exposure to partnered sexual strangulation is associated with different neural activation patterns during verbal and visual working memory tasks compared to controls, suggesting that being choked/strangled during sex may modify the allocation of neural resources at increasing levels of cognitive load. Further investigation into the neurologic effects of this sexual behavior is warranted, given the prevalence of sexual choking among adolescent and young adult women.
... An offence of non-fatal strangulation (NFS), titled 'Choking, suffocation or strangulation in a domestic setting', was introduced into Queensland law in 2016. It is set out in the Queensland Criminal Code 1899 (Qld) (QCC) section 315A, and its introduction follows many American states that established discrete offences of non-fatal strangulation throughout the 2000s (Pritchard, Reckdenwald & Nordham, 2017). ...
This report presents first findings from a sample of finalised non-fatal strangulation case files drawn from the Office of the Director of Public Prosecutions (ODPP) Queensland. The aim of the report is to provide an initial overview of case- defendant- and complainant-characteristics for non-fatal strangulation-related cases charged and / or prosecuted since the introduction of the offence.
... 7 Another review of 300 domestic violence cases in San Diego County, California, noted that 50% of strangulation victims had no visible injury, 8 a phenomenon that has historically led to trivialization of the violence that transpired (and potential medical sequelae thereof) by both law enforcement and medical personnel. 9,18 Complicating matters further, medical documentation has been shown to significantly impact outcomes in the minority of SA cases that do go to trial, 10 although there is a relative paucity of literature describing how often physical exam findings are documented in non-fatal strangulation during SA. In this study we sought to determine the frequency and characteristics of various symptoms and physical exam findings present in SA victims reporting strangulation, and to describe how these findings correlate with the mechanism of strangulation described in the victim's account of the assault. ...
Objective:
Our goal was to investigate the frequency of specific signs and symptoms following sexual assault-related non-fatal strangulation (NFS) and to explore the interaction between assault characteristics and physical exam findings.
Methods:
This retrospective observational study included all adults (>18 years) reporting strangulation during sexual assault who presented for a forensic sexual assault exam at one of six urban community hospitals contracted with a single forensic nurse agency. Demographic information, narrative elements, and physical exam findings were abstracted from standardized sexual assault reporting forms. We analyzed data with descriptive statistics and compared specific variables using chi-square testing.
Results:
Of the 580 subjects 99% were female, with a median age of 27 (interquartile range 22-35 years). The most common injury location was the neck (57.2%), followed by the mouth (29.1%). We found that 19.1% of the victims had no injuries evident on physical exam and 29.8% reported a loss of consciousness. Eye/eyelid and neck findings did not significantly differ between subjects who reported blows to the head in addition to strangulation and those who did not. The time that elapsed between assault and exam did not significantly correlate with the presence of most head and torso physical exam findings, except for nose injury (P = 0.02).
Conclusion:
Slightly more than half of the victims who reported strangulation during sexual assault had visible neck injuries. Other non-anogenital findings were present even less frequently, with a substantial portion of victims having no injuries documented on physical exam. The perpetrators' use of blows to the head may account for many of the non-anogenital injuries observed, but not for the neck and eye/eyelid injuries, which may be more specific to non-fatal strangulation. More research is needed to definitively establish strangulation as the causal mechanism for these findings, and to determine whether any long-term neurologic or vascular sequelae resulted from the observed injuries.
... Deterioration of health and death as a result of lack of oxygen occupy a significant place among the objects of forensic examination. Consequently, the study of hypoxic conditions is one of the current problems in the science and practice of forensic medicine (1,8). incomplete asphyxia cases have not been adequately covered (3,4). ...
This article discusses the forensic description of cases of Noletal asphyxia. Expertise materials on postasphystic cases in 2017-2020 in three regions of the country were studied. Incomplete asphyxia during this period accounted for 0.31% of the total number of forensic medical examinations of survivors, and the ratio of examinations for nonlethal and lethal asphyxia was 1: 6.6%. Non-lethal asphyxia was more often observed in men, in persons aged 19-39 years, after an attempt at self-improvement, in the morning and afternoon hours. The duration of asphyxia, loss of consciousness, and the severity of signs of brain activity were interrelated. The danger to the life of the victims arose with the development of a severe coma. Based on the characteristics of such incidents, it was emphasized that when conducting forensic medical examinations, medical documents are the main source of objective data.
... Ce type d'étude permet d'obtenir des informations cliniques riches et pouvant être utilisées directement par les intervenants et cliniciens. De plus, des études récentes indiquent que le comportement d'étranglement non létal, qu'il soit en lien ou non avec les relations sexuelles, est associé au risque de violences conjugales sévères, voire même l'homicide conjugal (Messing et al., 2018 ;Pritchard et al., 2017). L'étude des facteurs de risque et des caractéristiques des individus à risque de violences conjugales sévères s'avère essentielle afin de prévenir l'homicide conjugal. ...
Introduction
At a time when the issue of consent to sexual relations leads to heated debates, it is necessary to look at sexual violence committed in marital context.
Objectives
This study aims to evaluate sociodemographic, situational, criminological and psychological characteristics of perpetrators of sexual domestic violence (n = 27) and perpetrators of domestic violence who didn’t commit sexual violence (n = 76). The second objective of this study is to identify the predictive variables of domestic sexual violence.
Method
These men's characteristics were assessed using semi-structured interviews and questionnaires relating to psycholosocial issues (alexithymia, depression and impulsivity) and stressful life events.
Results
The results indicate that there are significantly more perpetrators of domestic violence who also commit sexual violence who are unemployed and have alcohol and/or drug use problems. In addition, men having a criminal history in the past five years and who commit violence of many forms, including verbal, psychological and economic, are at high risk of sexual violence against their intimate partner.
Conclusion
A better distinction between the different profiles of perpetrators of domestic violence is essential to promote their evaluation and the prevention of severe forms of intimate partner violence.
... Historically, NFS has been subsumed into broader categories of 'serious' physical domestic violence, meaning that the prevalence of this behaviour within abusive relationships has been overlooked (Connelly et al. 2006;Mechanic, Weaver & Resick 2008;Sabri et al. 2014). However, the significant harms associated with NFS and its links to IPH mean that it is increasingly being studied as a distinct category of behaviour (Pritchard, Reckdenwald & Nordham 2017). No. 626 May 2021 Consistent with research that has defined escalation as a pattern of behaviour, NFS has been measured using both longitudinal and cross-sectional data. ...
A key assumption in the domestic violence literature is that abuse escalates in severity and frequency over time. However, very little is known about how violence and abuse unfolds within intimate relationships and there is no consensus on how escalation should be defined or how prevalent it is. A narrative review of the literature identified two primary definitions of escalation: a pattern of increasingly frequent and/or severe violent incidents, or the occurrence of specific violent acts (ie outcomes). Escalation appears to be limited to serious or prolific offenders rather than characterising all abusive relationships. However, disparities in prevalence estimates between those provided by victim–survivors and recorded incident data highlight the difficulty of measuring this aspect of abusive relationships.
... Due to the high variability in both action and outcome and the frequent absence of external findings, the clinical-forensic assessment of nonfatal strangulation (NFS) has been identified as a current problem in forensic medicine [3,4]. Radiologic imaging is a helpful tool for the forensic interpretation of NFS. ...
Objective
This study is based on the hypothesis that occult cartilaginous fractures of the thyroid cartilage (TC) may result in asymmetry of the thyroid cartilage framework. Justification of this hypothesis was provided by an estimation of the prevalence of TC asymmetry based on a consecutive postmortem study group. The findings were then compared to three cases of nonfatal manual strangulation and one case of survival of blunt trauma to the neck.
Methodology
TC images from a consecutive two-year sample from the institutional postmortem computed tomography database (N= 1187) were assessed. Cases with acute TC injury were excluded. TC asymmetry, signs of prior TC trauma, sex and age, were retrieved.
Results
TC asymmetry was present in 72 cases (6.2%, 67 males). In 40 cases (3.5%), old TC fractures could be identified. The derived odds ratios were 7.48 for male sex and 1.02 for (each year of) age (p <0.001). Asymmetry of the TC laminae was observed significantly more often on the left side (N= 53, 73.6%, p <0.001). Cases 1 and 2 showed TC asymmetries following nonfatal manual strangulation. Cases 3 and 4 illustrated the limited visibility of cartilaginous fractures on computed tomography.
Conclusion
TC asymmetry is associated with male sex and older age and is typically located on the left side. TC asymmetry in young and female cases is rare. TC asymmetry in young and/or female cases may result from occult cartilaginous fractures, as cases 1 and 2 indicated. Further research is needed to validate this hypothesis.
... Attempts have already been made to synthesize our understanding of this new and important area. Pritchard et al. (2017) produced a narrative review, outlining the history of the subject, with particular focus on the US legal response, where strangulation has now been reclassified as a felony. However, the search was not systematic, and the study does not reference outcomes. ...
This systematic review draws together evidence from the literature for the pathological, neurological, cognitive, psychological, and behavioural outcomes of non-fatal strangulation in domestic and sexual violence. A systematic search of PubMed, PsycINFO, CINHAL, Proquest, ASSIA, Web of Science, WestLaw, Open Grey, and Ethos was conducted, with no date limits set, to identify eligible studies. Thirty empirical, peer-reviewed studies were found which met the inclusion criteria. Pathological changes included arterial dissection and stroke. Neurological consequences included loss of consciousness, indicating at least mild acquired brain injury, seizures, motor and speech disorders, and paralysis. Psychological outcomes included PTSD, depression, suicidality, and dissociation. Cognitive and behavioural sequelae were described less frequently, but included memory loss, increased aggression, compliance, and lack of help-seeking. However, no studies used formal neuropsychological assessment: the majority were medical case studies or based on self-report. Furthermore, few authors were able to control for possible confounds, including other physical violence and existing psychosocial difficulties. There is therefore a need for further neuropsychological research, focusing on cognitive and behavioural outcomes, using standardized tools, and control groups where possible. This is urgent, given societal normalization of strangulation, and legal systems which often do not reflect the act’s severity and its consequences.
... In addition to lethal consequences, strangulation can have nonfatal adverse physical and neurological effects, as well as negative mental health consequences, including stroke, memory loss, difficulty swallowing, depression, and post-traumatic stress disorder (Patch et al., 2018;Pritchard et al., 2017). However, strangulation often does not leave visible traces of the assault (De Boos, 2019) which can mask potential physical injuries, placing strangulation victims at risk for chronic and life-threatening health complications, including homicide (Anscombe & Knight, 1996;Clarot et al., 2005). ...
Nonfatal strangulation is a prevalent, underreported, and dangerous form of intimate partner violence (IPV). It is particularly important to assess for strangulation among abused women as this form of violence may not leave visible injury. The most severe negative physical and mental health consequences of strangulation appear to be dose-related, with those strangled multiple times or to the point of altered consciousness at higher risk of negative sequelae. This research examines the relationship between multiple strangulation, loss of consciousness due to strangulation, and risk of future near-fatal violence to modify the Danger Assessment (DA) and the Danger Assessment for Immigrant women (DA-I), IPV risk assessments intended to predict near-fatal and fatal violence in intimate relationships. Data from one study ( n = 619) were used to modify the DA to include an item on multiple strangulation or loss of consciousness due to strangulation. Data from an independent validation sample ( n = 389) were then used to examine the predictive validity of the updated DA and DA-I. The updated version of the DA predicts near-fatal violence at 7–8 months follow-up significantly better than the original DA. Adding multiple strangulation or loss of consciousness to the DA-I increased the predictive validity slightly, but not significantly. The DA and DA-I are intended to be used as a collaboration between IPV survivors and advocates as tools for education and intervention. Whether or not an IPV survivor has been strangled, she should be educated about the dangerous nature of strangulation and the need for medical intervention should her partner use strangulation against her. This evidence-based adaptation of the DA and DA-I may assist practitioners to assess for and intervene in dangerous IPV cases.
... To date, there have been several reviews of states' legislation, including in Massachusetts (Maalouf, 2017), New York (Strack and Gwinn, 2011), Minnesota (Francis, 2008) and Rhode Island (Verdi, 2013). These reviews have generally been positive about the introduction of NFS laws in closing a gap in the law, improving awareness of the seriousness of NFS and positively impacting on victim safety (Pritchard et al., 2017). For example, in their review of NFS offences in 50 states, Laughon et al. (2009) pointed out that most state laws do provide a broad definition of strangulation that includes 'occluding blood flow to the brain and/or interfering with the victim's ability to breathe' (p. ...
Non-fatal strangulation is commonly reported by women who have experienced intimate partner violence and it has been identified as both an immediate risk to health and life but also a risk for future serious harm and even death. While some Australian states and Canada have followed the lead of American states in introducing criminal offences of non-fatal strangulation the United Kingdom is yet to do so. Non-fatal strangulation offences have come with challenges of definition and identification. The success of criminal justice responses requires an understanding of the ways in which women understand and describe their non-fatal strangulation victimisation. We analyse 24 women’s experiences of non-fatal strangulation as a basis for considering how to ensure that jurisdictions considering introduction of a new non-fatal strangulation offence or reform of an existing offence do not reproduce obstacles to prosecution and legal recognition and suggest a model definition of non-fatal strangulation for an offence.
... Attempts have already been made to synthesize our understanding of this new and important area. Pritchard et al. (2017) produced a narrative review, outlining the history of the subject, with particular focus on the US legal response, where strangulation has now been reclassified as a felony. However, the search was not systematic, and the study does not reference outcomes. ...
This paper reviews the neurological, cognitive, psychological, and behavioural outcomes of non-fatal strangulation and, given shared physiological mechanisms, asks whether the hypoxic-ischaemic literature can serve as a proxy. 27 empirical, peer-reviewed studies meeting the inclusion criteria were found. Neurological consequences included loss of consciousness, indicating at least mild acquired brain injury, stroke, seizures, motor and speech disorders, and paralysis. Psychological outcomes included PTSD, depression, suicidality, and dissociation. Cognitive and behavioural sequelae were described less frequently, but included amnesia and compliance. Overall, the evidence suggested strangulation in IPV and sexual assault can share all the serious consequences of hypoxic-ischaemic injury, but carries additional neuropsychological burden. However, no papers used formal neuropsychological assessment: the majority were medical case studies, or based on self-report. There is therefore a need for further neuropsychological research, focusing on cognitive and behavioural outcomes, using standardised tools, and control groups where possible. This is urgent, given societal normalisation of strangulation, and consent to ‘rough sex’ being used as a legal defence. We also discuss broader implications: the popularity of the ‘choking game’ with teenagers, and carotid injuries within mixed martial arts.
... With research indicating domestic violence victims' credibility is often discounted and devalued throughout the criminal justice system (Epstein & Goodman, 2019), it is important to take the emphasis off the victim and place it on the nuances of strangulation injuries and how they present differently than other physical injuries. Pritchard et al. (2017) recommend the use of medical professional expertise to provide additional documentation of evidence of signs and symptoms of strangulation and other research has supported the use of forensic medical documentation to strengthen the ability to prosecute the offender (Baker & Sommers, 2008;Laughon, Glass, & Worrell, 2009;Strack et al., 2001). Expert medical personnel could also testify about the signs and symptoms of a strangulation in court. ...
Recent research has pointed to the need for systematic law enforcement training on domestic violence when nonfatal strangulation is involved to improve evidence-based prosecution of these potentially deadly assaults; however, virtually no research has examined the legal response to nonfatal strangulation since many states have made it a separate criminal felony. The current exploratory study examines filing, charging, and adjudication decisions of nonfatal strangulation cases over a 3-year period based on evidence documentation in law enforcement reports to explore how these cases are handled by the criminal justice system in Brevard County, Florida. Results support previous research showing the importance of training police officers and other personnel as insufficient evidence may be one possible factor limiting the prosecutors' ability to successfully prosecute domestic violence strangulation offenders to the highest extent available under the law. Implications spread across multiple disciplines.
... Finally, according to the FBI site for the SHR, NIBRS does not include drowning, pushed or thrown, or strangulation among the weapon types causing deaths, and the circumstances do not include sniper attacks, arguments over money or property, or Lover's triangles. Drowning and dying from being pushed or thrown are more likely to kill young children and the elderly (Huff-Corzine et al., 2014), whereas strangulation is common among victims of intimate partner violence (Pritchard, Reckdenwald, & Nordham, 2015;Pritchard, Reckdenwald, Nordham, & Holton, 2016). ...
Research Summary
Mass violence refers to victimization, resulting in multiple deaths and/or injuries. Thus, the measurement of mass violence cannot rest on a single definition or dataset. The purpose of this paper is to decompose mass violence into its various sub‐types, discuss measurement issues related to the sub‐types, evaluate potential datasets for future studies, and offer practical policy implications.
Policy Implication
Imposing a standard definition for mass violence at this time would be counterproductive and may stifle research and associated policy implications. We recommend developing an enhanced dataset on mass violence based on the National Incident‐Based Reporting System (NIBRS). The advantages of NIBRS include its linkages of fatalities and injuries from the same incident, no limitation on the number killed or wounded, and more information than alternative data sources, maintenance of the current crime data flow from local communities through the state and to the FBI for compilation.
Being choked or strangled during partnered sex is an emerging sexual behavior, prevalent among young adult women. The goal of this study was to test whether, and to what extent, frequently being choked or strangled during sex is associated with cortical surface functioning and functional connectivity. This case-control study consisted of two groups (choking vs. choking-naïve). Women who were choked four or more times during sex in the past 30 days were enrolled into the choking group, whereas those without were assigned to the choking-naïve group. We collected structural and resting-state functional magnetic resonance imaging (fMRI) data and analyzed the data for amplitude of low-frequency fluctuation (ALFF) and regional homogeneity (ReHo) using cortical surface-based resting-state fMRI analysis, followed by static and dynamic resting-state fMRI connectivity analysis. Forty-one participants (choking n=20; choking-naïve n=21) contributed to the analysis. An inter-hemispheric imbalance in neuronal activation pattern was observed in the choking group. Specifically, we observed significantly lower ALFF and ReHo in the left cortical regions (e.g., angular gyrus, orbitofrontal gyrus) and higher ALFF and ReHo in the right cortical regions (e.g., precentral/postcentral gyri) in the choking group compared with the choking-naïve group. A significant group difference was found in static functional connectivity between the bilateral angular gyrus and the whole brain, in which the choking group's angular gyrus showed hyperconnectivity with, for example, the postcentral gyrus, precentral gyrus, and Rolandic operculum, relative to the choking-naïve group. The dynamic analysis revealed hyperconnectivity between the left angular gyrus and the bilateral postcentral gyrus in the choking group compared with the choking-naïve group. Taken together, our data show that multiple experiences of sexual choking/strangulation are associated with an inter-hemispheric imbalance in neural activation pattern and hyperconnectivity between the angular gyrus and brain regions related to motor control, consciousness, and emotion. A longitudinal study using multimodal neurologic assessments is needed to clarify the acute and chronic consequences of sexual choking/strangulation.
Survivors of nonfatal strangulation face a number of physical health consequences, some of which can be fatal if untreated. Despite the known health risks and connections to delayed fatalities, little is known about strangulation and victims’ pursuit of medical care. Using data collected from prosecutors’ case files ( n = 143), this study attempts to understand what factors contribute to victims receiving medical attention following a nonfatal strangulation assault reported to police. Findings indicate that the suspect disrupting an emergency call increases the likelihood of the victim pursuing medical care. Implications are discussed.
Background
Sexual assault remains a highly prevalent crime worldwide and has the potential to cause a number of short and longer-term health sequelae. Complainants of recent sexual assault may undergo forensic and/or medical examinations for medical treatment or evidence collection, or both. However, the frequency and severity of acute health concerns requiring medical intervention in these patients at the time of examination is not well understood and has implications for their clinical care and safety.
Aims & objectives
To examine the frequency and severity of acute concomitant health concerns at the time of forensic examination following an allegation of recent sexual assault in post-pubertal (age >13 years) individuals, through a review of existing literature. Concomitant health concerns considered in this review include ano-genital and extra-genital injury, and acute substance intoxication.
Methods
Four online databases (PubMed, Ovid Medline, CINAHL, Embase) were systematically searched with key terms regarding the topics of sexual assault, forensic examination, injury and intoxication. Articles were assessed for relevance based on inclusion and exclusion criteria.
Results
Discussion Of 562 titles, 53 full-text publications met the inclusion criteria. Frequency of ano-genital and extra-genital injury was highly variable across studies, and severity was inconsistently assessed and rarely reported. Medical treatment or transfer to acute care settings was more commonly required for extra-genital injuries. Non-fatal strangulation (NFS) was found to represent an increasingly frequent feature of sexual assault cases. NFS complainants often exhibit signs and symptoms of potentially lethal complications requiring urgent review in acute care settings. Substance use around the time of sexual assault was commonly reported by patients and detected in toxicological screens, and could have significant implications on patient and staff safety at the time of examination.
Conclusion
The findings of this review highlight the clinical significance of acute concomitant health concerns following an allegation of recent sexual assault. Ano-genital and extra-genital injury, NFS and both voluntary and involuntary substance use may be more frequent and severe than previously understood. Further investigation into the assessment and management of these acute health needs is required to elucidate their clinical significance and inform evidence-based care for complainants of sexual assault.
The overwhelming scope and range of negative impacts of IPV are well-documented. Research underscores that IPV victims/survivors most often experience multiple forms of abuse. Mental health professionals are uniquely positioned through their close and confidential relationship with clients to promote a woman's physical and mental health safety. This chapter reviews the prevalence of IPV in general and clinical populations, describes the forms of abuse, and focuses on critical components of clinical care when working with IPV victim/survivors.
Background
Nonfatal strangulation has been identified as a common occurrence in intimate partner violence and can be associated with significant injuries and, at times, increased mortality.
Objective
This article describes a county interagency nonfatal strangulation initiative that efficiently disseminated an educational program for police, emergency medical services, emergency department staff, forensic nursing teams, and prosecuting attorneys, along with a forensic nurse response program. Prior to initiation of this program, no educational programs existed and no forensic examinations were being offered to victims of nonfatal strangulation.
Methods
Early cooperation between agencies was crucial, particularly between the two major health care systems in the county. A standardized forensic evaluation tool was developed, along with nonfatal strangulation courses. Education of forensic nurses together with prosecutors was unique and training of police, emergency medical services, and emergency department staff was coordinated. Forensic nurses traveled to meet victims for standardized examinations at 11 emergency departments. Creation of a secure Research Electronic Data Capture database captured forensic examination information and a strangulation task force provided means to assess the goals.
Results
This initiative educated > 80% of the county’s first responders and 79% of emergency department staff within 3 months. During the first year of the program, 259 forensic nurse examinations for nonfatal strangulation were recorded. Police reported a total of 367 arrests for felony assault by strangulation.
Conclusions
Professionals providing legal and medical care to victims of nonfatal strangulation can be educated and forensic nurse examinations can be implemented successfully in an expeditious period of time with a county collaborative program approach.
Many victimization studies have focused on one dimension of violence at a time, such as looking at the effect of a specific violence type on a health outcome. But the term common best describes the occurrence of intersecting violent experiences or, more specifically, intersecting dimensions of violence, abuse, and victimization. Over time, bodies of literature about this phenomenon have morphed in terms of conceptualization and operationalization. In this context, silos have developed that place barriers within and between fields and disciplines that concern the study and treatment of violence at various levels. However, shared catalysts and inhibitors, the common nature of experiencing more than one victimization event, and the possible concurrence of certain violence experiences offer points of disruption to these silos. In this light, there are many components, or dimensions, of violence that span from the most basic unit (the individual act of violence) to various means of categorization: violence type, severity or frequency, duration, and number of violence-perpetrating individuals. These dimensions, when identified within research, can help researchers map out how two acts (as well as their broader categorizations) intersect to influence lived experiences. Researchers use various terms to describe this phenomenon (e.g., poly-victimization, revictimization, cascading maltreatment, hybrid exploitation, cumulative violence exposure, cumulative patterns, constellations, and dose-response). This multidimensional approach offers the hope of (a) deconstructing the silos between and among fields and disciplines, (b) bringing research methods and analytical treatments of violence within studies closer to reality, (c) holistically acknowledging that violence varies, (d) deconstructing stereotypes, (e) identifying shared risk factors, (f) advocating for collaboration, (g) cultivating resilience, and (h) examining victims and survivors’ experiences through a lens that draws connections between intersecting abuse experiences and intersecting systems of oppression. Likewise, although there are some common instruments utilized for operationalization, these measurement tools vary greatly, as well. Analytical treatments of intersecting dimensions of violence, abuse, and victimization can be categorized into six overarching data analysis strategies: relationships between violent experiences, counting violence types, variety scores and indices, combinations of violent events or types, schemes, and person-centered approaches. Although these dimensions, terminologies, instruments, and analytical treatments can be identified within the literature, overlaps and mixtures of terms and analytical treatments become apparent when comparing studies. Implications for research include testing familiar cumulative relationships across fields, incorporating a broader policy context, and more thoroughly examining variation within and between violence types. Through the multidimensional perspective, violence prevention and intervention can be improved and advanced through thoroughness in application.
Nonfatal strangulation is a relatively newly recognized mechanism of injury that may not be taken seriously because of lack of physical injuries that many times accompany it. This comparison case series supports the importance of considering not only visually detected injuries but also symptoms the patient may be experiencing when determining diagnostics necessary to guide a treatment plan. A visually detectable injury is dependent on multiple factors. Bruises may occur with minimal pressure but may not be visible immediately after assault. Contrary to this, extensive bruising of the neck is not an accurate indicator of damage to underlying structures. The authors' experiences in these two cases signify the necessity of a comprehensive assessment utilizing both physical symptoms and assessments as the basis for determining nonfatal strangulation treatment plans.
Introduction:
CARE (Connect, Acknowledge, Respond, and Evaluate) is an advocacy framework developed for domestic violence service organization (DVSO) providers to address and accommodate domestic violence (DV) survivors with brain injury and mental health struggles. The CARE tools were designed for use by advocates and include the Just Breathe booklet, the Head Injury education card, and the Invisible Injuries booklet.
Objective:
The purpose of this study was to report findings on how CARE tools are being used by DVSO providers as well as their impact on DVSO advocacy practice.
Methods:
Post-CARE retrospective process evaluation online surveys (n = 60) and focus groups (n = 10 groups; 57 advocates) were conducted with consenting staff at 5 DVSOs in Ohio who partnered with the state coalition to develop and evaluate CARE, overseen by a university research partner. Rigorous, iterative coding qualitative analysis methods, endorsed by the Centers for Disease Control and Prevention, were used (Cohen's κ = 0.903 [stage 1] and 0.810 [stage 2]).
Results:
The use of CARE tools has been integral to DVSO providers' implementation of the CARE advocacy framework. DVSO advocates are using CARE tools to Connect with self, survivors, and other systems; to Acknowledge that head trauma and mental health struggles are common among survivors and that ongoing education and self-care are necessary for advocates. Advocates have been able to provide a more holistic Response through accommodation within DVSOs and referral to other providers, often by using the CARE tools, including the Head Injury education card.
Conclusion:
CARE tools were designed for lay use to address head trauma, strangulation, and mental health struggles with DV survivors and are free for download at the Center on Partner Inflicted Brain Injury website: https://www.odvn.org/brain-injury. More widespread use of these tools by advocates has the potential to improve services for DV survivors and address what have historically been invisible injuries and mental health struggles in the population.
Withdrawal: Carol E. Jordan, Adult Victim and Survivors of Intimate Partner Violence: Mental Health Implications and Interventions, Juvenile and Family Court Journal , 2021, ( https://doi.org/10.1111/jfcj.12205 ).
The above article, published online on 18 September 2021 in Wiley Online Library ( wileyonlinelibrary.com ), has been withdrawn by agreement between the author, the journal Managing Editor Melissa Sickmund, and Wiley Periodicals LLC. The withdrawal has been agreed at the request of the author due to an error by the publisher which caused the incorrect article to be published in the journal without the knowledge of the editorial office and NCJFCJ.
Purpose
The current study examined police response, specifically identification and arrest decisions, to nonfatal strangulation occurring within the context of intimate partner violence.
Design/methodology/approach
Data for the present study were derived from a sample of 117 possible nonfatal strangulation case reported to a police agency located in one of the fifth largest and most diverse US cities. A series of logistic regression models were employed to examine the role of victim, suspect and case characteristics on officer formal identification of strangulation and officer arrest decisions.
Findings
Results revealed that 14% of all intimate partner violence (IPV) cases reported to the police agency involved possible nonfatal strangulation and less than half of all possible nonfatal strangulation cases were formally identified as such by officers. The odds of formal identification of strangulation by police increased when strangulation was manual and when victims reported difficulty breathing. Injury and formal identification increased the odds of arrest.
Originality/value
This study is the first to examine predictors of police formal identification and arrest decisions in nonfatal strangulation occurring within intimate partner violence incidents.
Introduction
Nonfatal intimate partner strangulation poses significant acute and long-term morbidity risks and also heightens women’s risk for future femicide. The lifetime prevalence of nonfatal intimate partner strangulation has been estimated to be approximately 10%, or 11 million women, in the general United States population. Given the potential for significant health risks and serious consequences of strangulation, this study adds to the limited literature by estimating prevalence and describing the associated characteristics of strangulation-related visits among United States ED visits by adult women after intimate partner violence.
Methods
Prevalence estimation as well as simple and multivariable logistic regression analyses were completed using data from the Nationwide Emergency Department Sample spanning the years 2006 to 2014.
Results
The prevalence of strangulation codes was estimated at 1.2% of all intimate partner violence visits. Adjusting for visits, hospital characteristics, and visit year, higher odds of strangulation were noted in younger women, metropolitan hospitals, level I/II trauma centers, and non-Northeast regions. Increases in strangulation events among intimate partner violence–related visits in recent years were also observed.
Discussion
A relatively low prevalence may reflect an underestimate of true nonfatal intimate partner strangulation visits owing to coding or a very low rate of ED visits for this issue. Higher odds of strangulation among intimate partner violence visits by women in more recent years may be due to increased recognition and documentation by frontline clinicians and coding teams. Continued research is needed to further inform clinical, postcare, and social policy efforts.
This study seeks to determine the concurrent and predictive validity of a dual risk assessment protocol. It combines the risk of persistence in intimate partner violence (IPV) measured via the Domestic Violence Screening Instrument-Revised (DVSI-R) with supplemental items from the Danger Risk Assessment (DRA) bearing on the risk of potential lethality. We further test whether this assessment protocol reproduces disparities by race and ethnicity found in the larger population. Using a sample of 4,665 IPV male defendants with a female victim, analyses support both types of criterion validity. The DRA risk score is associated with felony charges, incarceration at the initial arrest, and the frequency of subsequent dangerous behavior. Results also suggest minimal predictive bias or disparate impact by race and ethnicity. Incorporating supplemental items bearing on potential lethality risk adds important information concerning the risk management strategies of those involved in IPV.
Intimate partner violence (IPV) is a significant public health problem that has profound effects on the physical and psychological well-being of millions of Americans. It is known that strangulation is one of the most lethal forms of IPV. Frequently, a lack of visible external trauma is present, and attempted strangulation may be accompanied by other more severe injuries to the head and face; thus, the signs and symptoms of nonfatal strangulation may be overlooked. Because the emergency department (ED) is frequently the first point of contact for an individual who has experienced any type of IPV, it is imperative that providers have the knowledge and skill set for the identification and management of this patient population. The purpose of this article is to present a discussion of the challenges faced by ED providers in the clinical decision-making process when caring for a patient who has experienced nonfatal strangulation.
Drawing on the findings from a recent study, conducted by the authors, of cross-applications and resulting orders in two Queensland Magistrates courts, this article explores the context in which cross-applications are made and the typical court outcomes in such cases to consider why cross-applications are being increasingly made in Queensland courts. In this article we begin with a discussion of the influence of feminist jurisprudence on the development of the civil protection order system in Australia and elsewhere and an examination of how this literature has understood the ‘problem’ of cross-applications and cross-orders. We next propose three interlinked explanations for the rise of cross-applications by both private applicants and the police in Queensland. Based on a review of the literature, possible explanations include increased acceptance, in some circles, of research that finds there is gender symmetry in the way violence is perpetrated, developments in Australian Family Law, and the role conflict experienced by police in responding to domestic violence. The article then considers these explanations in light of the Queensland case-study.
In risk assessment tools used by domestic violence workers and police, strangulation, short of causing death, is considered a 'red flag' for future serious abuse and fatality. This article discusses the risks and concerns associated with non-fatal strangulation and examines current legal responses to it in Australia, the United States and Canada. Drawing on a study of court files involving domestic violence protection orders, the authors consider how strangulation allegations made by those applying for protection orders are responded to by police and courts in Queensland. The authors conclude with a reflection on current policy and legislative approaches to non-fatal strangulation in Australia and make suggestions for law reform.
Strangulation is a unique and particularly gendered form of nonfatal intimate partner violence, affecting 10 times as many women as men. Medical research documents multiple negative health outcomes of such victimization, and in the past decade nearly 30 U.S. states have enacted laws making nonfatal strangulation a felony. We extended prior work by using grounded theory in a qualitative study to explore women's experiences of, thoughts about, and reactions to being strangled. Each of the 17 mostly well-educated and African American domestic violence shelter residents had been strangled at least once by an intimate partner; most had survived multiple strangulations. Despite other severe abuse and a high level of fear, all were shocked that their partner strangled them. Participants reported an intense sense of vulnerability when they recognized during the assault how easily they could be killed by their partner. Nonetheless, they seemed to think of strangulation, not as a failed murder attempt, but as a way to exert power. Efforts to extricate themselves from a choking largely failed and resistance resulted in an escalation of the violence. Moreover, strangulation is difficult to detect which, as participants observed, makes it especially useful to the abuser. The aftereffects permeated the relationship such that strangulation need not be repeated in order for her to be compliant and submissive, thus creating a context of coercive control.
Intimate partner sexual violence (IPSV) is a significant social problem, particularly among women who are concurrently experiencing physical violence in their intimate relationships. This research examined the prevalence and factors associated with IPSV among a sample of women recruited at the scene of police-involved intimate partner violence incidents (N = 432). Within this sample, 43.98 percent of participants reported experiencing IPSV; this includes 17.36 percent who reported sexual abuse and 26.62 percent who reported forced sex. Multinomial logistic regression was used to examine the factors related to sexual abuse and forced sex, controlling for victim and relationship characteristics. Compared with women not reporting IPSV, women who were sexually abused or forced into sexual intercourse were significantly more likely to experience strangulation, feelings of shame, and posttraumatic stress disorder symptoms. Women whose partners had forced sex were more likely to report that they had a child in common with their abusive partner; and that their partner was sexually jealous, had threatened to kill them, had stalked or harassed them, or caused them to have a miscarriage due to abuse. These findings can be used to better inform social work practitioners about the prevalence and nature of IPSV and the associated risk factors, and can assist in routine screening and intervention.
To present a case of traumatic hyoid bone fracture and a review of the literature
Traumatic hyoid bone fractures are rare, however with the increasing popularity of martial arts the incidence of traumatic hyoid bone fracture may increase in prevalence.
A thirteen year old taekwondo athlete collapsed after receiving a kick to the anterior neck. Following first aid emergency care the athlete reported pain with speaking and swallowing and was suffering from dyspnea. Ecchymosis and tenderness were noted over the hyoid bone.
Lateral radiographs revealed fracture of the hyoid. Patient was sent home with analgesics and instructed to rest. The athlete was cleared for sport at 4 weeks post injury.
Ensuring airway integrity and screening for signs of laryngeal laceration are essential in the management of suspected hyoid bone fractures. Observation for 48-72 hours is highly recommended.
Strangulation is one of the most dangerous forms of interpersonal violence (IVP), yet it is often not reported and missed by the health care provider because of lack of visible injury. The victim of strangulation can have critical injuries and a late onset symptoms. Victims of IVP should be directly asked whether they were choked or whether during the assault they felt like they could not breathe because of pressure on their neck. The objective of this article is to summarize "best practice" for health care providers so that they are better prepared to care for victims who report a history of strangulation. A summary of how to perform a forensic examination of the strangled patient is provided along with important documentation takeaways and useful forms to ensure that the severity of the strangulation is assessed, that critical injuries are identified, and that all injuries and findings are accurately documented for legal proceedings.
The findings of this study contribute to the discussion about the best method for predicting the recurrence of severe domestic violence. The findings are from a secondary data analysis comparing the accuracy of 177 domestic violence survivors' predictions of reassault to risk factors supported by previous research. The survivors' predictions were associated with recurrence of severe violence in a bivariate analysis. These predictions also added significantly to the accuracy of established risk factors in two multivariate equations predicting severe reassault within a 4-month period. Although not all of the survivors made accurate predictions, this research supports the use of survivors' predictions as an important element that should be included in risk prediction.
This article describes a revised Conflict Tactics Scales (the CTS2) to measure psychological and physical attacks on a partner in a marital, cohabiting, or dating relationship; and also use of negotiation. The CTS2 has (a) additional items to enhance content validity and reliability; (b) revised wording to increase clarity and specificity; (c) better differentiation between minor and severe levels of each scale; (d) new scales to measure sexual coercion and physical injury; and (e) a new format to simplify administration and reduce response sets. Reliability ranges from .79 to .95. There is preliminary evidence of construct validity.
Strangulation is a unique and particularly pernicious form of intimate partner violence. To increase the relatively little that is known about strangulation survivors, focus groups and interviews were conducted as part of a practice-research engagement with a domestic violence shelter. All of the participants had been strangled and, among them, almost all were strangled multiple times. The loss of consciousness was common. Participants associated "choking" with use of body parts and "strangling" with use of objects. Although some minimized the assault, most considered strangulation to be serious and reported a variety of medical conditions following the assault. Few sought medical care. Of those who did, few disclosed the assault, or were asked about strangulation, which commonly resulted in misdirected treatment. Implications for improving detection and treatment are discussed.
For decades, battered women’s advocates have placed coercive control squarely at the center of their analysis of intimate partner violence. Yet, little work has been done to conceptualize and measure the key construct of coercive control. In this article, we apply French and Raven’s social power model to a conceptualization of coercive control in intimate partner violence relationships. Central elements of the model include: social ecology; setting the stage; coercion involving a demand and a credible threat for noncompliance; surveillance; delivery of threatened consequences; and the victim’s behavioral and emotional response to coercion. These elements occur in spiraling and overlapping sequences to establish an overall situation of coercive control. The implications of this model for theory and practice are discussed.
This paper describes two related studies. Study 1 is a literature review of existing adult partner domestic violence assessment scales. Results of the review revealed that the scales varied on the available amount of empirical evidence for validity and reliability. More importantly, results showed that the content of the scales focused most heavily on the physical abuse aspects of domestic violence. Study 2 is a factor analysis performed on the results of 64 items taken from the Artemis Intake Questionnaire, a clinically relevant tool constructed by treatment providers used in working with the victims of domestic violence. Results indicate that reported humiliation and blame of the victim accounted for the largest amount of variance, followed by controlling the victim, and then physical violence. Results of this factor analysis suggest that greater emphasis must be put on factors other than physical violence in the construction of future domestic violence scales.
Vascular neck restraint (VNR) is a technique that police officers may employ to control combative individuals. As the mechanism of unconsciousness is not completely understood, we tested the hypothesis that VNR simply compresses the carotid arteries, thereby decreasing middle cerebral artery blood flow. Twenty-four healthy police officers (age 35 ± 4 yr) were studied. Heart rate (HR), arterial pressure, rate of change of pressure (dP/dt), and stroke volume (SV) were measured using infrared finger photoplethysmography. Bilateral mean middle cerebral artery flow velocity (MCAVmean) was measured by using transcranial Doppler ultrasound. Neck pressure was measured using flat, fluid-filled balloon transducers positioned over both carotid bifurcations. To detect ocular fixation, subjects were asked to focus on a pen that was moved from side to side. VNR was released 1-2 s after ocular fixation. Ocular fixation occurred in 16 subjects [time 9.5 ± 0.4 (SE) s]. Pressures over the right (R) and left (L) carotid arteries were 257 ± 22 and 146 ± 18 mmHg, respectively. VNR decreased MCAVmean (R 45 ± 3 to 8 ± 4 cm/s; L 53 ± 2 to 10 ± 3 cm/s) and SV (92 ± 4 to 75 ± 4 ml; P < 0.001). Mean arterial pressure (MAP), dP/dt, and HR did not change significantly. We conclude that the most important mechanism in loss of consciousness was decreased cerebral blood flow caused by carotid artery compression. The small decrease in CO (9.6 to 7.5 l/min) observed would not seem to be important as there was no change in MAP. In addition, with no significant change in HR, ventricular contractility, or MAP, the carotid sinus baroreceptor reflex appears to contribute little to the response to VNR.
Domestic violence victims are increasingly identified at emergency departments (ED). Studies report a prevalence of 6-30%; women are more frequently affected and to a more serious extent than men. Studies have shown that without screening domestic violence victims are often not recognised. The primary aim of the study is to collect data descriptive of domestic violence victims and to show whether medical documentation meets the requirements of forensic medicine.
Retrospective analysis of medical records using the ED electronic patient database (Qualicare, Qualidoc Bern) at the ED of Bern University Hospital, Inselspital. Demographics, injuries, perpetrators and a semi-quantitative analysis of the medical records have been evaluated for each case.
From 1 January 2000 to 31 December 2005, 40 914 women were admitted to the ED. During this time 160 women were identified as victims of domestic violence and met the inclusion criteria for our study. The age ranged from 15-68 years. 63.6% of these women are married or live in a steady relationship. 46% of all victims of domestic violence were treated from Fridays to Sundays. In 70.2% blunt trauma was documented, the head was affected in 49%, 53% showed injuries of only one body area. In 10 cases, strangulation was suspected. 75% of the assaults could be classified as simple assault on the basis of Swiss criminal law. The perpetrator was the husband or partner in 73.4%. 141 cases were included for a semi-quantitative evaluation of the forensic medical documentation. The type of injuries was described in every case, the localisation in 96%, the shape in 26% and the dimensions of the lesions in 36%.
The present retrospective assessment of medical reports over a 6-year period shows that domestic violence against female patients was documented in 0.4%. This figure is far below the proportions to be expected from recent data. If these data are to be believed the majority of female victims of domestic violence must have been overlooked at the ED. The implementation of screening for domestic violence seems to be crucial. The types of injury are chiefly the result of superficial, blunt violence, meaning of mild degree from the viewpoint of criminal law. The quality of the forensic documentation is poor and usually insufficient for criminal prosecution. Clinicians require training in the forensic aspects of medical records.
The Abuse Assessment Screen has been used since 1987 to identify and assess for intimate partner violence in a wide variety of clinical and research settings. It has been translated and successfully used in at least 7 languages in addition to English. Meanwhile, a growing body of research indicates that nonlethal strangulation (commonly called "choking") is a significant form of intimate partner violence and that choking has substantial consequences for the health of the woman. This paper describes the modification of the Abuse Assessment Screen to include "choking."
The Danger Assessment (DA) is an instrument designed to assess the likelihood of lethality or near lethality occurring in a case of intimate partner violence. This article describes the development, psychometric validation, and suggestions for use of the DA. An 11-city study of intimate partner femicide used multivariate analysis to test the predictive validity of the risk factors on the DA from intimate partner femicide cases (N = 310) compared with 324 abused women in the same cities (controls). The results were used to revise the DA (four items added; one "double-barreled" item divided into two), and the calculated weights (adjusted odds ratios) used to develop a scoring algorithm with levels of risk. These levels of risk were then tested with an independent sample of attempted femicides (N = 194) with a final outcome of .90 of the cases included in the area under the receiver operating characteristic (ROC) curve.
Strangulation is produced by pressure on the neck, and can take four
forms, depending on how the pressure is produced: hanging (the most common), ligature strangulation, manual strangulation, and postural strangulation.
It can also be classified by the setting in which death occurs: suicide,
accident, homicide, and judicial executions.
There are approximately 3,500 deaths reported from suicidal strangulation and hangings in the United States each year, with strangulation of all types accounting for between 5% and 10% of criminally violent deaths in large urban areas, and hangings responsible for approximately 5% of medico-legal
autopsies.
These studies were designed to demonstrate that the usual method of laryngeal dissection carries a significant risk of overlooking important laryngeal injuries. Formalin-fixed hyoid-larynx complexes were prepared in a prospective forensic study involving 191 cases of homicidal strangulation, 1984 to 1997. The basic steps of the applied method included: complete resection of the thyroid cartilage, a horizontal incision through the cricoid cartilage before opening the larynx dorsally, inspection of the laryngeal joints, and incisions of the laryngeal muscles. Using this procedure allowed us to detect the following injuries, which otherwise would have been destroyed or overlooked: (a) 17 incomplete fractures restricted to the dorsal surfaces of the thyroid laminae and 10 incomplete or non-dislocated fractures of the cricoid cartilage. In 7 cases, such a "hidden" fracture was the only laryngeal injury resulting from neck compression. (b) Extensive laryngeal muscle hemorrhages, especially of the vocal folds, were found in almost half of all cases, more rarely in strangulation by ligature and more frequently in manual strangulation. Gross hemorrhages were the decisive local laryngeal finding in 19 cases. (c) Laryngeal joint injuries (bleedings) were found in 18% to 52% of the different strangulation types. (d) Hemorrhages of the laryngeal mucosa were common findings that occur in about 60% of all cases; only in rare cases do such bleedings have a special diagnostic value. The quantity and significance of findings obtainable from complete preparation clearly document Camps's demand made in 1976 to dispense with the usual laryngeal dissection technique (dorsal scissor incision through the cricoid cartilage), at least in (questionable) strangulation cases. Language: en
. Objectives : To determine the prevalence of domestic violence among female patients and to identify clinical characteristics that are associated with current domestic violence. . Design : Cross-sectional, self-administered, anonymous survey. . Setting : 4 community-based, primary care internal medicine practices. . Patients : 1952 female patients of varied age and marital, educational, and economic status who were seen from February to July 1993. . Measurements : The survey instrument included previously validated questions on physical and sexual abuse, alcohol abuse, and emotional status and questions on demographic characteristics, physical symptoms, use of street drugs and prescribed medications, and medical and psychiatric history. . Results : 108 of the 1952 respondents (5.5%) had experienced domestic violence in the year before presentation. Four hundred eighteen (21.4%) had experienced domestic violence sometime in their adult lives, 429 (22.0%) before age 18 years, and 639 (32.7%) as either an adult or child. Compared with women who had not recently experienced domestic violence, currently abused patients were more likely to be younger than 35 years of age (prevalence ratio [PR], 4.1 [95% CI, 2.8 to 6.0]) ; were more likely to be single, separated, or divorced (PR, 2.5 [CI, 1.7 to 3.6]) ; were more likely to be receiving medical assistance or to have no insurance (PR, 4.3 [CI, 2.8 to 6.6]) ; had more physical symptoms (mean, 7.3 ± 0.38 compared with 4.6 ± 0.08 ; P < 0.001) ; had higher scores on instruments for depression, anxiety, somatization, and interpersonal sensitivity (low self-esteem) (P < 0.001) ; were more likely to have a partner abusing drugs or alcohol (PR, 6.3 [CI, 4.4 to 9.2]) ; were more likely to be abusing drugs (PR, 4.4 [CI, 1.9 to 10.4]) or alcohol (PR, 3.1 [CI, 1.5 to 6.5]) ; and were more likely to have attempted suicide (PR, 4.3 [CI, 2.8 to 6.5]). They visited the emergency department more frequently (PR, 1.7 [CI, 1.2 to 2.5]) but d
Alternative light sources (ALSs) are commonly used at crime scenes and in forensic laboratories to collect evidence such as latent fingerprints, body fluids, hair, and fibers. This article describes the use of this technology to reveal soft tissue injuries that are not visible to the naked or unaided eye in patients who report strangulation. The value of this information to the medical, nursing, and judicial systems is discussed. The records of the 172 strangulation patients seen in our forensic nurse examiner program between 2009 and 2010 were reviewed. The SPEX Crimescope (SPEX Forensics, Edison, New Jersey) was used during the assessment of all of them. Ninety-three percent of the patients had no visible evidence of external injuries on physical examination. The ALS revealed positive findings of intradermal injuries in 98% of that group. Information obtained with ALS devices helps medical and nursing practitioners understand the gravity of patients' injuries, influences medical treatment decisions and follow-up care, and supports the prosecution of the perpetrators of crimes of violence. Educational programs about the application of ALS and the interpretation of its findings are valuable for medical, nursing, and other forensic disciplines.
After all the positive changes in the criminal justice system over the last ten to fifteen years concerning the response to incidents of domestic violence, there remains the problem of battered women who are arrested as perpetrators of domestic violence. The reasons for these arrests are complex and varied. They range from the patriarchal structure of criminal justice agencies, to the staffing of these agencies, and finally to the inappropriate and inadequate training of police officers. This article includes real life examples of cases where victims were arrested, and why these arrests occurred. It also includes suggestions on how to minimize these illegal arrests.
Data from the National Violence Against Women Survey show that the two major forms of husband violence toward their wives (intimate terrorism and situational couple violence) have different effects on their victims. Victims of intimate terrorism are attacked more frequently and experience violence that is less likely to stop. They are more likely to be injured, to exhibit more of the symptoms of posttraumatic stress syndrome, to use painkillers (perhaps also tranquilizers), and to miss work. They have left their husbands more often, and when they do leave, they are more likely to acquire their own residence. If we want to understand the true impact of wife abuse from survey data (rather than from agency data), we must make distinctions among types of violence so that the data used to describe battering are not diluted by data regarding other types of partner violence.
Despite its great achievements, the domestic violence revolution is stalled, Evan Stark argues, a provocative conclusion he documents by showing that interventions have failed to improve women's long-term safety in relationships or to hold perpetrators accountable. Stark traces this failure to a startling paradox, that the singular focus on violence against women masks an even more devastating reality. In millions of abusive relationships, men use a largely unidentified form of subjugation that more closely resembles kidnapping or indentured servitude than assault. He calls this pattern "coercive control." Drawing on sources that range from FBI statistics and film to dozens of actual cases from his thirty years of experience as an award-winning researcher, advocate, and forensic expert, Stark shows in terrifying detail how men can use coercive control to extend their dominance over time and through social space in ways that subvert women's autonomy, isolate them, and infiltrate the most intimate corners of their lives. Against this backdrop, Stark analyzes the cases of three women tried for crimes committed in the context of abuse, showing that their reactions are only intelligible when they are reframed as victims of coercive control rather than as "battered wives." The story of physical and sexual violence against women has been told often. But this is the first book to show that most abused women who seek help do so because their rights and liberties have been jeopardized not because they have been injured. The coercive control model Stark develops resolves three of the most perplexing challenges posed by abuse: why these relationships endure, why abused women develop a profile of problems seen among no other group of assault victims, and why the legal system has failed to win them justice. Elevating coercive control from a second-class misdemeanor to a human rights violation, Stark explains why law, policy, and advocacy must shift their focus to emphasize how coercive control jeopardizes women's freedom in everyday life. Fiercely argued and eminently readable, Stark's work is certain to breathe new life into the domestic violence revolution. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
We conducted a qualitative study to examine acute, situational factors and chronic stressors that triggered severe intimate partner violence (IPV) in women.
Our sample consisted of 17 heterosexual couples, where the male was in detention for IPV and made telephone calls to his female victim. We used up to 4 hours of telephone conversational data for each couple to examine the couple's understanding of (1) acute triggers for the violent event and (2) chronic stressors that created the underlying context for violence. Grounded theory guided our robust, iterative data analysis involving audiotape review, narrative summation, and thematic organization.
Consistently across couples, violence was acutely triggered by accusations of infidelity, typically within the context of alcohol or drug use. Victims sustained significant injury, including severe head trauma (some resulting in hospitalization/surgery), bite wounds, strangulation complications, and lost pregnancy. Chronic relationship stressors evident across couples included ongoing anxiety about infidelity, preoccupation with heterosexual gender roles and religious expectations, drug and alcohol use, and mental health concerns (depression, anxiety, and suicide ideation/attempts).
Disseminated models feature jealousy as a strategy used by perpetrators to control IPV victims and as a red flag for homicidal behavior. Our findings significantly extend this notion by indicating that infidelity concerns, a specific form of jealousy, were the immediate trigger for both the acute violent episode and resulting injuries to victims and were persistently raised by both perpetrators and victims as an ongoing relationship stressor.
Post-mortem examination of a female homicide victim suggested a fracture of the larynx and increased flexibility, without associated hemorrhage, of the hyoid bone. There was a history of domestic violence, which included an allegation of attempted strangulation. Microscopy confirmed a recent fracture of the larynx and showed evidence of a healing fracture in the hyoid bone. Death was due to multiple blunt force trauma, including pressure to the neck. The deceased's partner admitted strangulation and was convicted of murder. The discussion concentrates on causation of laryngo-hyoid fractures and the potential usefulness of microscopy, particularly identifying evidence of previous trauma.
While Sexual Assault Nurse Examiner programs have improved the treatment of rape victims by offering more compassionate and thorough treatment, SANEs believe victims continue to face revictimization by the medical, criminal justice and legal systems. The purpose of this research is to explore SANEs' perceptions of the revictimization of rape victims by the police, legal system and medical system. Data from interviews with 39 Sexual Assault Nurse Examiners from four East Coast states reveal that most SANEs believe that the medical, criminal justice, and legal systems wield the power to revictimize rape victims. SANEs were more likely to cite the criminal justice system as a source of revictimization, followed by the medical system and legal system. According to SANEs, police contribute to victims' distress through failure to ask questions in a sensitive manner, failure to proceed with investigations, and by asking victim-blaming questions. Revictimization by the legal system results when charges are never filed, cases are postponed or dropped, plea bargains are unsatisfactory, and victims' character and credibility are questioned. Revictimization by the medical system is marked by long waits for medical attention.
The prevalence of reported domestic violence or intimate partner violence has greatly increased, with approximately 1.5 million women violently assaulted annually in the United States by an intimate partner. Strangulation is often seen in violence against women, including domestic violence cases. Strangulation is defined as "a form of asphyxia characterized by closure of the blood vessels or air passages of the neck as a result of external pressure on the neck." This is a 10-year case review of 102 living victims of strangulation who underwent medicolegal evaluation at the Clinical Forensic Medicine Program at a State Medical Examiner's Office serving Southern Indiana and all of Kentucky. The majority of victims (79%) were strangled by an intimate partner, and manual strangulation was the most common method (83%). A total of 38 victims (38%) described a history of domestic violence, and the same number lost consciousness while being strangled. Nine (9%) women were pregnant at the time of the attack, while 13 (13%) had a history of being sexually abused in addition to being strangled. A paucity of cases involved only strangulation, as most of the victims were subjected to myriad forms of blunt force trauma which included not only the head and neck but also other bodily regions. This is a unique presentation of strangulation of living persons as most evidence of strangulation in the forensic literature has been derived from postmortem examinations of the victims. This comprehensive study discussing the examination of a living strangulation victim offers valuable insight into the mechanism and the physical findings involved in the strangulation process.
The aim of the study was to examine the clinical forensic findings of strangulation according to their ability to differentiate between life-threatening and non-life-threatening strangulation, compare clinical and MRI findings of the neck and discuss a simple score for life-threatening strangulation (SLS).
Forensic pathologists classified a continuous sample of 56 survivors of strangulation into life-threatening cases by clinical history and examination alone. Subjective, objective and radiological signs were evaluated for discriminating the two groups.
In 27% of the cases life was in danger. The most significant signs of danger to life were congestive petechial hemorrhage in the face (eyes); hematoma of the neck and loss of consciousness. The radiological score could compete with the clinical scores.
Clinical forensic findings differ significantly in non-life-threatening and life-threatening manual strangulation. Thanks to MRI a rather objective test for life-threatening strangulation can be added to a SLS.
Little is known about the role of skin color in the forensic sexual assault examination. The purpose of this study was to determine whether anogenital injury prevalence and frequency vary by skin color in women after consensual sexual intercourse. The sample consisted of 120 healthy (63 Black, 57 White) women who underwent a forensic sexual assault examination following consensual sexual intercourse. Experienced sexual assault forensic examiners using visual inspection, colposcopy technique with digital imaging, and toluidine blue application documented the number, type, and location of anogenital injuries. Although 55% of the total sample was observed to have at least one anogenital injury of any type following consensual intercourse, the percentages significantly differed for White (68%) and Black (43%) participants (p= 0.02). When the presence of anogenital injury was analyzed by specific anatomical region, a significant difference between White and Black participants was only evident for the external genitalia (White = 56%, Black = 24%, p= .003), but not for the internal genitalia (White = 28%, Black = 19%, p= .20) or anus (White = 9%, Black = 10%, p= 0.99). A one standard deviation-unit increase in L* values (lightness) was related to a 150% to 250% increase in the odds of external genitalia injury prevalence (p < 0.001). While Black and White participants had a significantly different genital injury prevalence, dark skin color rather than race was a strong predictor for decreased injury prevalence. Sexual assault forensic examiners, therefore, may not be able to detect injury in women with dark skin as readily as women with light skin, leading to health disparities for women with dark skin.
This article examines the theory of gender presented in Stark's Coercive Control: How Men Entrap Women in Personal Life. Stark suggests that gender is a form of structural inequality that makes women more vulnerable than men to the strategies of coercive control. However, Stark assumes rather than demonstrates that gendered structural inequality increases women's vulnerability. In this article, the author applies the multilevel theory of gender as identity, interaction, and social structure to document the multiple ways coercive control is gendered. The author argues that, to understand the gender dynamics of coercive control, researchers must examine the interactions across levels of gender. The author concludes with an assessment of the prospects and pitfalls of applying the concept of coercive control to renew the feminist social movement to end domestic violence.
The aim of this study was to find characteristics in head-neck-facial (HNF) injuries among victims of violence and to test the hypothesis that the type of injury, location, and mechanism behind it vary between the genders.
A 1-year prospective study including all victims of violence attending the Accident & Emergency (A&E) Department or the Institute of Forensic Medicine in Aarhus was conducted. Every violence-related injury was recorded along with the mechanism behind it, the type of injury, and the specific anatomic location.
A total of 1,106 victims were examined of whom 83% had HNF injuries. Thirty-seven percent had more than one HNF injury. Injuries around the nose and mouth were significantly associated with male victims, whereas injuries to the neck were significantly more common among female victims. Most injuries were the results of assault with a blunt object, where the men much more frequently had open wounds, whereas injuries such as ecchymoses were significantly more frequent among female victims. Use of weapons, such as blunt objects and blows with glass/bottles, was associated much more with male victims, whereas strangulation attempts were significantly more frequent among women. Ten percent of the women had been exposed to strangulation attempts.
The findings support former studies that HNF injuries might be considered as markers of violence. Thus, the staff at A&E Departments must consider anyone with these types of injuries as potential victims of violence. The A&E Department may be the primary entrance for the victims and the main way in which to offer help. The high incidence of women who had been assaulted with strangulation, which is a potentially very dangerous trauma mechanism, intensifies the importance of conducting a careful medical examination, in part, because of the possible legal implications.
HNF injuries are characteristic among victims of violence, although significant differences exist in the type of injuries, the location, and the trauma mechanism between men and women.
Nonlethal strangulation of intimate partners has substantial direct health effects and is associated with an increased risk of later lethal violence by a partner or ex-intimate partner but can be difficult to prosecute under felony assault statutes. After review of state laws regarding assault, the authors identified 10 states with specific legislation related to strangulation as of March 2009 The authors examined the characteristics of these laws. They recommend that all states develop policies to improve prosecution of strangulation, include strangulation in their criminal codes, and use language that includes all potential victims.