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Non-fatal Strangulation is an Important Risk Factor for Homicide of Women



The purpose of this study was to examine non-fatal strangulation by an intimate partner as a risk factor for major assault, or attempted or completed homicide of women. A case control design was used to describe non-fatal strangulation among complete homicides and attempted homicides (n = 506) and abused controls (n = 427). Interviews of proxy respondents and survivors of attempted homicides were compared with data from abused controls. Data were derived using the Danger Assessment. Non-fatal strangulation was reported in 10% of abused controls, 45% of attempted homicides, and 43% of homicides. Prior non-fatal strangulation was associated with greater than six-fold odds (odds ratio [OR] 6.70, 95% confidence interval [CI] 3.91-11.49) of becoming an attempted homicide, and over seven-fold odds (OR 7.48, 95% CI 4.53-12.35) of becoming a completed homicide. These results show non-fatal strangulation as an important risk factor for homicide of women, underscoring the need to screen for non-fatal strangulation when assessing abused women in emergency department settings.
Non-fatal strangulation is an important risk factor for homicide of
Nancy Glass, PhD, MPH, RN [Associate Professor],
Johns Hopkins University, School of Nursing, Baltimore, Maryland
Kathryn Laughon, PhD, RN [Assistant Professor],
University of Virginia, School of Nursing, Charlottesville, Virginia
Jacquelyn Campbell, PhD, RN,
Johns Hopkins University, School of Nursing, Baltimore, Maryland
Anna D. Wolf Chair,
Johns Hopkins University, School of Nursing, Baltimore, Maryland
Carolyn Rebecca Block, PhD [Senior Research Analyst],
Illinois Criminal Justice Information, Authority, Chicago, Illinois
Ginger Hanson, MS [Senior Research Assistant],
Oregon Health & Science University, School of Nursing, Portland, Oregon
Phyllis W. Sharps, PhD, RN [Associate Professor], and
Johns Hopkins University, School of Nursing, Baltimore, Maryland
Ellen Taliaferro, MD, FACEP [Director, Health After Trauma]
Project, Creekside Communications, Half Moon Bay, CA
The purpose of the study is to examine non-fatal strangulation by an intimate partner as a risk factor
for major assault, or attempted or completed homicide of women. A case control design was used to
describe non-fatal strangulation among complete homicides and attempted homicides (n =506) and
abused controls (n = 427). Interviews of proxy respondents and survivors of attempted homicides
were compared with data from abused controls. Data were derived using the Danger Assessment.
Non-fatal strangulation was reported in 10% of abused controls, 45% of attempted homicides and
43% of homicides. Prior non-fatal strangulation was associated with greater than six-fold odds (OR
6.70, 95% CI 3.91–11.49) of becoming an attempted homicide, and over seven-fold odds (OR 7.48,
© 2007 Elsevier Inc. All rights reserved.
Corresponding author and address for reprints: Nancy Glass, PhD, MPH, RN, Associate Professor, Johns Hopkins University, School of
Nursing, 525 N. Wolfe Street, Rm 439, Baltimore, Maryland 21205, 410-614-2849,
The paper was presented as a “work in progress” at the June 2004 annual meeting of the Homicide Research Working Group in Ann
Arbor, Michigan.
1Although most of the collaborators of the Chicago Women’s Health Risk Study were silent partners in writing this report, they were
equal partners in the project. They include Olga Becker, Nanette Benbow, Jacquelyn Campbell, Debra Clemons, James Coldren, Alicia
Contreras, Eugene Craig, Roy J. Dames, Alice J. Dan, Christine Devitt, Edmund R. Donoghue, Barbara Engel, Dickelle Fonda, Charmaine
Hamer, Kris Hamilton, Eva Hernandez, Tracy Irwin, Mary V. Jensen, Holly Johnson, Teresa Johnson, Candice Kane, Debra Kirby,
Katherine Klimisch, Christine Kosmos, Leslie Landis, Susan Lloyd, Gloria Lewis, Christine Martin, Rosa Martinez, Judith McFarlane,
Sara Naureckas, Iliana Oliveros, Angela Moore Parmley, Stephanie Riger, Kim Riordan, Roxanne Roberts, Martine Sagan, Daniel
Sheridan, Wendy Taylor, Richard Tolman, Gail Walker, Carole Warshaw, and Steven Whitman. Collaborating agencies in the study
were the Mayor’s Office on Domestic Violence; the Chicago Police Department Domestic Violence Unit; the Erie Family Health Center;
the Chicago Department of Public Health; the Cook County Medical Examiner’s Office; the Cook County Hospital; the Chicago Abused
Women Coalition; and the Illinois Criminal Justice Information Authority.
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Published in final edited form as:
J Emerg Med. 2008 October ; 35(3): 329–335. doi:10.1016/j.jemermed.2007.02.065.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
95% CI 4.53–12.35) of becoming a completed homicide. These results show non-fatal strangulation
as an important risk factor for homicide of women, underscoring the need to screen for non-fatal
strangulation when assessing abused women in emergency department settings.
The 1993 National Mortality Followback Survey (NMFS) of adults (22,957 decedents 15 years
and older) shows that the percent dying from strangulation was much higher for women
(11.8%) than for men (1.9%) overall and in every age group (respectively, 1.1% versus 11.7%
at age 18–24 years; 1.6% versus 11.7% at age 25–39; 2.8% versus 6.7% at age 40–64; and
7.0% versus 33.0% at age 65 or older). Though there is no information about the relationship
of the victim and offender in the NMFS study, the findings provide the context to examine
strangulation as a risk factor for intimate partner attempted and completed homicide of women
There is little research specifically examining strangulation in the context of intimate partner
violence (IPV) or homicide. The prevalence of strangulation as a form of IPV and a risk factor
for attempted or completed homicide has not been established. Wilbur and colleagues' in
20012 found that 68% of a convenience sample of 62 women presenting to a domestic violence
advocacy program reported strangulation by their abuser (2). The Chicago Women’s Health
Risk Study (CWHRS) found that 24.6% of 57 adult women killed by a male intimate partner
in 1995 or 1996 in Chicago were killed by strangulation or smothering (3,4). Of the 494 women
sampled as they came into Chicago hospitals and clinics for any reason and who said that they
had experienced IPV in the past year, 47.3% had experienced at least one incident in the past
year in which her partner had tried to choke or strangle her, and 57.6% had "ever" experienced
choking or strangulation by the abusive partner. There was no difference between women who
were not killed and the women who were killed in having experienced prior choking or
strangulation. However, strangulation was associated with lethality of incident, with almost
five percent (4.8%) lethality in the 289 incidents in which a partner or ex-partner strangled the
woman, compared to 1.0% of the 4,722 incidents where the abuser used other types of violence.
This finding was true across racial and ethnic groups, but did not hold for women abused by a
same-sex partner. African American women were significantly more likely than Latinas and
other racial or ethnic groups of women to have experienced strangulation in the past year, or
"ever," but were less likely to be killed by strangulation.
A study of 300 consecutive cases of female attempted strangulations seen in the San Diego
Domestic Violence Unit of the city prosecutor’s office found that in 89% of the cases there
was a prior history of IPV (5). In a study in which women were directly questioned about
symptoms, at least 85% of intimate partner strangulation victims experienced physical
symptoms (such as sore throat, difficulty breathing, or neurological symptoms) and at least
83% reported one or more psychiatric symptom in the two weeks following the event (2). A
different analysis of the same data found that 56% of the women had experienced more than
one strangulation event (6). The frequency with which women reported some kind of
symptoms, particularly neurological, increased among women who were the victims of
multiple versus one strangulation event (6). In another study using police documentation of
injuries, 34% of strangulation victims reported symptoms, including pain, difficulty
swallowing, and breathing changes (5). Three case studies of carotid dissection resulting in
cerebrovascular accidents in women who were strangled by an intimate partner have been
reported (7).
In this article, we seek to achieve the following aims: 1) describe the prevalence of non-fatal
strangulation and demographic characteristics in a population based sample of urban abused
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women, 2) determine if non-fatal strangulation is a risk factor for completed and attempted
homicide for abused women, and 3) determine how the risk represented by non-fatal
strangulation varies for women according to personal and relationship factors.
Materials and Methods
Study design
We performed secondary analysis of data from an eleven-city case control study to identify
risk factors for intimate partner homicide and attempted homicide of women (8)Institutional
review board approval was obtained by each collaborating site.
Risk factor data were collected using a structured survey administered by researchers and
interviewers trained in interviewing victims of violence.
Selection of participants
Completed Homicide of Women Cases—All consecutive police or medical examiner
intimate partner female homicide records from 1994 – 2000 in each study city were examined
for victim-perpetrator relationship. Cases were eligible if the victim was a woman aged 18
years or older, the perpetrator was a current or ex-intimate partner, and the case was designated
as “closed” by the police. Records were abstracted for data specific to the homicide and to
identify potential proxy informants (i.e., mother, sister, brother or friend) who might be
knowledgeable about details concerning the victim’s relationship with the perpetrator. Proxies
were then sent a letter explaining the study and inviting their participation (9). Researcher
telephone and address contact information was provided in the letter for proxies to find out
more about the study or to request no further communication (9). Two weeks following the
letter, study personnel made contact, either by telephone or in person (in the few cases where
no phone contact was possible), with the proxies who had not requested non-contact. If the
first proxy reported that he or she was not knowledgeable about details of the relationship, the
proxy was asked to identify another willing potential proxy informant. Then, in-person or
telephone interviews were conducted, following informed consent, with the proxy who was
most knowledgeable about details of the victim-perpetrator relationship. In 373 of the 545
(68%) total intimate partner homicide cases abstracted, a knowledgeable proxy was identified
and located. Proxies agreed to participate in 83% (310/373) of cases, therefore, 310 homicides
of women are included in this analysis.
Attempted Homicide Cases—Attempted homicide cases were identified through the
offices of the district attorney, law enforcement, community domestic violence advocacy, or
trauma centers in each participating city. Attempted homicide was defined for this study as the
survival of a gun-shot or stab wound to the head, neck or torso; strangulation or near drowning
with loss of consciousness; severe injuries inflicted that easily could have led to death; or gun-
shot or stab wound to other body part with evidence of unambiguous (additional to victim
report) intent to kill on the part of a perpetrator who was a current or former intimate partner.
When a woman was identified, she was sent an introductory letter inviting her to participate
in a Woman’s Health Study and a statement that she would receive a follow-up telephone call
in two weeks unless she contacted the investigators requesting not to be called. The follow-up
telephone call established safety and privacy, further explained the study, established informed
consent, and either proceeded with the telephone interview or scheduled a safe and convenient
time to conduct the telephone or in-person interview. The attempted homicide cases gave us
the advantage of direct rather than proxy interviews but the disadvantage of a lower location
rate (56%), since a large proportion of the women had moved from the place where they were
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almost killed, as would be expected. However, once we located an attempted homicide victim
(n=215), almost all (90%) agreed to participate, for a sample of 194.
Abused Controls—Stratified random-digit dialing (up to 6 attempts per number) conducted
by an experienced survey research firm was used to select English and Spanish speaking women
aged 18 to 50 years who had been involved “romantically or sexually” in a relationship at some
time in the past 2 years in the same cities in which the homicides occurred. A woman was
considered “abused” if she had been physically assaulted or threatened with a weapon by a
current or former intimate partner during the past 2 years; we identified episodes of abuse using
a modified version of the Conflict Tactics Scale with stalking items added (10,11). A total of
4746 women met the age and relationship criteria and were read the consent statement. Among
these women, 3637 (76.6%) agreed to participate. A total of 427 (8.5%) women had been
physically abused or threatened with a weapon by a current or recent intimate partner and are
included in this analysis. Thirteen abused controls were excluded because they reported that
the injuries from their most severe incident of abuse were so severe that they thought they could
have died.
Methods of measurement
The interview included previously tested instruments, such as the Danger Assessment (DA),
along with demographic and relationship characteristics including type, frequency and severity
of any violence, psychological abuse and harassment, alcohol and drug use, and weapon
availability (12–14).
The DA is a research and clinical instrument developed to assist abused women in assessing
risk factors for intimate partner homicide in their relationship. The DA has the most published
data on risk factors for intimate partner homicide and concurrent and predictive validity
information (14). The DA item for strangulation is “did he try to choke you in the past year.”
While “choking” is technically different from strangulation, it is used in this instrument as a
word that is more familiar to women. The DA has been revised to the DA-2 based on the
findings from the larger multi-city case control study and can be located at: (15).
Primary Data Analysis
Means, standard deviations and frequencies were used to describe the demographic
characteristics of the intimate partner homicides, attempted homicides and abused controls
who experienced and did not experience strangulation. Within each group (abused control,
attempted homicide and completed homicide) tests were conducted to examine whether there
were demographic differences between women who had and had not been strangled by their
partner. These differences were tested using chi-square or t-test depending on the nature of the
variables being tested. Scores on the DA (excluding the strangulation item) were calculated
for each group. Analysis of variance was used to test for differences in DA scores among the
control, homicide/completed homicides cases who experienced strangulation. Multivariate
logistic regressions were conducted to determine the risk factors for strangulation and the
strength of association of strangulation with attempted and completed homicide cases. To
qualitatively determine if various personal and relationship factors moderated the association
between strangulation and risk for completed and attempted homicide, sub-group analyses
using multivariate logistic regression were conducted within the levels of race, employment
status, educational level, and relationship status, which were determined a priori. Within each
level of the personal and relationship variables, multivariate logistic regressions were
conducted to examine the degree of association between strangulation and attempted and
completed homicide.
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Demographic Differences Between Women with a history of attempted strangulation and
those without a history of attempted strangulation
The results are summarized in Table 1.
Women who were the victims of completed or attempted homicide were far more likely to
have a history of strangulation compared to the abused control women. Further, within each
group, scores on the DA (excluding the choking item) were significantly higher for women
who reported strangulation than for women without such a history (see Table 2). No significant
interaction between abuse group (control vs. attempted homicide/completed homicide) and
strangulation was observed, thus indicating that women strangled in both abuse groups have
higher DA scores.
Logistic Regression
We conducted two multivariate logistic regressions; the first logistic regression estimated the
odds of becoming an attempted homicide verses an abused control if the partner or ex-partner
had previously strangled the woman. The second logistic regression estimated the odds of
becoming a completed homicide verses an abused control if their partner or ex-partner had
previously strangled the woman. When conducting the logistic regressions, we entered all of
the demographic and relationship predictors in the first block. Strangulation was then added
in the second block to assess whether or not the addition improved the fit of the model. These
results are summarized in Table 2.
Both analyses found that controlling for the demographic predictors, the odds of becoming an
attempted homicide increased by about seven-fold for women who had been strangled by their
partner (OR 6.7, 95% CI 3.91, 11.49 and OR 7.48, 95% CI 4.53–12.35, respectively). In both
groups, in year increase in age resulted in a small increase of a woman’s odds of becoming an
attempted or completed homicide. African American race (compared to White) also increased
women’s odds of experiencing attempted and completed homicide.
Role of personal and relationship factors
Next, a sub-group analysis repeating the logistic regressions for all variables under
consideration was conducted within racial categories since that was the only significant
demographic categorical variable. Among African American women, strangulation increased
odds of becoming a completed homicide by 4.65 (95% CI 2.18–9.95), but among white and
Latina women the increase was much higher (13.72 for white women, and 21.16 for Latinas
5.4–34.8, and 5.8–77.8, respectively). Similar results were obtained for attempted homicide
when stratifying by race/ethnicity (see Table 3).
Strangulation is an important form of physical violence against women who are in abusive
relationships. Overall, 27% of this sample experienced non-fatal strangulation, 10% of the
abused controls and 45% of the attempted, and 43% of the completed homicide cases. Non-
fatal strangulation, as opposed to other severe forms of physical violence such as striking with
fists or another object, frequently leaves little in the way of observable injury, yet can result in
serious physical and mental health consequences (2,5)
Among African American women, strangulation was less of a risk factor for attempted and
completed homicide than for white and Latina women. This finding may be a result of one or
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both of the following. Because African American women were about 4 times as likely to be
killed or to become the victim of an attempted homicide by an intimate partner than were
women of other race/ethnicity groups, they were generally at greater risk regardless of whether
or not they had experienced non-fatal strangulation. Additionally, non-fatal strangulation was
a far more common form of physical abuse for African American women vs. other race/ethnic
groups whether or not they were the victim of actual or attempted homicide (40% of African
American vs. 17% for white and 22% for Latina women). Nonetheless, non-fatal strangulation
still increases the risk of becoming an attempted or completed homicide by about 4 times among
African American women, and thus remains a significant independent risk factor for death in
all the major race/ethnic groups. Given the significant sequelae associated with non-fatal
strangulation, these findings indicate that it remains important to specifically screen for
strangulation among African American women, despite the smaller association between non-
fatal strangulation and subsequent attempted or completed homicide (2,5,7).
Practice Implications
These findings indicate that strangulation is a relatively prevalent form of violence toward
women who experience physical violence in an abusive relationship (a finding consistent with
the sparse literature on the subject) and is a significant predictor for future lethal violence.
There is an urgent need for emergency physicians and nurses to be trained in the importance
of strangulation as a risk factor for homicide of women and how to thoroughly assess, document
and obtain appropriate treatment (5,16, 27). The documentation of the strangulation may be
particularly useful to expert witnesses in conveying the risk of lethality in cases of attempted
homicide. Further, forensic nurses can play an important role in this endeavor, and training
modules for forensic nurses in this arena have already been developed (16). In addition, it is
important for emergency medical technicians and police officers, as first responders, to be
trained on the importance of ensuring that these incidents are evaluated in an emergency
department, both to document the attempt and to thoroughly evaluate the injury.
Research Implications
More research is needed that specifically focuses on the context of strangulation. The marked
increase in non-fatal strangulation among African American women compared to women of
other racial/ethnic groups warrants further investigation to learn if there are risk factors for
intimate partner homicide specific to African American women. Additionally, further research
is needed to identify the long-term health implications of non-lethal strangulations by following
a cohort of identified survivors of strangulation over time.
Policy Implications
Based on the health consequences noted by other researchers, and given that all incidents of
strangulation could potentially result in death, it would appear logical that strangulation be
prosecuted as a more serious crime than simple assault and battery (usually a misdemeanor
with a possible sentence of up to one year) – under statutes such as attempted homicide or
malicious wounding. Because women’s injuries secondary to strangulation may not be
carefully documented and because the law is not clear regarding the definition of bodily injury,
prosecution of strangulation under this more serious statute is rare, and prosecution as an
“attempted homicide” is unusual in all but the most severe cases (5; personal communication,
Deputy Commonwealth’s Attorney Worrell, March 2005). This stands in contrast to crimes
such as stabbings that may result in relatively superficial injury, but can be prosecuted as
attempted homicide or even malicious wounding.
Idaho recently signed a bill into law (Senate Bill 1062-April 2005) that any person who willfully
and unlawfully chokes or attempts strangulation of a household member, or a person with
whom there was a dating relationship, guilty of a felony punishable by incarceration for up to
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fifteen (15) years. Importantly, no injuries are required to prove attempted strangulation and
the prosecution is not required to show that the defendant intended to kill or injure the victim,
the only intent required is the intent to choke or attempt to strangle. To our knowledge, the
Idaho law is the toughest legislation regarding strangulation in the US. Research is needed to
explore how more aggressive prosecution of strangulation could be supported. Current
literature suggests, however, that better attention to strangulation on the part of police officers
on the scene and better documentation of the physical findings by physicians, nurses and other
health care professionals could immediately improve prosecution. (5)
The study has some limitations to note. Specifically, our reliance on proxies for information
about women who were killed by their partners, while the data for the abused controls and the
attempted homicides were obtained from the women directly, is an important but inevitable
limitation of this study. This limitation and related analyses were discussed in greater depth in
the original report of this study (8). The most pertinent issue for this analysis is that of the
missing data for the “strangulation” item. About one-third of proxies simply did not know if
the victim had been strangled prior to her death and the rate of strangulation among that group
could be either higher or lower than reported here. Additionally, it is possible that abused
women who refused to participate in the control group may have been experiencing more severe
violence than the abused women who did participate, but we have no way of verifying that.
Finally, this study was limited to women living in large urban areas, and may not be
generalizable to women living in other kinds of communities.
In Retrospect
Because this was a secondary data analysis, some important information regarding
strangulation was not asked. Were we to replicate this important study, we would include
information about the woman’s response to the strangulation (did she seek medical attention?;
did she report it to the criminal justice system?) to better understand how to improve our
response to this form of violence. Additionally, we would have collected more specific
information about the strangulation itself, including the number of times she was strangled,
the proximity of these events to the homicide/attempted homicide, and the severity of the
incidents (did she lose consciousness? Was there visible injury such as swelling, redness or
bruising?) to better assess the characteristics of non-lethal strangulation most predictive of
near- or actual lethality.
In summary, non-lethal strangulation is an important predictor for future lethal violence among
women who are experiencing IPV. We urgently need to improve the clinical response to women
reporting an incident of non-lethal strangulation to improve treatment and enhance safety
planning for this high-risk group of abused women.
This research was supported by joint funding from the National Institute on Alcohol Abuse and Alcoholism, National
Institute on Drug Abuse, National Institute of Mental Health, National Institutes on Aging, Centers for Disease Control
and Prevention and the National Institute of Justice, R01 # DA/AA11156.
The Chicago Women’s Health Risk Study (CWHRS) was supported by grant #96-IJ-CX-0020 awarded by the National
Institute of Justice, Office of Justice Programs, and U.S. Department of Justice. Points of view in this article do not
necessarily represent the official position or policies of the U.S. Department of Justice.1
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Table 1
Comparisons of Demographic Characteristics Abuse Groups by Strangled verses Not Strangled
Abused Controls Attempted Homicide Completed Homicide
Strangulation No Strangulation Strangulation No Strangulation Strangulation No Strangulation
Mean N Mean N Mean N Mean N Mean N Mean N
(SD) (SD) (SD) (SD) (SD) (SD)
Age 27.07 41 30.40 385 32.06 86 34.21 102 31.82 89 35.28 114
(6.86) (8.66) (8.14) (9.82) (9.24) (14.84)
% N % N % N % N % N % N
Length of Relationship 40 384 87 102 89 116
<= 1 Year 17.5% 30.7% 13.8% 26.5% 14.6% 24.1%
>1 Year 82.5% 69.3% 86.2% 73.5% 85.4% 75.9%
Ethnicity 37 350 83 96 88 107
African American 51.4% 22.0% 67.5% 54.2% 51.1% 43.9%
Euro American 35.1% 53.1% 19.3% 22.9% 22.7% 30.8%
Latino 13.5% 24.9% 13.3% 22.9% 26.1% 25.2%
Education 87 101 87 112
< High School 20% 40 16.2% 383 35.6% 33.7% 43.7% 28.6%
>= High School 80% 83.8% 64.4% 66.3% 56.3% 71.4%
Employment 41 385 85 101 89 115
No 26.8% 24.2% 49.4% 46.5% 32.6% 34.8%
Yes 73.2% 75.8% 50.6% 53.5% 67.4% 65.2%
Relationship Status 41 384 73 90 85 104
Current 70.7% 45.8% 72.6% 73.3% 65.9% 49.0%
Former 29.3% 54.2% 27.4% 26.7% 34.1% 51.0%
Age was significantly different, between those strangled and not strangled for the abused controls only, t(424) = 2.36, p = .02. Length of relationship was significantly different, χ2(1) = 4.61, p=.03,
between those strangled and not strangled for the attempted homicides only.
Ethnicity was significantly different, between those strangled and not strangled for the abused controls, χ2(2) = 15.54, p = .000 Education was significantly different, χ2(1) = 4.90, p = .027, between
those strangled and not strangled for completed homicides only.
Relationship status was significantly different, between those strangled and not strangled for the abused controls, χ2(1) = 9.20, p = .002, and completed femicides, χ2(1) = 5.40, p = .02.
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Table 2
Odds Ratios and 95% Confidence Intervals From Logistic Regression Predicting Abuse Categories
Attempted Homicide Verses Abused ControlCompleted Homicide Verses Abused Control
Age 1.06 1.03–1.09 1.05 1.03–1.07
Length of Relationship (Referent < 1 Year)1.00 0.58–1.73 1.14 0.68–1.93
Ethnicity (Referent Euro-American)
African American 3.35 1.98–5.64 3.08 1.86–5.09
Latino 1.78 0.90–3.52 1.91 1.04–3.48
Education (Referent < High School) 0.45 0.25–0.79 0.41 0.25–0.70
Employment (Referent Unemployed) 0.48 0.29–0.78 0.83 0.51–1.34
Relationship Status (Referent Current) 0.41 0.25–0.66 0.75 0.48–1.17
Strangulation (Referent No Strangulation) 6.70 3.91–11.49 7.48 4.53–12.35
OR = odds ratio; CI = confidence interval.
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Table 3
Odds Ratios and 95% Confidence Intervals from Subgroup Analyses by Race of Logistical Regressions Predicting
Abuse Category
Models Completed Attempted
Sub-Group Analyses by Race OR 95% CI OR 95% CI
African American n=92 n=108
Strangulation 4.65 2.18–9.95 3.72 1.81–7.65
Age 1.04 1.00–1.08 1.04 1.00–1.08
Relationship status (referent broken up) 1.74 0.86–3.49 0.62 0.31–1.26
Employment (referent unemployed) 1.09 0.53–2.24 0.72 0.36–1.43
Education (referent no high school) .26 0.11–0.62 0.34 0.14–0.79
Relationship length (referent < 12 months)1.08 0.48–2.42 1.44 0.65–3.22
White n=53 n=38
Strangulation 13.725.40–34.8414.224.67–43.30
Age 1.06 1.02–1.09 1.1 1.04–1.16
Relationship status 0.40 0.15–1.01 0.16 0.05–0.48
Employment status 0.22 0.08–0.61 0.11 0.04–0.30
Education 0.55 0.17–1.72 0.26 0.08–0.85
Relationship length (referent < 12 months)0.99 0.41–2.41 0.90 0.32–2.60
Latina n=50 n=33
Strangulation (referent no strangulation) 21.165.8–77.8 16.303.7–72.1
Age 1.07 1.01–1.13 1.11 1.03–1.18
Relationship status (referent broken up) 0.18 0.07–.48 0.30 0.11–0.84
Employment (referent unemployed) 1.80 0.62–5.07 0.90 0.31–2.59
Education (referent : no high school) 0.78 0.30–2.04 0.91 0.32–2.61
Relationship length (referent < 12 months)3.73 0.98–14.3 0.54 0.17–1.76
J Emerg Med. Author manuscript; available in PMC 2009 October 1.
... 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). ...
... Furthermore, since NFS commonly co-occurs along with other forms of violence, visible injuries to the body (especially the face and head) may receive medical attention, whereas less visible or delayed symptoms of NFS may go unnoticed [21]. In addition to research showing delayed NFS consequences seen months or years after the incident (for a review see [6]), research has also shown that NFS is a significant risk factor for femicide with previous NFS increasing the risk of femicide by 750% [2]. ...
... 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.
... 3 Medical sequelae of strangulation have been well-documented and range from difficulty speaking and sore throat to laryngeal fracture, pulmonary edema, carotid dissection, stroke, coma, and death. 1,4,5 Moreover, victims of intimate partner violence (IPV) who report a history of nonfatal strangulation have been shown to be at 7.48-fold greater risk of death by homicide than cohort-matched controls, 6 making non-fatal strangulation an important prognostic indicator for recidivism and mortality. ...
... Our sample demonstrates a high prevalence of IPVrelated assaults, which is consistent with prior epidemiologic studies of assailant types in non-fatal strangulation, 6 although surprisingly, acquaintances represented the most frequent assailant type in our sample. Because the perpetrator relationship is self-reported by the victim, more complex interpersonal relationships between victim and perpetrator may have escaped either the coding by the forensic nurse examiner or the categorization scheme that we used to report the perpetrator category. ...
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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.
... Furthermore, female victims of IPH appear to have a more extensive history of IPV compared to male-victim cases [8]. More specific risk factors of IPH include battering, previous strangulation, a perpetrator's recent release from prison, stalking, use of or threats with weapons, serious injury in prior incidents, drug or alcohol use, forced sex of a female partner, threats to kill, and recent estrangement after a history of IPV [36][37][38][39]. A recent meta-analysis comparing non-lethal IPV to IPH went further to quantify the impact of specific forms of violence in elevating risk for lethality. ...
... Violence, coercion, and other abusive behavior may be reactions to perceived threats to this control, such as in suspicion of infidelity or risk of female-initiated separation [50,51]. Identified IPH motives that may be tied to male proprietariness include jealousy, estrangement, perceived relationship infidelity, and control [38,52]. Along this view, a recent meta-analysis of IPH risk factors from 192 studies concluded that perpetrator-related factors include reported sexual jealousy, stalking, previous controlling behaviors, and forced sex; victim-related risk factors include separation from the abuser and if the woman has children from a different relationship [53 •]. ...
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Purpose of Review Intimate partner homicide (IPH), the lethal consequence of intimate partner violence (IPV), continues to account for a significant proportion of homicides worldwide. This review will highlight known risk factors of IPH, the state of risk assessment in healthcare settings, and examples of public policies that have impacted IPH risk. Recent Findings Studies have identified risk factors unique to IPH, which include female and transgender identities, a larger age gap between victim and perpetrator, race and ethnic minority identities, IPV during pregnancy, migration to the USA, socioeconomic instability, and a previous history of IPV. There are a variety of risk assessment tools used in healthcare settings, each developed within specific contexts of providers, participants, and settings. Finally, policies restricting firearm access to previous perpetrators of IPV has been associated with decreased rates in IPH. Summary While there are discrete risk factors and vulnerabilities for IPH, further work is needed to better understand risk within historically marginalized communities. The variation in risk assessment tools suggests that the administrator should select the one that best meets the patient’s specific situation. Finally, the association between firearm control and IPH rates is an encouraging example for future directions of impacting IPH. While there are still challenges to identifying and intervening on IPH, there are promising opportunities to innovate new methods of providing safety and empowerment.
... Ideally, we would control for the effects of partner violence to understand the degree to which strangulation-related AIC vs. abuse more generally contributes to the between-group differences. Unfortunately, strangulation is, by definition, very strongly associated with abuse severity, is considered an extreme form of abuse, and is associated with serious injury and a 7-fold increased risk of lethality [38][39][40] It is reported to be one of the most terrifying experiences of IPV. 41 Also, "choked you" is an item within the abuse severity scale. ...
Objective: The aim of this work was to examine the relationship between strangulation-related alterations in consciousness (AIC) and cognitive and psychological outcomes in women who have experienced intimate partner violence (IPV). Setting: Participants were recruited from a variety of settings, including women's shelters and support programs. Participants: A total of 99 women were enrolled in the study. After applying exclusion criteria for factors that could mask or confound the effects of strangulation, 52 women remained for analyses. Design: Cross-sectional, retrospective. Main measures: We used several cognitive measures to assess learning, long-term and working memory, visuomotor speed, cognitive flexibility, and nonverbal cognitive fluency as well as several psychological measures to assess posttraumatic stress symptomatology, general distress, worry, anhedonic depression, and anxious arousal. We also used the Brain Injury Severity Assessment interview to examine the association between strangulation-related AICs and these measures of cognitive and psychological functioning. Results: Women who had experienced strangulation-related AICs performed more poorly on a test of long-term memory (P < .03) and had higher levels of depression (P < .03) and posttraumatic stress symptomatology (P < .02) than women who had not experienced strangulation-related AIC. When controlling for potential confounding variables, including number of IPV-related traumatic brain injuries, women who had experienced strangulation also performed more poorly on a measure of working memory. Conclusion: This is the first report to assess strangulation in this manner and demonstrate links to cognitive and psychological functioning. These preliminary data contribute to our knowledge of strangulation and its effects on women who have experienced IPV.
... 10,11 Those surviving strangulation by a partner are at a grave risk of future homicide. 12,13 Healthcare clinicians face various challenges in recognizing and assessing NF-IPS, due, in part, to limited literature on characteristics of those presenting for care. Some survivors may be reluctant to disclose strangulation out of fear or shame; some may have difficulty remembering the event secondary to hypoxic insult or other brain injury, psychological trauma, or both; and external injuries may be difficult to visualize or absent. ...
Objective: To describe characteristics of strangulation, and associated medical care, documentation, and injuries of women after nonfatal intimate partner strangulation (NF-IPS) who present for care to a community-based emergency department (ED) with an associated intimate partner violence (IPV) advocacy program between 2008 and 2016. Setting, design, and participants: A retrospective review of 345 female ED patients' medical records who sought care at a community hospital ED following a physical assault including strangulation by an intimate partner was conducted. Demographics, characteristics related to reported signs and symptoms, injuries, and subsequent imaging, diagnoses, and discharge information were abstracted. Results: Commonly reported symptoms were neck pain (67.2%) and headache (45.8%), with fewer patients reporting more severe symptoms such as loss of consciousness (22.6%), dysphagia (25.0%), or dysphonia (26.7%). Rates of patients disclosing strangulation to the entire multidisciplinary team and dedicated neck imaging appeared to improve between 2008 and 2014. Among the 45 patients with noted head and neck findings, 2 patients were found to have an internal carotid artery dissection, 2 patients were found to have strokes, and 1 patient was found to have an intracranial hemorrhage. Conclusions: Survivors of NF-IPS may present to community-based hospitals, and existing imaging guidelines can support clinicians in identifying serious internal injury such as carotid artery dissection and stroke. Further research is needed to better discern symptoms previously attributed to psychological trauma from poststrangulation brain injury. This study contributes to the growing literature on NF-IPS with data specific to community-based ED visits.
... Violent escalatory behavior such as nonfatal strangulation signifies an individual's determination to harm the other person. Glass et al. (2008) found that victims of attempted IPH were 6.7 times more likely to have been strangled by the perpetrator compared to victims of IPV, and victims of completed IPH were 7.48 times more likely to have been previously choked by the perpetrator than victims of IPV. ...
The study aims to expand our understanding of escalation from intimate partner violence to intimate partner homicide (IPH) by exploring the known circumstances leading up to a lethal event. The study draws on qualitative data from law enforcement reports and coroner/medical examiner reports within the National Violent Death Reporting System to identify themes preceding and surrounding IPH incidents. Findings support the utility of risk assessments in identifying escalation while illustrating the complex ways that violence between current or former intimate partners can escalate to lethality, particularly the role of separation and the use of firearms.
Choking/strangulation during sex has become prevalent in the United States. Yet, no qualitative research has addressed men’s choking experiences. Through interviews with 21 young adult men, we examined the language men use to refer to choking, how they first learned about it, their experiences with choking, and consent and safety practices. Men learned about choking during adolescence from pornography, partners, friends, and mainstream media. They engaged in choking to be kinky, adventurous, and to please partners. While many enjoyed or felt neutral about choking, others were reluctant to choke or be choked. Safety and verbal/non-verbal consent practices varied widely.
Objectives To describe the imaging findings of intimate partner violence (IPV)–related injury and to evaluate the role of longitudinal imaging review in detecting IPV.Methods Radiology studies were reviewed in chronological order and IPV-related injuries were recorded among 400 victims of any type of abuse (group 1) and 288 of physical abuse (group 2) from January 2013 to June 2018. The likelihood of IPV was assessed as low/moderate/high based on the review of (1) current and prior anatomically related studies only and (2) longitudinal imaging history consisting of all prior studies. The first radiological study date with moderate/high suspicion was compared to the self-reported date by the victim.ResultsA total of 135 victims (33.8%) in group 1 and 144 victims (50%) in group 2 demonstrated IPV-related injuries. Musculoskeletal injury was most common (58.2% and 44.5% in groups 1 and 2, respectively; most commonly lower/upper extremity fractures), followed by neurologic injury (20.9% and 32.9% in groups 1 and 2, respectively; most commonly facial injury). With longitudinal imaging history, radiologists were able to identify IPV in 31% of group 1 and 46.5% of group 2 patients. Amongst these patients, earlier identification by radiologists was provided compared to the self-reported date in 62.3% of group 1 (median, 64 months) and in 52.6% of group 2 (median, 69.3 months).Conclusions Musculoskeletal and neurological injuries were the most common IPV-related injuries. Knowledge of common injuries and longitudinal imaging history may help IPV identification when victims are not forthcoming.Key Points • Musculoskeletal injuries were the most common type of IPV-related injury, followed by neurological injuries. • With longitudinal imaging history, radiologists were able to better raise the suspicion of IPV compared to the selective review of anatomically related studies only. • With longitudinal imaging history, radiologists were able to identify IPV earlier than the self-reported date by a median of 64 months in any type of abuse, and a median of 69.3 months in physical abuse.
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Determination of risk of intimate partner homicide needs to be based on the underlying theoretical premise of male coercive control of females. Thus, although informed by risk of dangerousness literature, from other fields (such as sexual assault and mentally disordered individuals), this chapter concentrates on the literature specific to domestic homicide and the emerging field of risk assessment specific to domestic violence. The chapter first presents an overview of risk factors associated with intimate partner homicide. The second section reviews the existing instruments that attempt to predict risk of intimate partner homicide and dangerousness with in-depth information on 3 of the instruments with available psychometric data: Spousal Assault Risk Assessment, Danger Assessment, and Kingston Screening Instrument for Domestic Violence. The state of development of these instruments is placed in the context of the state of the science of violence risk assessment with other populations. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
To help a broad array of practitioners identify women at greatest risk, the Chicago Women's Health Risk Study explored factors indicating significant danger of death or life-threatening injury in intimate violence situations. The study compared longitudinal interviews with physically abused women sampled at health centers with similar interviews of people who knew intimate partner homicide victims. The many agencies and individuals who collaborated to accomplish this complex project feel that the collaboration was successful because it evolved, developed a collaborative culture, had permeable role definitions, and agreed on a few central research and practice standards.
As a means of better understanding homicide incidents, methods for identifying, locating, and interviewing confidants of homicide victims are still in their infancy. This article discusses a set of strategies that worked in studies conducted on risk of injury and death in intimate partner relationships in Houston and Chicago and key factors that may affect completion rates of proxy interviews. Primary considerations when using proxy respondent methodology include maximizing the use of public records, hiring and training interviewers for fieldwork skills as well as interview skills, and developing a protocol for interviewer and respondent safety.
The Danger Assessment is a clinical and research instrument that has been designed to help battered women assess their danger of homicide. Completing the Danger Assessment with a nurse is conceptualized as a means of increasing the self-care agency of battered women, according to Orem's nursing conceptual framework. The instrument was used in a study of 79 battered women. Results of this study, which give initial support for the reliability and validity of the Danger Assessment, are reported. The instrument is available from the author on request.
Patients hurt during intimate partner abuse are crime victims who may seek legal relief and protection from one or more court systems. What the health care provider documents or does not document may have tremendous forensic implications; yet, most health care providers have received little formal training in clinical forensics. Being subpoenaed to court as a witness can trigger fear and anxiety. This article reviews the basic principles of clinical forensic documentation, evidence collection and preservation, forensic photography, and accurate wound identification, as well as tips on working with police and on testifying in court. PIP This paper reviews the basic principles of forensic documentation, evidence collection and preservation, forensic photography, and accurate wound identification, as well as tips on working with police and on testifying in court. Intimate partner abuse is a cyclic process that often escalates in frequency and severity over time. It is a major public health crisis that requires numerous identification and intervention strategies to protect the survivors and the children who reside and witness such violence in their homes. Issues of safety for the patient, her children, family and friends, and for health care staff should guide all clinical interventions as battered women patients struggle with the often difficult and dangerous choices involved in breaking free of violent and controlling relationships.
Domestic violence leading to strangulation by an abusive spouse can cause carotid artery dissection. This phenomenon is rare and has been described in only three previous instances. The authors present their management strategies in three additional cases. Three young women aged 24 to 43 years were victims of manual strangulation committed by their spouses 3 months to 1 year before presentation. Two of the patients suffered delayed cerebral infarctions before presentation and angiography demonstrated focal, mirror-image severe residual stenoses in the high-cervical internal carotid artery (ICA), which were characteristic of a healed chronic dissection; there was no evidence of fibromuscular dysplasia. One of these patients underwent unilateral percutaneous angioplasty with stent placement, and the other underwent bilateral percutaneous angioplasty. Both patients have recovered from their strokes and remain clinically stable at 8 and 20 months posttreatment, respectively. The third patient presented with bilateral ischemic frontal watershed infarctions resulting from an occluded left ICA and a severely narrowed right ICA. Given the extent of the established infarctions, this case was managed with a long-term regimen of anticoagulation medications, and the patient remains neurologically impaired. These cases illustrate the susceptibility of the manually compressed ICA to traumatic injury as a result of domestic violence. They identify bilateral symmetrical ICA dissection as a consistent finding and the real danger of delayed stroke as a consequence of strangulation. Endovascular therapy in which percutaneous angioplasty and/or stent placement are used can be useful in treating residual focal stenoses to improve cerebral perfusion and to lower the risk of embolic or ischemic stroke.