A systematic review of the epidemiology of nonfatal strangulation, a human rights and health concern

Partner-Inflicted Brain Injury: Intentional, Concurrent, and Repeated Traumatic and Hypoxic Neurologic Insults

(1) Background: Traumatic brain injury (TBI) is caused from rapid head acceleration/deceleration, focal blows, blasts, penetrating forces, and/or shearing forces, whereas hypoxic-anoxic injury (HAI) is caused through oxygen deprivation events, including strangulation. Most service-seeking domestic violence (DV) survivors have prior mechanistic exposures that can lead to both injuries. At the time of our study, some evidence existed about the exposure to both injuries over the course of a survivor's lifetime from abuse sources, yet little was known about their co-occurrence to the same survivor within the same episode of physical intimate partner violence (IPV). To better understand the lived experience of service-seeking DV survivors and the context in which partner-inflicted brain injury (PIBI) is sustained, we sought to understand intentional brain injury (BI) exposures that may need to be addressed and accommodated in services. Our aims were to 1. characterize the lifetime co-occurrence of strangulation and intentional head trauma exposures from all abuse sources to the same survivor and within select physical episodes of IPV and 2. establish the lifetime prevalence of PIBI. (2) Methods: Survivors seeking DV services in the state of Ohio in the United States of America (U.S.) completed interview-administered surveys in 2019 (n = 47). Community-based participatory action approaches guided all aspects of the study development, implementation, and interpretation. (3) Results: The sample was primarily women. Over 40% reported having Medicaid, the government-provided health insurance for the poor. Half had less than a postsecondary education. Over 80% of participants presented to DV services with both intentional head trauma and strangulation exposures across their lifetime from intimate partners and other abuse sources (i.e., child abuse, family violence, peer violence, sexual assault, etc.), though not always experienced at the same time. Nearly 50% reported an experience of concurrent head trauma and strangulation in either the first or last physical IPV episode. Following a partner's attack, just over 60% reported ever having blacked out or lost consciousness-44% experienced a loss of consciousness (LOC) more than once-indicating a conservative estimate of a probable brain injury by an intimate partner. Over 80% of service-seeking DV survivors reported either a LOC or two or more alterations in consciousness (AICs) following an IPV attack and were classified as ever having a partner-inflicted brain injury. (4) Conclusions: Most service-seeking IPV survivors experience repetitive and concurrent exposures to abusive strangulation and head trauma through the life course and by intimate partners within the same violent event resulting in brain injury. We propose the use of the term partner-inflicted brain injury (PIBI) to describe the physiological disruption of normal brain functions caused by intentional, often concurrent and repeated, traumatic and hypoxic neurologic insults by an intimate partner within the context of ongoing psychological trauma, coercive control, and often past abuse exposures that could also result in chronic brain injury. We discuss CARE (Connect, Acknowledge, Respond, Evaluate), a brain-injury-aware enhancement to service delivery. CARE improved trauma-informed practices at organizations serving DV survivors because staff felt knowledgeable to address and accommodate brain injuries. Survivor behavior was then interpreted by staff as a "can't" not a "won't", and social and functional supports were offered.

The grip of crime: Analyzing strangulation and asphyxiation typologies in homicide cases

Strangulation-related homicides represent a complex and under-researched form of violent crime, characterized by distinct behavioral and situational elements. The aim of the research was to identify perpetrator typologies in strangulation homicides and to analyze their relationships with victim characteristics and crime scene factors. A retrospective analysis of 200 systematically sampled cases from the Radford/Florida Gulf Coast University Serial Killer Database employed Smallest Space Analysis (SSA) to examine 42 behavioral variables. The analysis revealed four primary typologies: Excessive (characterized by severe violence beyond lethality, including mutilation and torture), intended (marked by premeditation and organizational elements), personal (distinguished by intimate engagement and direct manual methods), and sexual (defined by sexual assault and sadistic behaviors). Statistical analysis demonstrated significant correlations between offender-victim relationships, crime scene characteristics, and degrees of violence within each typological category, with 97% of cases fitting distinctly into one category and 3% showing hybrid characteristics. The findings provide empirically based frameworks for forensic profiling and inform specific investigative strategies aligned with each typological pattern. These results equip law enforcement with targeted investigation and risk assessment approaches, potentially leading to more accurate offender identification and prevention efforts. The research advances the understanding of psychological and situational factors in strangulation-related homicides, contributing to both forensic literature and practical applications in criminal investigations.

The Extremely High Risk Category Model for Nonfatal Strangulation

AIMS

This study investigates the risk factors and prevalence of nonfatal strangulation (NFS) within the contexts of intimate partner violence and sexual assault, with a particular focus on the demographic and relational dynamics that influence its occurrence.

DESIGN/METHODS

A comprehensive literature review was undertaken, encompassing both quantitative and qualitative data from existing research on NFS.

RESULTS

The Extremely High Risk Category Conceptual Model for NFS emerged as an innovative, investigator-developed framework that synthesizes the current literature on factors associated with NFS risk.

CONCLUSION

Frameworks that integrate current evidence on NFS risk factors, such as the Extremely High Risk Category model, have the potential to inform the practices of healthcare, social services, and law enforcement professionals. By identifying higher risk individuals, these professionals can implement targeted safety planning and support services. There is an urgent need for focused research and intervention strategies to address the complexities of NFS within intimate partner violence and sexual assault contexts. Expanding research to include diverse populations across genders and ages is crucial for the development of comprehensive prevention and support measures.

Hyoid fracture: consensual sex-play or non-consensual nonfatal strangulation: a case report

Hyoid fractures are uncommon, but when they occur they are commonly the result of strangulation or hanging. Although there is a lack of available quantitative data, there is increasing evidence to suggest that strangulation is a relatively common feature of consensual sex play. This creates difficulty in clinical forensic medicine given the "rough sex" defence has previously been used successfully in cases of fatal intimate partner strangulation. We present a case where consensual and non-consensual strangulation has occurred in a woman who presents with a hyoid fracture. While manual strangulation was thought to be a more likely mechanism than consensual wearing of a sex-collar; ultimately the similar timeframes of the collar-wearing and the non-consensual manual strangulation meant that the accused was not convicted of this particular strangulation offense. This case highlights the importance of further research into consensual strangulation and the incidence of resultant injuries. It also demonstrates the importance of collecting a detailed forensic history and adequately documenting injuries in a contemporaneous matter.

The Characteristics and Circumstances of Fatal Interpersonal Strangulation in Australian Adults

Strangulation involves the application of force to the neck to restrict blood flow or breathing. It is often utilized in both homicides and non-fatal incidences of coercive control, interpersonal altercations, and sexual assaults. The intention of this study was to provide a comprehensive understanding of interpersonal fatal strangulation in Australian adults through the documentation and analysis of characteristics and circumstances involved in these fatalities. Currently, there is limited research within this field in Australia leading to a medico-legal knowledge deficit that needs to be rectified to ensure public health intervention and preventative death policies and initiatives. Researchers conducted a retrospective review of all closed interpersonal strangulation coronial cases within Australia between 2000 and 2021 using the National Coronial Information System online repository. Researchers identified 195 cases to be included in the study. Strangulation currently accounts for 1.1% to 5.8% of all assault fatalities in Australia per year. Most victims of strangulation are women (68.2%), under the age of 45 (52.3%), and Anglo-European (73.3%). Most individuals are killed by someone they know (89.2%), often in the context of intimate partner violence (52.3%). The leading cause of death within the sample is directly related to the strangulation (90.8%), and the leading manner of death is homicide (94.4%). The study is the first of its kind to utilize descriptive forensic epidemiology to explain the circumstances and characteristics of fatal interpersonal strangulation in Australia providing an Australia-specific medico-legal voice to aid in future research, policy development, and criminal prosecution. The findings within this study are foreseen to contribute to improvements in public health policy surrounding fatal and non-fatal strangulation and assist future medico-legal death investigations, and provide LGBTQ+ and Indigenous Australian representation, which has not been considered in previous studies.

Choking/Strangulation During Sex: Understanding and Negotiating "Safety" Among 18-35 Year Old Australians

Despite its potentially fatal consequences, sexual choking/strangulation is an increasingly common sexual practice. Existing research suggests that its growing prevalence is partly a consequence of its popular construction as "risky yet safe." Few studies have directly examined how people frame and engage in choking/strangulation in terms of "safety"-what people think it means for strangulation to be (or not be) "safe" and how people think safety during strangulation can be achieved. Drawing on qualitative text responses from a survey collected in 2023, this paper examined whether and how Australian adults aged between 18-35 perceived choking/strangulation in terms of "safety." We identified and discussed four main themes arising from the data: choking/strangulation during sex can be safe; pressure/intensity is a safety mechanism; consent is a safety mechanism; and trust and communication are necessary. In consideration of these themes, we suggest that many Australian young people are not aware of the risks of choking/strangulation during sex and frequently equate pressure/intensity and consent, within a trusting relationship, with safety. Given the significant risks and harms associated with any sexual choking/strangulation and the resultant difficulty in achieving safe use, we concluded that appropriate education and information should be provided to young people.

The Intersection of Intimate Partner Violence, Strangulation, and Brain Injury Screening: A Pilot Project

BACKGROUND

Survivors of intimate partner violence are at a high risk for having a brain injury because of high rates of strangulation and head and face injuries sustained from physical abuse. In addition to acute physical injuries, survivors experience various health complications.

PROBLEM

Many survivors do not seek medical attention for their injuries, and when they do, their brain injury often goes unrecognized and untreated. Research indicates that screening for brain injury can be an effective intervention to increase the identification of brain injuries and medical referrals for diagnosis and treatment. Unfortunately, brain injury screening is not a standard of care.

METHODS

Shelter-seeking clients were routinely screened for brain injury using a modified HELPS screening tool. A positive screen prompted a medical referral.

INTERVENTION

A modified HELPS screening tool was utilized with permission for the project.

RESULTS

Before implementation, 36 individuals entered shelter, 0 were screened for brain injury, and the medical referral rate was 19.4% ( n = 7). After implementation, 40 clients entered shelter, 36 were screened for brain injury, 77.8% ( n = 28) screened positive, and the medical referral rate was 80.6% ( n = 29).

CONCLUSIONS

Brain injury screening may be an effective evidence-based intervention for shelter-seeking survivors of intimate partner violence to increase medical referrals.

Enhancing foundational validity of forensic findings in nonlethal medico-legal strangulation examinations

BACKGROUND

Nonlethal strangulation occurs when the brain is deprived of oxygen because of external compression leading to the occlusion of the neck's blood vessels and/or airway. The current state of strangulation science confines expert testimony to merely describing injuries attributed to strangulation 'based on the expert's experience and training.' Expert testimony that can quantify the likelihood that observed injuries are attributable to strangulation would strengthen the scientific validity of such testimony.

PURPOSE

This study aims to identify those documented features, or clusters of features, that are associated with cases where strangulation is reported versus cases where strangulation is not reported.

METHODS

This study is a retrospective analysis of medical record data from patients seeking forensic examinations for strangulation and/or sexual assault who presented to the emergency department of an academic medical center from January 2018 to June 2022.

RESULTS

Among the 170 cases, 77 were documented as strangulation-absent and 93 were documented as strangulation-present. A simple classification algorithm was developed to identify these cases where strangulation was present. Prominent features of this algorithm included: presence of petechiae, observed number of injuries around the mouth, face, head and neck, and total number of injuries. This algorithm has a false positive rate of 5 % and a false negative rate of 32 %.

DISCUSSION

To our knowledge, this is the first medico-legal research study to produce an algorithm to assist with classifying cases of strangulation given specific forensic examination characteristics. The study demonstrates the value of data collection in medico-legal research for developing an algorithm that enables forensic examiners to use data-driven methods to verify victims' reports of strangulation.

The Relationship Between Speech and Language Disorders and Violence Against Women: A Scoping Review

Violence against women with disabilities has received more attention in recent years recognizing the intersectionality of experiences of abuse, yet little is known about the less visible forms of disability such as speech and language disorders. This review aimed to identify and synthesize existing literature exploring the relationship between speech and language disorders and victimization, including child sexual abuse (CSA), exposure to domestic violence in childhood, and intimate partner violence (IPV) and sexual assault in adulthood. Five electronic databases were systematically searched using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews guidelines. Studies were included if they were English-language peer-reviewed articles or grey literature publications focusing on domestic violence and/or sexual assault and speech and language disorders. Twenty studies met the inclusion criteria. The findings showed a clear link between childhood exposure to domestic violence and/or CSA and speech and language disorders. Women with speech and language disorders appear to be at heightened risk of IPV and sexual assault relative to the general population. Nonfatal strangulation emerged as a growing area of concern in the literature with acute and chronic symptoms requiring treatment from speech and language therapists. Practice implications include enhanced training at the undergraduate and professional level for therapists to better identify and respond to suspected abuse in their patients. Emergency and specialist support services need protocols and training to better support women with speech and language disorders. Future research should examine the help-seeking behavior of women with speech and language disorders post-victimization and collect longitudinal data to understand the long-term consequences of abuse.

Recognising and responding to non-fatal strangulation in domestic abuse

Victims/survivors (the authors use this term throughout the article but acknowledge that individuals may use various terms to describe their experiences) of non-fatal strangulation associated with domestic abuse are at risk of further serious harm or death, but often do not disclose the assault. In addition, some of the signs and symptoms are not immediately apparent or obvious. Nurses have a professional responsibility to respond to suspicions about and/or disclosure of any type of domestic abuse by initiating safeguarding and protection procedures and must provide effective care. This article discusses non-fatal strangulation in domestic abuse, including the presenting signs and symptoms and barriers to disclosure, and describes the role of the nurse. The authors include a fictional case study to demonstrate the type of situation nurses may experience when they encounter a victim/survivor of non-fatal strangulation.

Factors Associated with Non-Fatal Strangulation Victimization in Intimate Relationships: A Meta-Analysis

Intimate partner violence (IPV) is a public health crisis across the globe, and one particular act of IPV, non-fatal strangulation, warrants serious attention. Non-fatal strangulation is a risk factor for intimate partner homicide (IPH) and can create long-term negative mental and physical health consequences. In this meta-analysis, we sought to examine factors associated with non-fatal strangulation victimization among women to help inform education and assessment efforts. Using database searches and Boolean search terms, a total of 16 studies met the inclusion criteria. A total of 16 factors that were found in at least two unique studies were examined. The strongest associated factors included physical IPV victimization, physical injury, IPH, and sexual IPV victimization. Other significant associated factors included lower education, anxiety symptoms, perceived risk of harm, post-traumatic stress symptoms, depressive symptoms, stalking victimization, and identifying as a Black woman. Experiencing childhood trauma, the length of the relationship, age, substance use, and identifying as Hispanic were not significantly related to strangulation victimization by an intimate partner. Education and assessment implications are discussed.

Assault-related anoxia and neck injuries in US emergency departments

BACKGROUND

Early identification of non-fatal strangulation in the context of intimate partner violence (IPV) is crucial due to its severe physical and psychological consequences for the individual experiencing it. This study investigates the under-reported and underestimated burden of IPV-related non-fatal strangulation by analysing assault-related injuries leading to anoxia and neck injuries.

METHODS

An IRB-exempt, retrospective review of prospectively collected data were performed using the National Electronic Injury Surveillance System All Injury Programme data from 2005 to 2019 for all assaults resulting in anoxia and neck injuries. The type and mechanism of assault injuries resulting in anoxia (excluding drowning, poisoning and aspiration), anatomical location of assault-related neck injuries and neck injury diagnosis by morphology, were analysed using statistical methods accounting for the weighted stratified nature of the data.

RESULTS

Out of a total of 24 493 518 assault-related injuries, 11.6% (N=2 842 862) resulted from IPV (defined as perpetrators being spouses/partners). Among 22 764 cases of assault-related anoxia, IPV accounted for 40.4%. Inhalation and suffocation were the dominant mechanisms (60.8%) of anoxia, with IPV contributing to 41.9% of such cases. Neck injuries represented only 3.0% of all assault-related injuries, with IPV accounting for 21% of all neck injuries and 31.9% of neck contusions.

CONCLUSIONS

The study reveals a significant burden of IPV-related anoxia and neck injuries, highlighting the importance of recognising IPV-related strangulation. Comprehensive screening for IPV should be conducted in patients with unexplained neck injuries, and all IPV patients should be screened for strangulation events.

Traumatic brain injury screening and neuropsychological functioning in women who experience intimate partner violence

Objective: The potential for traumatic brain injury (TBI) to occur as the result of intimate partner violence (IPV) has received increased interest in recent years. This study sought to investigate the possible occurrence of TBI in a group of women who survived IPV and to measure the specific profile of cognitive deficits using standardized neuropsychological measures. Method: A comprehensive questionnaire about abuse history; neuropsychological measures of attention, memory and executive functioning; and measures of depression, anxiety and post-traumatic stress disorder were given to women who were IPV survivors, women who were sexual assault (SA) survivors, and a comparison group of women who did not experience IPV or SA. Results: Overall, rates of potential TBI, as measured by the HELPS brain injury screening tool, were high and consistent with previous studies. Consistent with potential TBI, lower scores were demonstrated on measures of memory and executive functioning compared to survivors of SA or those not exposed to violence. Importantly, significant differences on measures of memory and executive functioning remained, after controlling for measures of emotion. Of note, cognitive changes were highest among women who experienced non-fatal strangulation (NFS) compared to IPV survivors who did not. Conclusions: Rates of TBI may be high in women who survive IPV, especially those who survive strangulation. Better screening measures and appropriate interventions are needed as well as larger studies that look at social factors associated with IPV.

Otolaryngology contribution to the care of patients following non-fatal strangulation in the settings of alleged sexual assault

BACKGROUND

Non-fatal strangulation as a consequence of a sexual assault attack or domestic violence represents serious bodily harm. Otolaryngologists have an important role in documenting physical findings and managing airway symptoms. This study aimed to describe our otolaryngology department's experience managing patients referred from the sexual assault referral centre who suffered non-fatal strangulation.

METHOD

A retrospective analysis of patients suffering non-fatal strangulation referred to the Manchester University Hospitals NHS Foundation Trust Otolaryngology Department from Saint Mary's Sexual Assault Referral Centre in Manchester between 1 January 2017 and 31 December 2019 was carried out.

RESULTS

A total of 86 patients were referred from Saint Mary's Sexual Assault Referral Centre. Of these patients, 56 were given telephone advice and the remaining 30 were seen by the on-call otolaryngology team. In addition, 20 out of 30 (66.6 per cent) patients underwent fibre-optic nasal endoscopy. Common presenting symptoms were neck pain (81.4 per cent), dyspnoea (80.2 per cent) and dizziness (72.1 per cent). Five patients had identifiable laryngeal injury on endoscopy.

CONCLUSION

Meticulous documentation is recommended when managing patients who suffer non-fatal strangulation because medical records may be used as evidence in criminal investigations.

The neuropathology of intimate partner violence

Lifelong brain health consequences of traumatic brain injury (TBI) include the risk of neurodegenerative disease. Up to one-third of women experience intimate partner violence (IPV) in their lifetime, often with TBI, yet remarkably little is known about the range of autopsy neuropathologies encountered in IPV. We report a prospectively accrued case series from a single institution, the New York City Office of Chief Medical Examiner, evaluated in partnership with the Brain Injury Research Center of Mount Sinai, using a multimodal protocol comprising clinical history review, ex vivo imaging in a small subset, and comprehensive neuropathological assessment by established consensus protocols. Fourteen brains were obtained over 2 years from women with documented IPV (aged 3rd-8th decade; median, 4th) and complex histories including prior TBI in 6, nonfatal strangulation in 4, cerebrovascular, neurological, and/or psychiatric conditions in 13, and epilepsy in 7. At autopsy, all had TBI stigmata (old and/or recent). In addition, white matter regions vulnerable to diffuse axonal injury showed perivascular and parenchymal iron deposition and microgliosis in some subjects. Six cases had evidence of cerebrovascular disease (lacunes and/or chronic infarcts). Regarding neurodegenerative disease pathologies, Alzheimer disease neuropathologic change was present in a single case (8th decade), with no chronic traumatic encephalopathy neuropathologic change (CTE-NC) identified in any. Findings from this initial series then prompted similar exploration in an expanded case series of 70 archival IPV cases (aged 2nd-9th decade; median, 4th) accrued from multiple international institutions. In this secondary case series, we again found evidence of vascular and white matter pathologies. However, only limited neurodegenerative proteinopathies were encountered in the oldest subjects, none meeting consensus criteria for CTE-NC. These observations from this descriptive exploratory study reinforce a need to consider broad co-morbid and neuropathological substrates contributing to brain health outcomes in the context of IPV, some of which may be potentially modifiable.

Medical evidence assisting non-fatal strangulation prosecution: a scoping review

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.

The Pursuit of Medical Care for Female Victims of Nonfatal Strangulation at the Time of Police Response

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.

The Domestic Abuse Act 2021 England and Wales: implications for nurses

As the COVID-19 pandemic enveloped the globe there was a parallel increase in the incidence of domestic abuse (DA). This has been ascribed to the restrictions in movement and growing tensions during lockdown periods. The Domestic Abuse Act covering England and Wales was about to be passed prior to the COVID-19 outbreak, but progress halted as attention focused on managing infection control and treatment nationally. The unfolding DA 'shadow pandemic' led to pressure groups lobbying for specific changes to the Act which, in its revised form, became law in April 2021. This article sets out the changes in definition, statutory response and prevention of DA and relates these to nursing practice. Health education and promotion theory is considered and linked to nursing practice with those who are both victims/survivors and perpetrators of DA.

Assessing Polyvictimization in a Family Justice Center: Lessons Learned From a Demonstration Project

There is a growing interest in developing comprehensive assessments that measure intimate partner violence (IPV) alongside other adverse events that correlate with IPV and compound its effects. One promising line of research in this area has focused on the impact of exposure to multiple types of victimization, i.e., polyvictimization. The purpose of this study is to examine the experience of administration of a polyvictimization tool from staff and client perspectives in order to inform future tool developments and assessment procedures. Qualitative interviews and focus groups with clients and staff from a family justice center who had experience with the assessment tool were used to identify strengths and challenges of the assessment too and inform future tool development. Findings demonstrate that an assessment tool provides the space for clients to talk about trauma and facilitate empowerment, while providing the opportunity for psychoeducation and service referrals. Concerns about the assessment tool included adverse reactions without proper framing and language, as well as shifting the emphasis from screening for adversities toward strengths, coping skills, and resilience. Implications for future measurement development and establishing best practices in polyvictimization assessment are discussed, with an emphasis on the benefits of social service agencies utilizing assessment tools.

Death Threats and Attempted Femicide in the Context of Domestic Violence in Portugal

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.

Didn't put a label on it: Examining intimate partner strangulation within a diagnostic framework

AIMS

The aim was to examine and describe women's emergency department visits and care-seeking experiences, including recognition, evaluation and communication of symptoms, injuries and health risks after non-fatal intimate partner strangulation.

DESIGN

Using a diagnostic process framework, this mixed-methods study explores concordance and discordance of interview and medical records data to highlight opportunities for clinical diagnostic improvement.

METHODS

In-depth, semi-structured interviews with women after an emergency department visit for non-fatal intimate partner strangulation, concurrent with medical records reviews, were conducted between March 2018 and January 2019. A constant comparative approach was used to analyse interview and medical record data using an a priori codebook designed based on the National Academies of Science, Engineering and Medicine's conceptual model of the diagnostic process and prior intimate partner violence research.

RESULTS

Interviews reflected participants did not have a sense of long-term health risks from their strangulation beyond addressing emotional trauma. Women noted that forensic and emergency nursing support was treatment in and of itself that allowed them to be heard and validated. Medical record clinical impressions and final diagnoses included domestic violence, domestic abuse or sexual assault, but not specifically strangulation.

CONCLUSION

This study contributes to the growing literature regarding strangulation diagnosis and care. Our findings provide new details of women's emergency department care-seeking experiences which, whilst overall aligned with medical records documentation, were not reflected in final diagnostic impressions nor in patient recollection of long-term health risks.

IMPACT

Nurses are strongly positioned as clinical practice leaders and policy advocates to improve collective responses to this dangerous violence mechanism. Actions such as improving patient education, referral and follow-up options to better communication and address long-term strangulation risk are one example. Further research on non-fatal intimate partner strangulation and care-seeking is warranted to expand this knowledge, particularly in longitudinal cohorts and varied geographical areas.

Nonfatal Strangulation: More Than Meets the Eye

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.

Accounting for Multiple Nonfatal Strangulation in Intimate Partner Violence Risk Assessment

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.

Approach considerations for the management of strangulation in the emergency department

Patients with a history of strangulation present to the emergency department with a variety of different circumstances and injury patterns. We review the terminology, pathophysiology, evaluation, management, and special considerations for strangulation injuries, including an overview of forensic considerations and legal framework for strangulation events.

Nonfatal Strangulation During Domestic Violence Events in New South Wales: Prevalence and Characteristics Using Text Mining Study of Police Narratives

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.

Examining Relationship and Abuse Tactics Associated with Nonfatal Strangulation Experiences Before and After a Protective Order

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.

United States ED Visits by Adult Women for Nonfatal Intimate Partner Strangulation, 2006 to 2014: Prevalence and Associated Characteristics

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.

A Comparison of Intimate Partner Violence Strangulation Between Same-Sex and Different-Sex Couples

Strangulation is a common and dangerous form of intimate partner violence (IPV). Nonfatal strangulation is a risk factor for homicide; can lead to severe, long-term physical and mental health sequelae; and can be an effective strategy of coercion and control. To date, research has not examined strangulation within same-sex couples. The objective of this cross-sectional, observational research is to identify whether and to what extent the detection of strangulation and coercive control differs between same-sex and different-sex couples in police reports of IPV. Data (n = 2,207) were obtained from a single police department in the southwest United States (2011-2013). Bivariate analyses examined differences in victim and offender demographics, victim injury, violence, and coercive controlling behaviors between same-sex (male-male and female-female) and different-sex couples (female victim-male offender). Logistic regression was used to examine associations between strangulation, victim and offender demographics, coercive controlling behaviors, and couple configuration. Strangulation was reported significantly more often in different-sex (9.8%) than in female and male same-sex couple cases (5.2% and 5.3%, respectively; p < .05). Injury, however, was reported more frequently in same-sex than in different-sex couples (p < .05). Couple configuration (p < .05), coercive control (p < .05), and injury (p < .05) significantly predict strangulation. Findings suggest that nonfatal strangulation occurs within at least a minority of same-sex couples; it is possible that underdetection by law enforcement makes it appear less common than it actually is. Regardless of couple configuration, timely identification of strangulation and subsequent referral to medical and social service providers is essential for preventing repeated strangulation, life-threatening injury, and the long-term health effects of strangulation.

'I thought he was going to kill me': Analysis of 204 case files of adults reporting non-fatal strangulation as part of a sexual assault over a 3 year period

BACKGROUND

There is growing awareness internationally around the prevalence and dangerousness of non-fatal strangulation (NFS). The aim of this study was to: (i) identify the prevalence of NFS in patients presenting to the Saint Mary's Sexual Assault Referral Centre (SARC), Manchester, UK for an acute forensic medical examination (FME) after a report of rape or sexual assault, (ii) explore the characteristics of patients reporting NFS compared to those who did not and (iii) explore the prevalence of various symptoms and signs associated with NFS.

METHOD

Data from case files of all patients attending in a three year period, January 1, 2017 to December 31, 2019, were analysed. There was not any age or gender related exclusion criteria. In the NFS cases the Saint Mary's SARC NFS pro-forma used as part of the contemporaneous medical notes was also reviewed.

RESULTS

A total of 2196 adults (≥18 years old) attended Saint Mary's SARC for an acute FME during the three year study period. This comprised 1994 (90.7%) non-NFS cases and 204 (9.28%) NFS cases. The prevalence of NFS was 18.9% where the alleged perpetrator was a partner or ex-partner. For NFS cases, 96.6% (n = 197) of the patients were female and the alleged perpetrator was male in 98% (n = 200) of the NFS cases. 40% of the NFS cases had been strangled in their own homes and in 33% of cases children lived in that home. In 27% (n = 55) of the NFS cases the patient said that the alleged perpetrator had also strangled them on a previous occasion. 46.6% had an injury to the neck or above attributable to the NFS. 15.7% (n = 32) of the NFS cases reported loss of consciousness, 8.8% (n = 18) were incontinent of urine and 2% (n = 4) incontinent of faeces as a result of the NFS. Over a third of the patients (36.6%) thought that they were going to die during the NFS.

CONCLUSION

The study shows that NFS in sexual assault is a gendered crime, with most victims female and most assailants male. NFS is prevalent and this prevalence increases where the alleged perpetrator is a partner or ex-partner. Many are assaulted in their own homes, homes frequently shared with children. Visible NFS injuries are not the norm yet fear of death is not uncommon. Over 1 in 6 (15.7%) reported loss of consciousness suggesting that they were victims of a near lethal assault. That 27% had previously been a victim of NFS by the same alleged perpetrator indicates that there are considerable numbers potentially living in fear and at risk. Awareness of the risk of NFS, and an enhanced response to it, is required by those looking after victims and all those in the criminal justice system.

The neuropsychological outcomes of non-fatal strangulation in domestic and sexual violence: A systematic review

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.

Assault by strangulation: sex differences in patient profile and subsequent readmissions

OBJECTIVES

Assault by strangulation has the potential for severe brain injury or death. The objectives of this study were to describe the profile of individuals who had strangulation-related emergency department (ED) or acute care visits, and to explore 1-year readmission outcomes among survivors.

METHODS

A population-based retrospective cohort study was conducted using health administrative data in Ontario, Canada. Adults aged 15 years and older who were seen in the ED or acute care with assault by strangulation between fiscal years 2002/2003 and 2016/2017 were included in the study. Bivariate analyses were conducted to compare the patient profile and subsequent readmissions within 1 year of discharge, stratified by sex.

RESULTS

A total of 586 patients were included in the study. The majority of these patients were seen in the ED (93%), predominantly female (70%), aged ≤ 39 years (68%), and of lower income quintiles of ≤ 3 (73%). Of the 579 patients who survived the initial admission, 52% had subsequent ED readmission and 21% had acute care readmission within 1 year. In sex-stratified analyses, a higher proportion of females were between 20 to 39 years (58.7% vs. 44.1%, p = 0.001), discharged home (88% vs. 81%, p < 0.001), and had ED readmission within 1 year of discharge (56% vs. 17%, p = 0.002). Males had comparatively higher 1-year acute care readmissions.

CONCLUSION

The study shows high readmissions with sex differences among individuals with an assault by strangulation, suggesting sex-specific approach to health care practices to support the needs of this vulnerable population, thus reducing health system inefficiencies.

The Intersection of Firearms and Intimate Partner Homicide in 15 Nations

Intimate partners commit approximately one in three homicides against women worldwide. Little is known about situational factors that contribute to intimate partner homicides (IPH) and how they may differ across nations. This article provides a cross-national exploration of one situational factor, the use of firearms in the commission of homicides, and considers whether nations have laws designed specifically to keep firearms out of the hands of batterers. We conducted a systematic search of peer-reviewed research and governmental and nongovernmental reports for data on weapon use in IPH. Data were located for 15 nations and subnational areas, which varied from firearms being involved in no IPHs in Fiji to 59% in Antalya, Turkey. Seven nations have legislation that addresses gun ownership as it relates to those who have been charged with, convicted of, or show a propensity toward the commission of intimate partner violence. These laws vary in whether domestic violence is a factor considered in whether to allow firearm ownership or whether it served to disqualify ownership. Due to the small number of nations for which data on weapon use in IPH were located, we did not conduct any hypothesis testing. There is a need for detailed homicide surveillance systems among nations so that researchers can explore the epidemiology of these homicides and ultimately identify opportunities for intervention.

Evaluation of Nonfatal Strangulation in Alert Adults

STUDY OBJECTIVE

There is a paucity of evidence to guide the diagnostic evaluation of emergency department (ED) patients presenting after nonfatal strangulation (manual strangulation or near hanging). We seek to define the rate of serious injuries in alert strangled patients and determine which symptoms and examination findings, if any, predict such injuries.

METHODS

Using prospectively populated databases and electronic medical record review, we performed a retrospective analysis of alert strangled patients treated in the ED of an academic Level I trauma center. Exclusions were Glasgow Coma Scale (GCS) score less than 13, younger than 16 years, and interhospital transfers. Trained researchers used structured forms to abstract demographics, symptoms, examination findings, radiology and operative findings, and final diagnoses. Injuries requiring greater than 24 hours' observation or specific treatment (surgery, procedure, specific medication) were considered clinically important. The electronic medical record was searched for 30 days after presentation to identify missed injuries.

RESULTS

Advanced imaging (computed tomography or magnetic resonance maging) was obtained in 60%. Injuries were identified in 6 patients (1.7%, 95% CI, 0.7% to 3.6%). Two injuries were clinically important (0.6%, 95% CI, 0.1% to 2.0%). Both were cervical artery dissections with no neurologic deficits, treated with aspirin. No additional injuries were identified within 30 days or at next medical contact. Of 343 uninjured patients, 291 (85%) had documented medical follow up confirming the absence of any new diagnosis of injury or stroke. The small number of injuries precluded analyses of associations.

CONCLUSION

Alert, strangled patients had a low rate of injuries. All patients with neck injuries had concerning findings besides neck pain; specifically, GCS score less than 15 or dysphagia. Our findings suggest, but do not prove, that a selective imaging strategy is safe in alert patients after strangulation findings besides neck pain.

Validation and adaptation of the danger assessment-5: A brief intimate partner violence risk assessment

AIMS

The aim of this study was to assess the predictive validity of the DA-5 with the addition of a strangulation item in evaluating the risk of an intimate partner violence (IPV) victim being nearly killed by an intimate partner.

BACKGROUND

The DA-5 was developed as a short form of the Danger Assessment for use in healthcare settings, including emergency and urgent care settings. Analyzing data from a sample of IPV survivors who had called the police for domestic violence, the DA-5 was tested with and without an item on strangulation, a potentially fatal and medically damaging IPV tactic used commonly by dangerous abusers.

DESIGN

Researchers interviewed a heterogeneous sample of 1,081 women recruited by police between 2009-2013 at the scene of a domestic violence call; 619 (57.3%) were contacted and re-interviewed after an average of 7 months.

METHODS

The predictive validity of the DA-5 was assessed for the outcome of severe or near lethal IPV re-assault using sensitivity, specificity and ROC curve analysis techniques.

RESULTS

The original DA-5 was found to be accurate (AUC = .68), equally accurate with the strangulation item from the original DA substituted (AUC = .68) and slightly more accurate (but not a statistically significant difference) if multiple strangulation is assessed.

CONCLUSION

We recommend that the DA-5 with the strangulation item be used for a quick assessment of homicide or near homicide risk among IPV survivors. A protocol for immediate referral and examination for further injury from strangulation should be adopted for IPV survivors at high risk.

Injuries of Women Surviving Intimate Partner Strangulation and Subsequent Emergency Health Care Seeking: An Integrative Evidence Review

INTRODUCTION

Nonfatal strangulation by a current or former intimate partner is a distinct mechanism of violence with the potential for severe injury or death. As nonfatal strangulation has gained recognition for its significant medical and legal implications, there have been multiple calls for nursing and other health care providers to improve practices related to strangulation screening, assessment, and treatment. Given that US estimates suggest higher prevalence of strangulation of women than of men, this integrative evidence review examines existing literature related to women's injuries and their subsequent experiences in seeking health care after surviving intimate partner strangulation.

METHODS

Following PRISMA guidelines, 5 electronic databases were searched, ultimately resulting in 13 articles for inclusion.

RESULTS

Overall, nonfatal intimate partner strangulation was associated with multiple negative physical and psychological outcomes for women, although only 5% to 69% of strangled women sought health care in studies reporting this finding.

DISCUSSION

Nonprobability sampling, participant self-reports, and relatively small sample sizes were frequently encountered limitations across studies. Heterogeneity of women's ages and race/ethnicities also limited comparisons. However, existing research provides a beginning framework to support practice and future inquiry.

Differentiating among Attempted, Completed, and Multiple Nonfatal Strangulation in Women Experiencing Intimate Partner Violence

PURPOSE

Because identification of intimate partner violence (IPV) in health care settings is low and strangulation increases lethality risk among women experiencing IPV, we examined the prevalence and correlates of nonfatal strangulation among 1,008 women survivors of IPV.

METHODS

Trained researchers conducted semistructured interviews with women survivors of IPV referred by police. Multinomial logistic regression examined differential correlates of attempted, completed, and multiple strangulation.

RESULTS

Interviews were conducted with 71.14% of eligible women contacted by researchers. A high proportion (79.66%) of the women interviewed experienced attempted (11.70%), completed (30.16%), or multiple (37.80%) strangulation. Each form of strangulation was independently significantly associated with sexual violence when compared with no strangulation. African American women were at increased risk of attempted (adjusted relative risk ratio [ARR], 2.02; p < .05), completed (ARR, 1.79; p < .05), and multiple strangulation (ARR, 2.62; p < .001). Compared with no strangulation, multiple strangulation was associated with more IPV injury and risk factors for homicide, including loss of consciousness (ARR, 2.95; p < .05) and miscarriage (ARR, 5.08; p < .05). Women who had lost consciousness owing to strangulation were more likely to seek medical care than those who had been strangled but had not lost consciousness (p < .01).

CONCLUSIONS

Strangulation is a prevalent form of IPV that presents significant health risks to women. Women's health practitioners are optimally positioned to identify subtle signs and symptoms of strangulation, help women to understand the delayed sequelae and potential future fatality associated with strangulation, and connect them with appropriate resources to reduce the risk of morbidity and mortality.

Acknowledging the Risk for Traumatic Brain Injury in Women Veterans

Since the Iraq and Afghanistan wars began, an unprecedented number of women have been engaging in combat operations. Likewise, the number of women using Department of Veterans Affairs (VA) services has doubled since 2001. Military service, and deployment to combat in particular, poses certain risks for traumatic brain injury (TBI)-for all service members. However, women may have additional military and nondeployment risk factors such as intimate partner violence (IPV). We briefly review the definition and classification issues related to TBI, as well as common acute and chronic health symptoms after TBI. Specific sex differences in prognosis after TBI, in particular the neurobehavioral symptoms, are also reviewed. We then focus on the emerging literature regarding TBI in women veterans including the etiologies, outcomes, and unique challenges this population faces. The article concludes with suggestions for enhanced screening by VA and non-VA providers alike, as well as directions for future research and clinical inquiry.

Non-fatal strangulation in sexual assault: A study of clinical and assault characteristics highlighting the role of intimate partner violence

OBJECTIVE

To describe the prevalence, risk factors, signs and symptoms of non-fatal strangulation (NFS) in women referred to a Sexual Assault Resource Centre (SARC) following recent sexual assault.

METHODS

A cross-sectional study using data routinely collected at time of forensic examination of women (age ≥ 13 years) referred to the Western Australian SARC between Jan-2009 and Mar-2015 alleging a recent sexual assault. Data on demographics, assault characteristics and forensic findings were available.

RESULTS

A total of 1064 women were included in the study; 79 (7.4%) alleged NFS during the sexual assault. The prevalence of NFS varied significantly by age-group and assailant type. Of women aged 30-39 years 15.1% gave a history of NFS compared to less than 8.2% in all other age groups. Of women assaulted by an intimate partner, 22.5% gave a history of NFS compared to less than 6% of women assaulted by other assailant types. Of all sexual assaults with NFS, intimate partners were the assailant in 58.2% of cases, whereas in sexual assault cases without NFS, intimate partners were the assailant in 15.9% of cases. Odds of NFS were 8.4 times higher in women sexually assaulted by an intimate partner compared to women assaulted by an acquaintance/friend and 4.9 times higher compared to women assaulted by a stranger. When considering both age and assailant type the highest proportion of NFS (33.9%) was in women aged 30-39 years sexually assaulted by an intimate partner. Other factors associated with NFS during sexual assault included deprivation of liberty, verbal threats, being assaulted in the woman's home and use of additional blunt force. External physical signs of NFS were absent in 49.4% of all NFS sexual assault cases.

CONCLUSIONS

This study identifies and quantifies NFS risk factors in female sexual assault and highlights the strong association with intimate partner sexual assault. Greater awareness of NFS in sexual assault should lead to improvement in medical screening, forensic management and safety risk assessment by sexual assault and domestic violence services, emergency departments and police.

Prevalence of strangulation in survivors of sexual assault and domestic violence

OBJECTIVES

Both sexual assault (SA) survivors and domestic violence (DV) survivors are populations at risk of strangulation injury. Our goal was to identify the prevalence of strangulation in patients who are survivors of SA and DV, identify presence of lethality risk factors in intimate partner violence, and assess differences in strangulation between SA and DV populations.

METHODS

We reviewed all patient encounters from our health system's SA/DV forensic nurse examiner program from 2004 to 2008. Medical records were reviewed for documented physical signs of strangulation or documentation of strangulation. Risk factors for lethality included presence of firearm, threats of suicide/homicide by the perpetrator, significant bodily injury, loss of consciousness, loss of bladder or bowel control, voice changes, or difficulty swallowing. Data were analyzed with Pearson χ(2) and 95% confidence intervals (CIs).

RESULTS

A total of 1542 encounters were reviewed. The mean patient age was 30 (range, 13-98) years and 97% were female. Six hundred forty-nine encounters were for DV assaults and 893 were SA. An intimate partner was the assailant 46% of the time; 84% DV vs 16% SA (P<.001). Patients reported strangulation in 23% (351/1542; 95% CI, 21%-25%) of their assaults. The prevalence of strangulation was 38% with DV and 12% with SA (P<.001). Most of the intimate partner encounters with strangulation had significant risk for lethality (97%, 261/269; 95% CI, 94%-99%).

CONCLUSIONS

Patients presenting to our forensic nurse examiner program who were survivors of DV were more likely than SA patients to sustain strangulation. Lethality risk factors were common.