Physical Injury From Intimate Partner Violence: Measurement Strategies and Challenges

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.

Dissemination Strategies of a Nonfatal Strangulation Program: Success of an Interagency Initiative

BACKGROUND

Nonfatal strangulation has been identified as a common occurrence in intimate partner violence and can be associated with significant injuries and, at times, increased mortality.

OBJECTIVE

This article describes a county interagency nonfatal strangulation initiative that efficiently disseminated an educational program for police, emergency medical services, emergency department staff, forensic nursing teams, and prosecuting attorneys, along with a forensic nurse response program. Prior to initiation of this program, no educational programs existed and no forensic examinations were being offered to victims of nonfatal strangulation.

METHODS

Early cooperation between agencies was crucial, particularly between the two major health care systems in the county. A standardized forensic evaluation tool was developed, along with nonfatal strangulation courses. Education of forensic nurses together with prosecutors was unique and training of police, emergency medical services, and emergency department staff was coordinated. Forensic nurses traveled to meet victims for standardized examinations at 11 emergency departments. Creation of a secure Research Electronic Data Capture database captured forensic examination information and a strangulation task force provided means to assess the goals.

RESULTS

This initiative educated > 80% of the county's first responders and 79% of emergency department staff within 3 months. During the first year of the program, 259 forensic nurse examinations for nonfatal strangulation were recorded. Police reported a total of 367 arrests for felony assault by strangulation.

CONCLUSIONS

Professionals providing legal and medical care to victims of nonfatal strangulation can be educated and forensic nurse examinations can be implemented successfully in an expeditious period of time with a county collaborative program approach.

Strangulation as an Acquired Brain Injury in Intimate-Partner Violence and Its Relationship to Cognitive and Psychological Functioning: A Preliminary Study

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.

Forensic documentation of non-fatal strangulation

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.

Coercive Control Between Intimate Partners: An Application to Nonfatal Strangulation

Nonfatal strangulation between intimate partners represents an extreme controlling form of violent behavior, increasing the risk that intimate partner violence (IPV) becomes lethal. Guided by Dutton and Goodman's conceptualization of coercive control, the present research explored the relation between death threats and subsequent nonfatal strangulation to amplify the credibility of those threats, using a large sample of IPV perpetrators (n = 6,488). Logistic regression analyses determined the relation between overt threats to a partner's life during an initial incident arrest and subsequent nonfatal strangulation postincident arrest, accounting for perpetrator characteristics and assessed risk. Results showed the highly gendered nature of this violent behavior, noting that men were significantly more likely than women to persist in nonfatal strangulation. Given the potential lethality of this violent behavior, the analysis also explored whether treatment service recommendations (family violence education, counseling, and mental health evaluation) mitigate these patterns. These preliminary findings support the further exploration of treatment and intervention efforts for reducing nonfatal strangulation.

Prosecutorial Response to Nonfatal Strangulation in Domestic Violence Cases

Recent research has pointed to the need for systematic law enforcement training on domestic violence when nonfatal strangulation is involved to improve evidence-based prosecution of these potentially deadly assaults; however, virtually no research has examined the legal response to nonfatal strangulation since many states have made it a separate criminal felony. The current exploratory study examines filing, charging, and adjudication decisions of nonfatal strangulation cases over a 3-year period based on evidence documentation in law enforcement reports to explore how these cases are handled by the criminal justice system in Brevard County, Florida. Results support previous research showing the importance of training police officers and other personnel as insufficient evidence may be one possible factor limiting the prosecutors' ability to successfully prosecute domestic violence strangulation offenders to the highest extent available under the law. Implications spread across multiple disciplines.

Nonfatal Strangulation as Part of Domestic Violence: A Review of Research

This article reviews recent scholarship around the issue of nonfatal strangulation in cases of domestic violence. In the mid-1990s, the San Diego City Attorney's Office began a systematic study of attempted strangulation among 300 domestic violence cases, becoming one of the first systematic research studies to specifically examine the prevalence of attempted strangulation as a form of injury associated with ongoing domestic violence. Prior to this time, most of the research into strangulation was conducted postmortem, and little was known about the injuries and signs of attempted strangulation among surviving victims. This article reviews the research that has since been conducted around strangulation in domestic violence cases, highlighting topics that are more or less developed in the areas of criminology, forensic science, law, and medicine, and makes recommendations for future research and practice.

Identification of Nonfatal Strangulation by 911 Dispatchers: Suggestions for Advances Toward Evidence-Based Prosecution

Research highlights the need for systematic law enforcement training on nonfatal strangulation in domestic violence situations to improve evidence-based prosecution of these violent felonies. However, most of this research focuses on the role of police officers in the safety response. Although often overlooked, this research examines the role of 911 dispatchers, who are many times the first person the victim calls for assistance. This study examines official domestic violence records, gathered through a partnership with a County Sheriff's agency, to determine whether domestic violence strangulation is being adequately identified and documented by first responders. This research highlights the need for considering 911 dispatchers as having a potentially critical role in a comprehensive response to domestic violence strangulation from initial screening to eventual prosecution.

Exploring Genitoanal Injury and HIV Risk Among Women: Menstrual Phase, Hormonal Birth Control, and Injury Frequency and Prevalence

BACKGROUND

Genital, anal, and oral injuries sustained from sexual intercourse may explain HIV transmission among women. We determined the variability in genitoanal injury frequency and prevalence in women after consensual sexual intercourse, exploring the role of menstrual phase and hormonal birth control.

METHODS

We used a longitudinal observational design with a convenience sample of 393 women aged 21 years and older. Participants had a baseline interview with gynecological examination, followed by consensual sexual intercourse with a male partner and a second gynecological examination. We analyzed injury prevalence with logistic regression and injury frequency with negative binomial regression among women who were (1) menstrual, not using hormonal birth control, (2) menstrual, using hormonal birth control, or (3) menopausal. We also compared injury among menstrual women in the follicular, ovulatory, and luteal phases.

FINDINGS

Women using hormonal birth control had 38% more external genitalia injuries [adjusted rate ratio (ARR) = 1.38, P = 0.030] and more than twice the anal injuries (ARR = 2.67, P = 0.005) as the nonhormonal birth control menstruating group. Menopausal women had more than 3 times the anal injuries (ARR = 3.36, P = 0.020) than those in the nonhormonal menstrual group. Among menstrual women, those in the follicular phase had a greater prevalence and frequency of external genitalia injuries than those in other phases.

INTERPRETATION

Increased rates of postcoital genitoanal injuries are noted among women using hormonal birth control and/or in the follicular phase of menstruation. Biological factors that influence women's risk for HIV warrant further investigation.

“Do You Know What It Feels Like to Drown?”

Strangulation is a unique and particularly gendered form of nonfatal intimate partner violence, affecting 10 times as many women as men. Medical research documents multiple negative health outcomes of such victimization, and in the past decade nearly 30 U.S. states have enacted laws making nonfatal strangulation a felony. We extended prior work by using grounded theory in a qualitative study to explore women’s experiences of, thoughts about, and reactions to being strangled. Each of the 17 mostly well-educated and African American domestic violence shelter residents had been strangled at least once by an intimate partner; most had survived multiple strangulations. Despite other severe abuse and a high level of fear, all were shocked that their partner strangled them. Participants reported an intense sense of vulnerability when they recognized during the assault how easily they could be killed by their partner. Nonetheless, they seemed to think of strangulation, not as a failed murder attempt, but as a way to exert power. Efforts to extricate themselves from a “choking” largely failed and resistance resulted in an escalation of the violence. Moreover, strangulation is difficult to detect which, as participants observed, makes it especially useful to the abuser. The aftereffects permeated the relationship such that strangulation need not be repeated in order for her to be compliant and submissive, thus creating a context of coercive control.

"I didn't know I could turn colors": Health problems and health care experiences of women strangled by an intimate partner

Strangulation is a unique and particularly pernicious form of intimate partner violence. To increase the relatively little that is known about strangulation survivors, focus groups and interviews were conducted as part of a practice-research engagement with a domestic violence shelter. All of the participants had been strangled and, among them, almost all were strangled multiple times. The loss of consciousness was common. Participants associated "choking" with use of body parts and "strangling" with use of objects. Although some minimized the assault, most considered strangulation to be serious and reported a variety of medical conditions following the assault. Few sought medical care. Of those who did, few disclosed the assault, or were asked about strangulation, which commonly resulted in misdirected treatment. Implications for improving detection and treatment are discussed.