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

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.

A Four-Country Study of Strangulation-Related Alterations in Consciousness in Women Who Have Experienced Intimate Partner Violence: Co-Occurrence with Traumatic Brain Injuries and Measures of Psychological Distress

At least one in three women experience intimate partner violence (IPV) in their lifetime. The most commonly sustained IPV-related brain injuries include strangulation-related alterations in consciousness (S-AICs) and traumatic brain injuries (TBIs). Moreover, survivors of IPV-related S-AICs and/or TBIs often demonstrate psychological distress such as depression, anxiety, and post-traumatic stress. However, the co-occurrence of S-AICs and TBIs, and whether such TBIs may be moderate to severe, has not been systematically examined, and most data have been collected from women in North America. The purpose of this study was to examine the co-occurrence of IPV-related S-AICs and TBIs across a range of geographical locations and to determine the extent to which these S-AICs are related to psychological distress. Women who had experienced physical IPV (n = 213) were included in this secondary analysis of retrospectively collected data across four countries (Canada, the United States, Spain, and Colombia). The Brain Injury Severity Assessment (BISA) was used to assess IPV-related BI across all sites. Because various questionnaires were employed to assess levels of depression, anxiety, and post-traumatic stress disorder at each site, we created a standardized composite score by converting raw scores into Z-scores for analysis. Mann-Whitney U tests and chi-square tests were conducted to examine differences between women with and without experience of S-AICs and to discover if there was a relationship between the occurrence of S-AICs and TBIs. Analysis of variance and analysis of covariance (to control for the potential confounding effects of age, education, and non IPV-related TBI) were used to compare levels of psychological distress in women who had or had not experienced S-AICs. Approximately, 67% of women sustained at least one IPV-related BI (i.e., TBI and/or S-AIC). In a subsample of women who sustained at least one IPV-related BI, approximately 37% sustained both S-AICs and TBIs, 2% sustained only S-AICs (with no TBIs), and 61% sustained TBIs exclusively (with no S-AICs). Furthermore, women who had sustained S-AICs (with or without a TBI) were more likely to have experienced a moderate-to-severe BI than those who had not sustained an S-AIC (BISA severity subscale: U = 3939, p = 0.006). In addition, women who experienced S-AICs (with or without a TBI) reported higher levels of psychological distress compared with women who never experienced S-AICs, irrespective of whether they occurred once or multiple times. These data underscore the importance of assessing for S-AIC in women who have experienced IPV and when present, to also assess for TBIs and the presence of psychological distress. Unfortunately, there were methodological differences across sites precluding cross-site comparisons. Nonetheless, data were collected across four culturally and geographically diverse countries and, therefore, highlight IPV-related BIs as a global issue that needs to be aggressively studied with policies established and then implemented to address findings.

Investigating the Efficacy of a Community Support Network Rehabilitation Intervention for Improving Resiliency, Quality of Life, and Neurocognitive Function in Survivors of Intimate Partner Violence-Caused Brain Injury: Protocol for a Feasibility Study

BACKGROUND

Globally, approximately 1 in 3 women experience intimate partner violence (IPV) in their lifetime. Brain injury (BI) is a common, yet often unrecognized, consequence of IPV. BIs caused by IPV tend to be mild, occur repetitively over the course of months or years, are remote in time, and result in chronic symptoms. Similar to BI from other causes, therapeutic treatment for women with IPV-caused BI (IPV-BI) is crucial to help resolve any physical or cognitive impairments, enhance the quality of life (QoL), and minimize longer-term neurodegeneration.

OBJECTIVE

This study aims to investigate the feasibility and efficacy of a community support network (CSN) rehabilitation intervention regarding its impact on resiliency, QoL, and neurocognitive function.

METHODS

In this pre- and postexperimental design, women (aged 18 to 50 years) who are survivors of IPV and IPV-BI will be recruited from various community organizations serving survivors of IPV. Exclusion criteria will include current pregnancy and any diagnosed neurological disorder known to affect cerebrovascular, neurocognitive, or sensorimotor function. A CSN rehabilitation intervention that includes aerobic exercise, cognitive training, mindfulness meditation, and counseling will be administered. A trauma-informed approach will be integrated into the design and implementation of the program. Furthermore, the program will include a participant navigator who will provide trauma- and violence-informed advocacy and systems navigation support to participants, in addition to facilitating a monthly peer support group. The intervention will be provided for 2.5 hours a day and 2 days a week for 3 months. Participants will complete psychological assessments and provide clinic-demographic information in the first assessment. In the second (before intervention), third (after intervention), and fourth (at follow-up) sessions, they will complete tests of resiliency, QoL, and neurocognition. The estimated sample size is 100. The objective of this study will be accomplished by quantitatively measuring resiliency, QoL, and neurocognition before and immediately after the intervention. A follow-up assessment will occur 3 months after the completion of the intervention to evaluate the maintenance of any improvements in function. One-way ANOVAs will be used to evaluate the intervention outcome across the testing times. Relationships among various variables will be explored using regression analysis.

RESULTS

We anticipate that the CSN rehabilitation intervention will be effective in improving resiliency, QoL, and neurocognitive function in women who have experienced IPV-BI. Furthermore, we anticipate that this intervention will be feasible in terms of study recruitment, adherence, and retention.

CONCLUSIONS

The CSN rehabilitation intervention will have a positive impact on resiliency, QoL, and neurocognitive functions in survivors of IPV-BI. Subsequently, a comparative study will be conducted by recruiting a control group receiving usual care.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/54605.

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.

From intimate partners to serial killers: Nearly 40 years of female homicides in King County, Washington (1978-2016)

An extreme, known potential outcome of intimate partner violence (IPV) is death, with national data revealing females are more likely to be killed by intimate partners than by others. In a novel pairing, the King County Medical Examiner's Office data management system and the Washington State Attorney General's Office's Homicide Information Tracking System were retrospectively analyzed (1978-2016) with information gathered pertaining to female homicide victims. Analyses show that female victims commonly knew their assailant(s) (79.3%) who were overwhelmingly male (92.8%) and commonly intimate partners (31.4%). Disproportionately represented were Black (20.17%) and Native American (4.25%) females; Asian/Pacific Islander (2.5 times that of Whites) and elderly (24%) females among homicide-suicide deaths; and Asian/Pacific Islander and Hispanic females in cases of IPV. "Domestic violence" was the most cited motive (34.3%) and most assaults occurred in a residence (58.73%). Females under 10 years of age were most commonly killed by a parent or caregiver (42.86%), while those over 70 were most likely to be killed by a child (23.08%) or spouse (21.80%). Serial murders, most commonly by the Green River Killer (80%) but including others, accounted for at least 7% of deaths, with victims notably young and commonly sex workers (68%). As compared to males, females were more likely to be killed by multiple modalities, asphyxia, and sharp force, though IPV-related deaths were more likely to be associated with firearms. This study reinforces the vulnerability of females to IPV, sexual assault, and serial murders as well as to caretakers at the extremities of age.

Intimate Partner Violence-Related Brain Injury: Unmasking and Addressing the Gaps

Intimate partner violence (IPV) is a significant, global public health concern. Women, individuals with historically underrepresented identities, and disabilities are at high risk for IPV and tend to experience severe injuries. There has been growing concern about the risk of exposure to IPV-related head trauma, resulting in IPV-related brain injury (IPV-BI), and its health consequences. Past work suggests that a significant proportion of women exposed to IPV experience IPV-BI, likely representing a distinct phenotype compared with BI of other etiologies. An IPV-BI often co-occurs with psychological trauma and mental health complaints, leading to unique issues related to identifying, prognosticating, and managing IPV-BI outcomes. The goal of this review is to identify important gaps in research and clinical practice in IPV-BI and suggest potential solutions to address them. We summarize IPV research in five key priority areas: (1) unique considerations for IPV-BI study design; (2) understanding non-fatal strangulation as a form of BI; (3) identifying objective biomarkers of IPV-BI; (4) consideration of the chronicity, cumulative and late effects of IPV-BI; and (5) BI as a risk factor for IPV engagement. Our review concludes with a call to action to help investigators develop ecologically valid research studies addressing the identified clinical-research knowledge gaps and strategies to improve care in individuals exposed to IPV-BI. By reducing the current gaps and answering these calls to action, we will approach IPV-BI in a trauma-informed manner, ultimately improving outcomes and quality of life for those impacted by IPV-BI.

How Advocates Use CARE to Accommodate the Needs of Domestic Violence Survivors Seeking Services With Brain Injuries and Mental Health Challenges: A Process Evaluation

We evaluated the implementation of Connect, Acknowledge, Respond, and Evaluate (CARE), an organization-level intervention, to accommodate the health needs of survivors, including brain injury. Participants were staff or administrators at agencies serving domestic violence (DV) survivors (n = 57 advocates; n = 5 agencies). Process evaluation focus groups (n = 10 groups) were conducted. Two researchers coded/analyzed focus group transcripts using grounded theory. The use of CARE increased advocate awareness/knowledge of brain injury among survivors leading to improvements to the agencies' provision of structural and functional social support to survivors. CARE is a valuable resource to accommodate survivors, thereby improving staff's perception of their ability to provide trauma-informed service provision for DV survivors.

Association of Frequent Sexual Choking/Strangulation With Neurophysiological Responses: A Pilot Resting-State fMRI Study

Being choked or strangled during partnered sex is an emerging sexual behavior, prevalent among young adult women. The goal of this study was to test whether, and to what extent, frequently being choked or strangled during sex is associated with cortical surface functioning and functional connectivity. This case-control study consisted of two groups (choking vs. choking-naïve). Women who were choked 4 or more times during sex in the past 30 days were enrolled into the choking group, whereas those without were assigned to the choking-naïve group. We collected structural and resting-state functional magnetic resonance imaging (fMRI) data and analyzed the data for amplitude of low-frequency fluctuation (ALFF) and regional homogeneity (ReHo) using cortical surface-based resting-state fMRI analysis, followed by static and dynamic resting-state fMRI connectivity analysis. Forty-one participants (choking n = 20; choking-n-aïve n = 21) contributed to the analysis. An inter-hemispheric imbalance in neuronal activation pattern was observed in the choking group. Specifically, we observed significantly lower ALFF and ReHo in the left cortical regions (e.g., angular gyrus, orbitofrontal gyrus) and higher ALFF and ReHo in the right cortical regions (e.g., pre-central/post-central gyri) in the choking group compared with the choking-naïve group. A significant group difference was found in static functional connectivity between the bilateral angular gyrus and the whole brain, in which the choking group's angular gyrus showed hyperconnectivity with, for example, the post-central gyrus, pre-central gyrus, and Rolandic operculum, relative to the choking-naïve group. The dynamic analysis revealed hyperconnectivity between the left angular gyrus and the bilateral postcentral gyrus in the choking group compared with the choking-naïve group. Taken together, our data show that multiple experiences of sexual choking/strangulation are associated with an inter-hemispheric imbalance in neural activation pattern and hyperconnectivity between the angular gyrus and brain regions related to motor control, consciousness, and emotion. A longitudinal study using multi-modal neurological assessments is needed to clarify the acute and chronic consequences of sexual choking/strangulation.

The Darker the Skin, the Greater the Disparity? Why a Reliance on Visible Injuries Fosters Health, Legal, and Racial Disparities in Domestic Violence Complaints Involving Strangulation

The reliance on external injuries for justice is misguided given that assault injuries may be less visible among victims of color due to increased melanin in the skin. To date, however, less is known whether racial/ethnic disparities extend to officers' identification of signs of nonfatal strangulation (NFS). The current study estimates the extent of NFS indicators identified by officers who completed a standardized strangulation assessment in 133 family violence complaints. Breathing difficulties were the most common symptoms identified by officers (98%), followed by external signs (89%), and symptoms of impeded blood circulation (87%). Compared to cases involving White/Asian survivors, officers were less likely to identify external injuries on Black survivors' neck, chin, and chest/shoulders. While racial/ethnic differences did not emerge for symptoms of disrupted airflow, Hispanic survivors were twice as likely to report losing control of bodily functions. Implications for policy and practice are discussed.

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.

Impact of the Domestic Violence Housing First Model on Survivors' Safety and Housing Stability: 12-Month Findings

Intimate partner violence (IPV) is a widespread and devastating phenomenon resulting in a myriad of long-term consequences for survivors and their children. IPV victimization not only has negative health and economic consequences, it has also been linked to homelessness and housing instability. In response, the Domestic Violence Housing First (DVHF) model is being used in some domestic violence (DV) agencies to help survivors attain safe and stable housing. The model includes using individualized advocacy and/or flexible funding to help survivors meet these goals. Using a longitudinal, quasi-experimental design, the current study involved conducting interviews with survivors and examining agency records to investigate the effectiveness of this model. We hypothesized that survivors who received DVHF would experience less re-abuse and greater housing stability over 12 months compared to those who received services as usual (SAU). The sample included 345 IPV survivors who had been homeless or unstably housed when they approached one of five DV programs for help. Interviews were spaced 6 months apart (when survivors first sought services as well as 6 months and 12 months later). Longitudinal analyses showed that survivors who received the DVHF model reported greater improvements in housing stability at both the 6-month and 12-month time points compared to those receiving SAU. At the 12-month time point, survivors who had received DVHF reported decreased physical, psychological, and economic abuse, as well as the use of their children against them as a form of abuse. This study adds to a growing body of evidence supporting this model's effectiveness and adds to our understanding of factors impacting the long-term housing stability and safety for IPV survivors.

Front-line health professionals' recognition and responses to nonfatal strangulation events: An integrative review

AIM

The aim of this study was to determine how front-line health professionals identify and manage nonfatal strangulation events.

DESIGN

Integrative review with narrative synthesis was conducted.

DATA SOURCES

A comprehensive database search was conducted in six electronic databases (CINAHL, Wed of Science, DISCOVER, SCOPUS, PubMed and Scholar) resulting in 49 potentially eligible full texts, reduced to 10 articles for inclusion after exclusion criteria were applied.

REVIEW METHODS

An integrative review was undertaken in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement guidelines. Data were extracted, and a narrative synthesis using Whittemore and Knafl (2005) framework was undertaken to determine how front-line health professionals identify and manage nonfatal strangulation events.

RESULTS

The findings identified three main themes: an overall failure by health professionals to recognize nonfatal strangulation, a failure to report the event and a failure to follow up on victims after the event. Stigma and predetermined beliefs around nonfatal strangulation, along with a lack of knowledge about signs and symptoms, were the salient features in the literature.

CONCLUSION

Lack of training and fear of not knowing what to do next are barriers to providing care to victims of strangulation. Failure to detect, manage and support victims will continue the cycle of harm through the long-term health effects of strangulation. Early detection and management of strangulation are essential to prevent health complications, particularly when the victims are exposed to such behaviours repeatedly.

IMPACT

This review appears to be the first to explore how health professionals identify and manage nonfatal strangulation. It identified the significant need for education and robust and consistent screening and discharge policies to assist health providers of services where victims of nonfatal strangulation attend.

NO PATIENT OR PUBLIC CONTRIBUTION

This review contains no patient or public contribution since it was examining health professionals' knowledge of identifying nonfatal strangulation and the screening and assessment tools used in clinical practice.

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.

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.

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.

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.

Frequent and Recent Non-fatal Strangulation/Choking During Sex and Its Association With fMRI Activation During Working Memory Tasks

Being strangled, or “choked,” by a sexual partner has emerged as a prevalent, often wanted and consensual sexual behavior among adolescent and young adult women, yet the neurological consequences of repeated exposure to this behavior are unknown. The objective of the study was to examine the association between a history of repeated, recent choking/strangling episodes during sex and fMRI activation during working memory tasks in young adult women. This case-control study involved young adult women (18–30 years old) at a large, public university, and consisted of two study groups: a choking group consisting of participants who were recently and frequently choked/strangled during sex by a partner (≥4 times in the past 30 days) and a choking-naïve (control) group who had never been choked/strangled during sex. Participants completed two variations of the N-back (0-back, 1-back, and 2-back) working memory task during functional magnetic resonance imaging (fMRI): verbal and visual N-back tasks. Data from 20 participants per group were available for analysis. Between-group differences for accuracy and reaction time were not significant for either variation of the N-back task. Significant differences in fMRI activation patterns were detected between the choking and the choking-naïve groups for the three contrasts of interest (1-back > 0-back, 2-back > 0-back, and 2-back > 1-back). The choking group exhibited increased activation in multiple clusters relative to the choking-naïve group for the contrasts between the 1-back and 2-back conditions compared to the 0-back conditions (e.g., superior frontal gyrus, corpus callosum). However, the choking-naïve group exhibited increased activation relative to the choking group in several clusters for the 2-back > 1 back contrast (e.g., splenium, middle frontal gyrus). These data indicate that recent, frequent exposure to partnered sexual strangulation is associated with different neural activation patterns during verbal and visual working memory tasks compared to controls, suggesting that being choked/strangled during sex may modify the allocation of neural resources at increasing levels of cognitive load. Further investigation into the neurologic effects of this sexual behavior is warranted, given the prevalence of sexual choking among adolescent and young adult women.

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.

Non-fatal strangulation and COVID-19 common symptoms and signs: considerations for medical and forensic assessment

Emerging evidence suggests that an onset or escalation of interpersonal violence has been occurring during the COVID-19 pandemic, particularly among persons in intimate or familial relationships. Strangulation (or neck compression) is a common form of interpersonal violence and can result in serious adverse health outcomes, including death. The identification and attribution of injuries from non-fatal strangulation are complex, as there may be an absence of external signs of injury and their appearance may be delayed by many days. There is a heavy reliance on clinician identification of ‘red flag’ symptoms and signs, the presence of which necessitates urgent further assessment. Additional challenges arise when acute non-fatal strangulation symptoms and signs are shared with other clinical conditions. In such cases, differentiating between the conditions based on the symptoms and signs alone is problematic. We present the diagnostic challenges faced when conducting forensic assessments of COVID-19-positive and suspected COVID-19 (S/COVID) patients following allegations of non-fatal strangulation in the setting of physical and sexual assaults. The implications of shared symptoms and signs, for forensic clinicians, primary healthcare, and emergency practitioners, as well as other frontline service providers, are discussed.

How CARE Tools Are Being Used to Address Brain Injury and Mental Health Struggles With Survivors of Domestic Violence

INTRODUCTION

CARE (Connect, Acknowledge, Respond, and Evaluate) is an advocacy framework developed for domestic violence service organization (DVSO) providers to address and accommodate domestic violence (DV) survivors with brain injury and mental health struggles. The CARE tools were designed for use by advocates and include the Just Breathe booklet, the Head Injury education card, and the Invisible Injuries booklet.

OBJECTIVE

The purpose of this study was to report findings on how CARE tools are being used by DVSO providers as well as their impact on DVSO advocacy practice.

METHODS

Post-CARE retrospective process evaluation online surveys (n = 60) and focus groups (n = 10 groups; 57 advocates) were conducted with consenting staff at 5 DVSOs in Ohio who partnered with the state coalition to develop and evaluate CARE, overseen by a university research partner. Rigorous, iterative coding qualitative analysis methods, endorsed by the Centers for Disease Control and Prevention, were used (Cohen's κ = 0.903 [stage 1] and 0.810 [stage 2]).

RESULTS

The use of CARE tools has been integral to DVSO providers' implementation of the CARE advocacy framework. DVSO advocates are using CARE tools to Connect with self, survivors, and other systems; to Acknowledge that head trauma and mental health struggles are common among survivors and that ongoing education and self-care are necessary for advocates. Advocates have been able to provide a more holistic Response through accommodation within DVSOs and referral to other providers, often by using the CARE tools, including the Head Injury education card.

CONCLUSION

CARE tools were designed for lay use to address head trauma, strangulation, and mental health struggles with DV survivors and are free for download at the Center on Partner Inflicted Brain Injury website: https://www.odvn.org/brain-injury. More widespread use of these tools by advocates has the potential to improve services for DV survivors and address what have historically been invisible injuries and mental health struggles in the population.

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.

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.

How Victims of Strangulation Survived: Enhancing the Admissibility of Victim Statements to the Police When Survivors are Reluctant to Cooperate

Holding perpetrators accountable for family violence is challenged when survivors are reluctant to testify. In light of recent Supreme Court precedents limiting the admissibility of statements to law enforcement in victimless prosecutions, the current study examined 130 cases of nonfatal strangulation (NFS) to determine whether case characteristics and themes across survivors' on-scene statements can help prosecutors combat common legal defenses raised when victims are unavailable for trial. The history of prior violence and how only 6% of perpetrators stopped strangling victims on their own suggests that NFS complaints should be investigated as an attempted homicide until evidence suggests otherwise.

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.

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.

A Case of Nonfatal Strangulation Associated With Intimate Partner Violence

Intimate partner violence (IPV) is a significant public health problem that has profound effects on the physical and psychological well-being of millions of Americans. It is known that strangulation is one of the most lethal forms of IPV. Frequently, a lack of visible external trauma is present, and attempted strangulation may be accompanied by other more severe injuries to the head and face; thus, the signs and symptoms of nonfatal strangulation may be overlooked. Because the emergency department (ED) is frequently the first point of contact for an individual who has experienced any type of IPV, it is imperative that providers have the knowledge and skill set for the identification and management of this patient population. The purpose of this article is to present a discussion of the challenges faced by ED providers in the clinical decision-making process when caring for a patient who has experienced nonfatal strangulation.

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.

Persistence and Potential Lethality in Intimate Partner Violence: Evaluating the Concurrent and Predictive Validity of a Dual Risk Assessment Protocol

This study seeks to determine the concurrent and predictive validity of a dual risk assessment protocol. It combines the risk of persistence in intimate partner violence (IPV) measured via the Domestic Violence Screening Instrument-Revised (DVSI-R) with supplemental items from the Danger Risk Assessment (DRA) bearing on the risk of potential lethality. We further test whether this assessment protocol reproduces disparities by race and ethnicity found in the larger population. Using a sample of 4,665 IPV male defendants with a female victim, analyses support both types of criterion validity. The DRA risk score is associated with felony charges, incarceration at the initial arrest, and the frequency of subsequent dangerous behavior. Results also suggest minimal predictive bias or disparate impact by race and ethnicity. Incorporating supplemental items bearing on potential lethality risk adds important information concerning the risk management strategies of those involved in IPV.

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.

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.

Examining Associations Between Strangulation and Depressive Symptoms in Women With Intimate Partner Violence Histories

Intimate partner violence (IPV) is associated with poor mental health outcomes among women. Studies on IPV and mental health show that experiencing more than one type of IPV often enhances women's depression or depressive symptoms. However, most of these studies conceptualize IPV as physical, psychological, or sexual violence. Little is known about specific experiences of severe IPV, such as strangulation, that put victims at greater risk of lethality and serious injury and their association with women's depression. This study examined associations between IPV, strangulation, and depression among women using secondary data collected for a randomized clinical trial testing an integrated HIV-IPV prevention intervention for abused women. Women were recruited from healthcare service delivery organizations, Department of Health and Human Services, and family court. Women (n = 175) completed assessments on IPV, strangulation, mental health, social support, and self-esteem. The majority reported strangulation (n = 103) and depressive symptoms (n = 101). Women who experienced strangulation also reported more severe physical (p < .001), sexual (p < .001), and psychological (p < .001) abuse. However, in multivariate logistic regression with sociodemographics, violence variables, and strangulation, none of these variables were associated with a higher risk for depressive symptoms. Social support had a protective effect on depressive symptoms. Findings suggest strangulation is prevalent among abused women seeking services, warranting screening, assessment, and referral in these settings.

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.

The Effects of Intimate Partner Violence and Probable Traumatic Brain Injury on Central Nervous System Symptoms

INTRODUCTION

Abused women often report a wide range of physical and psychological symptoms that present challenges to providers. Specifically, injuries to the head or strangulation, may initiate neurological changes that contribute to central nervous system (CNS) symptoms. These symptoms are often attributed to mental health diagnoses in this population. The purpose of this analysis is to examine the prevalence of and associations between reported probable traumatic brain injury (TBI) and CNS symptoms in a sample of women of African descent.

METHODS

A convenience sample of 901 women of African descent from Baltimore, MD and the US Virgin Islands, aged 18-55, was used to examine relationships among self-reported intimate partner violence (IPV), TBI, and CNS symptoms. Data were collected via Audio Computer-Assisted Self-Interview.

RESULTS

Abused women who experienced a probable TBI were more likely to report CNS symptoms than those who did not. When controlling for demographics, IPV, and mental health symptoms, probable TBI was associated with a two point increase in CNS symptom frequency score (95% confidence interval: 1.55-2.93, p < 0.001).

CONCLUSIONS

Women who reported both probable TBI and IPV were more likely than their abused counterparts who reported no TBI to report CNS symptoms. This relationship held true even when controlling for symptoms of depression and post-traumatic stress disorder (PTSD). Clinicians working with women should be aware of TBI as a possible etiology for symptoms in abused women. Appropriate screening and treatment protocols should be designed and implemented across medical settings to improve outcomes for women who have experienced IPV and TBI.