answers. The San Diego City Attorney’s Office immediately launched one of the first and largest studies of nonfatal strangulation cases by conducting a careful analysis of 300 cases submitted for prosecution by the San Diego Police Department. The results of that study proved that most victims of strangulation did not present with visible injuries; however, there were subtle, identifiable signs and symptoms that could be documented by well-trained professionals. With the support of adequate laws, protocols, and leadership, the cases could be handled much more effectively.
Today, it is understood unequivocally that strangulation is one of the most lethal forms of domestic violence. Victims may have no visible injuries, but because of underlying brain damage or other internal injuries caused by the lack of oxygen during the strangulation assault, they may sustain serious internal injuries. They may die days or weeks after the attack because of a stroke, suffer a traumatic brain injury, or experience other long-term physical and mental health consequences. Nonfatal strangulation and suffocation assaults are also more prevalent than we realized years ago, with prevalence rates between 68% to 80% for high-risk domestic violence victims.
When a victim is strangled, she is at the edge of a homicide. Strangulation is one of the most accurate predictors for the subsequent homicide of victims of domestic violence. One study showed that the odds of becoming an attempted homicide victim increased by about seven fold for women who had been strangled by their partner. Women who are strangled multiple times are at even higher risk.
Strangulation has also been linked to officer-involved critical incidents, officers killed in the line of duty in intentional homicides, and mass murders. The research clearly shows the need for all professionals to improve their screening and documentation of strangulation cases. When working with a strangled victim, advocates, detectives, nurses, and prosecutors must all make good use of risk assessment tools, encourage medical treatment, create personalized safety plans, and offer long-term follow-up. Today, we know far more about strangulation than we knew in 1995.
It is now our responsibility to do something about it. We cannot continue to hear the words “He choked me,” and treat this assault like we would a slap or a punch. The difference between life and death in most strangulation assaults is only a matter of seconds. We have an opportunity to stop stranglers before they kill, but we must seize that opportunity.
We must learn to more effectively investigate and prosecute near-fatal and nonfatal strangulation assaults as felony offenses even with little or no external visible injury. We must pursue these complicated cases even without victim participation or testimony whenever possible. We must work in Family Justice Centers and multidisciplinary teams to effectively hold offenders accountable and provide the victim the medical advocacy and support survivors need. Every time we hold a strangler accountable, we reduce the likelihood of a homicide, and we send a message to men who strangle and suffocate women: We see you, and we will not let you commit life-threatening and often brain-damaging assaults with impunity.
Thankfully, 25 years later, San Diego has figured it out and is leading the way in felony strangulation prosecutions with a 96% conviction rate thanks to a county-wide protocol that includes strong on-scene and follow-up investigation; domestic violence and strangulation medical assessments by forensic nurses; expert testimony; and specially trained dispatchers, paramedics, prosecutors, and probation officers.
The authors of the Domestic Violence and Nonfatal Strangulation Assessment, Diana Faugno, Valerie Sievers, Michelle Shores, Patricia Speck, and William Smock, are some of the leading experts in the field of nonfatal strangulation. They all serve as advisors, mentors, faculty, and friends of our internationally recognized Training Institute on Strangulation Prevention, which we officially launched in 2011.
There is a growing body of peer-reviewed articles published in medical, social science, and legal journals about all aspects of nonfatal strangulation cases, including signs and symptoms, internal injuries, and delayed or long-term consequences. Education and training for professionals who deal with strangulation patients has dramatically improved. Advancements in the field now allow for more accurate evaluations of findings, or lack of findings, in strangulation patients.
Domestic Violence and Nonfatal Strangulation Assessment for Health Care Providers and First Responders is one of those valuable tools available to all disciplines. This workbook will allow both new and experienced practitioners the opportunity to build skills in identification, documentation, assessment, and treatment of strangulation assaults. We strongly recommend this material as a valuable addition to every basic training curriculum and to every professional handling nonfatal strangulation cases, but especially to medical and emergency medical services professionals. Had this workbook been available back in 1995, we are confident both Casondra and Tamara would be alive today because police officers and prosecutors would have known how to investigate and prosecute these cases, victims would have been adequately assessed and treated by medical professionals, and offenders would have been held accountable for their crimes.
Thank you, Diana, Valerie, Michelle, Patricia, and Bill for creating this powerful, effective tool for the field. It will be a lifesaver and a hope-giver.
Gael Strack, Esq.
CEO & Co-Founder
Training Institute on Strangulation Prevention
A Project of Alliance for HOPE International
Casey Gwinn, Esq.
President & Co-Founder
Training Institute on Strangulation Prevention
A Project of Alliance for HOPE International
PREFACE
In the last 35 years, the published literature has evolved to address violence against women with a variety of titles and terms including: battered wives, battered women syndrome, domestic violence, and perhaps the more widely used reference, intimate partner violence. According to the Centers for Disease Control and Prevention,1 the overall definition for intimate partner violence includes physical violence, sexual violence, stalking, and psychological aggression (including coercive tactics) by a current or former intimate partner (ie, spouse, boyfriend/girlfriend, dating partner, or ongoing sexual partner). Physical violence is defined as the intentional use of physical force with the potential for causing death, disability, injury, or harm. Physical violence includes, but is not limited to scratching, pushing, shoving, throwing, grabbing, biting, choking, shaking, hair-pulling, slapping, punching, hitting, burning, use of a weapon (gun, knife, or other object), and use of restraints or one’s body, size, or strength against another person.1
Currently, intimate partner violence is widely recognized as a public health issue. In the past 17 years, recognition of nonfatal strangulation within the context of intimate partner violence has garnered a lot of attention, largely in response to a seminal study that has helped to shape law enforcement responses, health care practice, legislation, and research. The study of 300 victims of nonfatal strangulation conducted in San Diego identified that most victims reporting strangulation lacked physical, observable injuries; 50% of the victims had no visible injuries, and 35% of the victims had injuries too minor to photograph. Additionally, many of these victims did not present or were not referred to an emergency department for evaluation.2 The impact of early studies has increased awareness that nonfatal strangulation is more serious than has previously been considered and may have been the impetus for legislation and developing best practices for clinical evaluation and treatment recommendations.3
While much of the published literature on nonfatal strangulation has identified that women of child-bearing age are most often the
