Non-Fatal Strangulation: A Serious Form of Violence

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Non-fatal strangulation (NFS) is the intentional compression of the neck, using hands or a ligature, that obstructs blood vessels and/or airways, ultimately restricting oxygen flow to the brain^1–3. It is crucial to distinguish NFS, a violent act, from choking, which involves blockage of the airway by a foreign object^2,4.

NFS is a significant public health and human rights issue with alarming global prevalence^1,3. Women are disproportionately affected by NFS, often in the context of intimate partner violence (IPV)³. The World Health Organization (WHO) reports that physical abuse constitutes a large proportion of IPV cases, and women subjected to such violence face double the risk of poor physical and mental health compared to women without IPV experience³. Tragically, one in five women experiencing IPV threatens or attempts suicide³.

Statistics demonstrating the prevalence of NFS are concerning³:

• In the United States, 9.7% of women report lifetime experience of NFS perpetrated by an intimate partner.

• This number rises to 18.9% in the United Kingdom.

• In Australia, almost 60% of sexual assaults involving NFS were perpetrated by an intimate partner.

• Disturbingly, an average of five people per day are charged with strangulation in New Zealand since its criminalisation in December 2018.

The severity of NFS is further underscored by the fact that up to 17% of those strangled lose consciousness, indicating potential brain injury.

NFS manifests across various settings:

• IPV: Studies indicate that the lifetime incidence of NFS within intimate relationships could be as high as 58%, with Indigenous populations experiencing higher rates due to factors like poverty. NFS is often used as a tactic of coercive control, instilling fear in the victim and reinforcing the perpetrator's power³.
• Sexual Assault: NFS is reported in a significant percentage of sexual assault cases, particularly when the perpetrator is known to the victim^1,3.
• Consensual sexual activity: There is a worrying trend of NFS being incorporated into consensual sex, especially among young adults. This normalisation of a dangerous practice raises concerns about the understanding of risks and consent in such encounters⁵.

Addressing Research Gaps

Despite growing attention, there are significant gaps in our knowledge about NFS:

• Terminology confusion between victims and healthcare professionals (e.g., "choking" versus "strangulation") can lead to inaccurate reporting and misinterpretation of the severity of the violence³.
• Underreporting by victims due to fear, shame, or lack of understanding about the potential long-term consequences of NFS is a major obstacle to accurately measuring its prevalence and providing appropriate support³. This is compounded by the fact that NFS often leaves no visible external injuries^3,6, making detection and documentation challenging⁶.
• Lack of focus on perpetrators is evident in the frequent absence of perpetrator information in health records³. This lack of data impedes our understanding of perpetrator characteristics and motivations, hindering the development of targeted interventions.
• Limited geographic representation in existing research, with a concentration of studies from the USA, limits the generalisability of findings to other healthcare systems and cultures³.
• Long-term health consequences of NFS, including potential brain injury and other neurological damage, are not yet fully understood. This lack of knowledge impacts the development of effective long-term treatment and support strategies for survivors³.

Future research can address these gaps by:

• Investigating the effectiveness of various screening tools, particularly those specifically designed for IPV-related ABI, across diverse populations and healthcare settings⁷.
• Developing and evaluating educational materials to raise awareness about NFS among both the public and healthcare professionals³.
• Advocating for policy changes to mandate consistent and detailed documentation of NFS cases, including information about the perpetrator, and to improve support services for survivors^3,8.
• Conducting in-depth research on the long-term health consequences of NFS, including the impact on brain function, mental health, and quality of life, to inform the development of targeted interventions and support strategies^3,8,9.

Understanding the Physiological Mechanisms of Injury

NFS involves the application of external pressure to the neck, leading to the occlusion of critical anatomical structures such as airways, blood vessels, and nerves. The forces required to cause obstruction vary depending on the method used. For instance¹⁰:

• Occlusion of the jugular veins requires approximately 2 kg of pressure.
• Obstruction of the carotid arteries needs around 5 kg of pressure.
• Complete airway occlusion can occur with pressure exceeding 15 kg.

These forces can lead to various mechanisms of death, including:

• Asphyxia: Compression of the airway restricts oxygen flow to the lungs, leading to suffocation^10–12.
• Cardiac Arrest: Pressure on the carotid arteries can disrupt blood flow to the brain, causing a rapid drop in blood pressure and heart rate, ultimately leading to cardiac arrest^10,12.
• Delayed Airway Collapse: In some cases, injury to the larynx or surrounding tissues may cause swelling and airway obstruction hours or even days after the initial strangulation event^11,12.

Recognising the Spectrum of Symptoms

NFS can present with a wide range of symptoms, varying in severity and duration. It's important to note that visible external injuries are frequently absent, making accurate diagnosis challenging^4,8,10,12. Symptoms can be categorized as:

• Physical:
• Neck pain, tenderness, and swelling: These are common symptoms often accompanied by difficulty swallowing (dysphagia) and changes in voice quality (dysphonia)^4,12.
• Petechial haemorrhages: Tiny red or purple spots on the skin or eyes (conjunctivae) caused by ruptured capillaries due to increased pressure in the head and neck^4,10,12.
• Breathing difficulties: Victims may experience shortness of breath, rapid breathing (hyperventilation), or wheezing^4,12.
• Loss of consciousness: A significant indicator of cerebral hypoxia and potential brain injury^4,8,12.

• Neurological^4,10,12:
• Headaches: A common symptom that can range in intensity and duration.
• Dizziness and light-headedness: Resulting from disrupted blood flow to the brain.
• Vision changes: Blurred vision, double vision, or seeing flashing lights.
• Tinnitus: Ringing or buzzing in the ears.
• Seizures: Caused by oxygen deprivation to the brain.
• Memory problems: Difficulty forming new memories or recalling events around the time of the assault.

• Psychological^3,8,12:
• Fear and anxiety: The experience of being strangled can be terrifying and lead to post-traumatic stress disorder (PTSD).
• Depression: Feelings of sadness, hopelessness, and worthlessness can emerge after NFS.
• Emotional lability: Sudden and unpredictable mood swings.
• Sleep disturbances: Difficulty falling asleep, staying asleep, or experiencing nightmares.

Short-Term and Long-Term Consequences

The effects of NFS can be immediate and long-lasting, with some complications potentially emerging years after the event. These consequences include:

• Traumatic Brain Injury (TBI): NFS can cause various forms of brain injury, ranging from mild concussions to severe hypoxic-ischemic damage^{2,3,7,8,12,13}. The lack of oxygen and blood flow to the brain during strangulation can lead to cell death and permanent neurological deficits.
• Stroke: Strangulation can trigger strokes, both haemorrhagic (bleeding in the brain) and ischemic (blocked blood flow)^3,4,6,10,12. This risk is particularly elevated in cases involving carotid artery dissection, a tear in the lining of the carotid artery, which can happen due to the force applied during strangulation.
• Post-Traumatic Stress Disorder (PTSD): The traumatic nature of NFS can lead to PTSD, a mental health condition characterised by intrusive memories, flashbacks, nightmares, avoidance behaviours, negative thoughts, and emotional distress^3,12,13.
• Other Psychological Trauma: Beyond PTSD, victims may experience a range of psychological difficulties, including anxiety disorders, depression, substance abuse, and relationship problems^2,3,12.

It is crucial for healthcare professionals to be aware of the potential consequences of NFS and to conduct thorough assessments even when visible injuries are absent.

Forensic Investigation Techniques

In cases of fatal strangulation, forensic pathologists play a crucial role in determining the cause of death. They achieve this by conducting a thorough autopsy, which involves examining the body for external and internal signs of injury, and analyzing tissue samples to identify microscopic evidence of strangulation^14,15. These signs may include:

• soft-tissue haemorrhages
• fractures of the laryngeal skeleton
• congestion haemorrhage in the conjunctivae¹⁵.

Challenges in Investigating NFS

The lack of visible external injuries in many NFS cases poses a significant challenge^6,10,14,15. This absence of clear physical evidence can make it difficult to establish the occurrence and severity of the assault, particularly in legal proceedings^6,10.

Evaluating Medical Evidence in NFS Cases

Various diagnostic tools can be employed to reveal evidence of NFS, each with its strengths and limitations:

·       Alternate light sources (ALSs): ALSs can be particularly effective in detecting subtle injuries, such as petechiae or bruising, that may not be visible to the naked eye⁶. However, research on the utility of ALSs in NFS cases is limited⁶.

·       MRI: MRI scans of the head and neck can identify internal injuries, such as:

• Perilaryngeal fluid accumulation¹⁰.
• Hemorrhages in the muscles, soft tissues, and lymph nodes of the neck¹⁵.
• Carotid artery dissection^10,13,16.

While MRI can reveal internal injuries not visible externally, its use is not always indicated, especially in cases with clear external signs of strangulation or in the absence of neurological symptoms^10,17. MRI scans can also be expensive and time-consuming.

·       CT scans: CT scans can detect bone fractures in the hyoid bone or larynx that may occur during NFS^10,15. CT scans are generally faster and less expensive than MRI; however, they are less sensitive in detecting soft tissue injuries¹⁰.

Analysing the Importance of Thorough Documentation

Thorough documentation by healthcare professionals is vital in NFS cases for both clinical care and legal prosecution^6,8. This documentation should encompass all aspects of the assault, including:

• Physical injuries: Detailed descriptions, measurements, and photographs of all visible injuries, including those on the neck, head, and other areas¹⁸.
• Internal injuries: Findings from diagnostic tools, such as ALSs, MRI, and CT scans, should be meticulously documented⁶.
• Subjective complaints: The victim's account of their symptoms, including pain, difficulty swallowing, breathing difficulties, neurological symptoms, and psychological distress, should be recorded^6,10,19.
• Victim's account of the event: It is crucial to document the victim's narrative of the assault in detail, including the method of strangulation, duration, and any loss of consciousness^6,10.

Standardised documentation tools specifically designed for NFS can facilitate thorough and consistent recording of relevant information^6,20. These tools often include body maps to pinpoint injury locations, checklists for physical examinations, and prompts for detailed questioning about the strangulation event.

Detailed notes, including verbatim quotes from the victim, can provide compelling evidence in legal proceedings⁶. Verbatim quotes can corroborate the victim's testimony and demonstrate the intent to cause harm. Photographs of injuries and the scene can further strengthen the case⁶.

High-quality medical documentation can be more convincing than similar observations recorded by law enforcement. The thoroughness and accuracy of medical records are essential for successful prosecution, as highlighted by data showing a 40% higher likelihood of case filing when NFS victims were examined by forensic nurses using standardised procedures for evidence collection⁶.

A multi-faceted approach is required for effective forensic investigation of NFS cases. The collaboration of forensic pathologists, healthcare professionals, and law enforcement is essential for thorough documentation, accurate diagnosis, and successful prosecution, ultimately contributing to the safety and well-being of potential victims.

The Legal Frameworks Surrounding NFS

Many jurisdictions are increasingly recognising the severity of NFS and are implementing specific legislation to address it^6,21. For example, the Australian Capital Territory (ACT) has specific legislation for NFS²¹. Additionally, jurisdictions in the USA, UK, New Zealand, Canada, and most of Australia have introduced specific offences of NFS^6,8.

There are calls for improved awareness and responses to strangulation, particularly across the health sector³. For example, New Zealand has implemented routine enquiry about family violence; however, these assessments may contain only a single question related to strangulation³.

The UK government has implemented a Violence Against Women and Girls Strategy (VAWG)²², and the Tackling Violence Against Women and Girls Strategy has outlined steps to address violence against women and girls²³. These include:

• Establishing the position of a Domestic Abuse Commissioner in law.
• Introducing new Domestic Abuse Protection Notices and Domestic Abuse Protection Orders.
• Making non-fatal strangulation a specific offence and widening the law on ‘revenge porn’.

Evaluating the Effectiveness of Existing Legal Responses

The sources highlight various challenges in prosecuting NFS cases. One significant challenge is the difficulty in proving intent, particularly when external injuries are minimal or absent²¹. Proving intent often relies heavily on the victim’s testimony, which can be challenging for several reasons²¹.

Cultural norms that normalise violence against women can also hinder prosecution²⁴. These norms can discourage victims from reporting the assault or seeking help, and they can also influence the perceptions of law enforcement, jurors, and judges, potentially leading to a lack of recognition of the severity of NFS.

Proposing Recommendations for Legal Reform

While the sources don't explicitly propose legal reforms, they imply several areas for improvement:

• Enhanced training for law enforcement and justice officials on NFS, its signs and symptoms, and its potential consequences²⁵.
• Increased use of expert medical testimony to explain the nature of NFS injuries and their potential long-term effects, particularly in cases where visible injuries are absent²⁵.
• Development and implementation of standardised protocols for investigating and documenting NFS cases, including the use of validated screening tools and thorough forensic medical examinations^3,6.
• Public awareness campaigns to educate communities about the dangers of NFS and to challenge cultural norms that condone violence against women²³.

These reforms would aim to:

• Improve the identification and documentation of NFS cases.
• Increase the likelihood of successful prosecution and hold perpetrators accountable.
• Enhance victim safety and access to support services.
• Ultimately, reduce the incidence and impact of this dangerous form of violence.

Assessing Healthcare Professionals’ Knowledge and Awareness of NFS

Studies and surveys highlight a concerning lack of adequate knowledge and training among healthcare professionals regarding NFS^8,24.

Key Findings:

• A survey of 103 frontline healthcare professionals in New Zealand revealed that 59% had received no formal education on NFS³. Only informal learning experiences, such as on-the-job exposure or casual workplace discussions, were reported.
• A systematic review of qualitative studies indicated that healthcare providers often fail to recognise NFS, report it, or provide appropriate follow-up care⁸.
• The same review found that healthcare professionals frequently misinterpret signs and symptoms of NFS, attributing them to other causes or dismissing their severity⁸.

Barriers to Recognition, Reporting, and Follow-Up Care

Several factors contribute to these knowledge gaps and inadequate responses:

• Lack of formal training: Many healthcare professionals receive minimal or no specific training on NFS during their education or professional development³.
• Stigma and normalisation of violence: Societal norms that downplay or excuse violence against women can lead healthcare professionals to overlook or minimise the severity of NFS⁸.
• Fear of not knowing what to do: Healthcare professionals may hesitate to inquire about NFS due to a lack of confidence in their ability to respond appropriately or a fear of "opening Pandora's box"^3,8.
• Time constraints and competing priorities: Busy healthcare settings can make it difficult for professionals to conduct thorough assessments or provide comprehensive care for NFS victims, especially when other injuries are present⁸.
• Inadequate screening and assessment tools: The absence of widely adopted, validated screening tools specific to NFS hinders early detection and accurate diagnosis².
• Limited resources and referral pathways: Healthcare professionals may struggle to connect victims with appropriate support services due to a lack of resources or knowledge about available referral pathways⁸.

Developing Recommendations for Training and Education

To bridge these knowledge gaps and improve healthcare responses to NFS, comprehensive training programmes are essential. These programmes should cover^2,8,24:

• Identification: Equipping healthcare professionals to recognise the signs and symptoms of NFS, including those that may be subtle or delayed.
• Assessment: Training on conducting thorough physical examinations, using validated screening tools, and understanding the utility and limitations of diagnostic tools like ALSs, MRI, and CT scans.
• Documentation: Emphasising the importance of meticulous documentation, including the use of standardised documentation tools, verbatim quotes, and photographs.
• Referral: Providing guidance on appropriate referral pathways for medical treatment, mental health support, advocacy services, and legal assistance.
• Follow-up care: Educating healthcare professionals on the potential long-term consequences of NFS and the importance of providing ongoing support and monitoring for victims.

Integrating NFS education into medical and nursing curricula is crucial to ensure that all healthcare professionals are equipped to address this issue.

Exploring the Role of Healthcare Professionals in Supporting Victims

Providing trauma-informed care is paramount for NFS survivors. Healthcare professionals should prioritize^2,3:

• Appropriate medical treatment: Addressing both physical injuries and potential internal injuries, including neurological complications.
• Mental health support: Recognising the psychological impact of NFS and facilitating access to mental health services for trauma recovery, PTSD treatment, and coping strategies.
• Safety planning: Assisting victims in developing a safety plan to mitigate risks and enhance their safety, potentially involving collaboration with domestic violence advocates and law enforcement.

Trauma-informed care involves:

• Creating a safe and supportive environment for disclosure.
• Validating the victim’s experiences.
• Avoiding re-traumatisation through insensitive questioning or procedures.
• Empowering victims to make informed decisions about their care and safety.

By embracing these principles and equipping themselves with the necessary knowledge and skills, healthcare professionals can play a vital role in supporting NFS survivors, improving health outcomes, and holding perpetrators accountable.

Examining the Long-Term Effects of NFS on Victims

NFS has a devastating and multifaceted impact on victims, with long-term physical, neurological, and psychological consequences.

• Physical Effects: While some physical injuries from NFS, such as bruising, may be visible, internal injuries can be more severe and less apparent. These can include damage to the carotid artery, leading to stroke, as well as intracranial haemorrhage. Victims also report experiencing a range of physical symptoms, such as neck pain, headache, difficulty swallowing, and voice changes^3,26.
• Neurological Effects: NFS can cause brain injury due to oxygen deprivation and blood flow disruption². This can lead to a range of cognitive impairments, including memory loss, confusion, difficulty concentrating, headaches, and seizures³. Research suggests that NFS is associated with neuroanatomical structural changes in the brain, highlighting the severity of the neurological impact³.
• Psychological Effects: The traumatic experience of NFS can have profound and lasting psychological effects. Victims frequently experience depression, anxiety, post-traumatic stress disorder (PTSD), and suicidal thoughts⁸. The fear, powerlessness, and loss of control associated with NFS can deeply affect survivors' mental well-being and sense of safety.

Qualitative research and case studies illuminate the lived experiences of NFS survivors, emphasising the profound impact this form of violence has on their lives. Survivors often describe feelings of terror, vulnerability, and a sense of being trapped during the strangulation³. The long-term effects can permeate various aspects of their lives, affecting their relationships, work, and overall quality of life. Survivors may live with constant fear of future attacks, leading to social isolation and difficulty trusting others.

Exploring the Wider Societal Implications of NFS

The sources don't provide specific data on the social, economic, and healthcare costs associated with NFS. However, the information presented allows for an understanding of the wider societal implications of this issue:

• Healthcare costs: The need for emergency medical care, ongoing treatment for physical and neurological injuries, and mental health services for survivors contributes to substantial healthcare expenditures.
• Economic costs: Lost productivity due to injuries, disability, and the need to take time off work for medical appointments and legal proceedings results in significant economic losses.
• Social costs: The ripple effects of NFS extend beyond the individual victim, impacting families, communities, and society as a whole. Children exposed to domestic violence, including NFS, are at increased risk of developing behavioural and emotional problems, perpetuating a cycle of violence²⁷.

The high prevalence of NFS and its associated costs underscore the urgent need for preventative measures and early intervention strategies. Investing in prevention and early intervention is not only ethically imperative but also economically prudent, as it can reduce the long-term burdens on healthcare systems, social services, and the criminal justice system.

Advocating for Increased Awareness and Prevention

Raising public awareness about NFS is crucial to challenge the cultural norms that condone violence against women. Public health campaigns should aim to:

• Educate the public about the seriousness of NFS, its potential consequences, and the warning signs of abusive relationships.
• Encourage bystander intervention by empowering individuals to recognise and safely intervene in situations where they suspect NFS or other forms of domestic violence.
• Promote healthy relationships by teaching young people about respect, consent, and non-violent conflict resolution.

Community-based initiatives play a vital role in prevention efforts. These initiatives can:

• Provide education and training on NFS to community members, including faith-based organisations, schools, and workplaces.
• Offer support groups and resources for survivors of NFS.
• Advocate for policies that promote gender equality and address the root causes of violence against women.

By working collaboratively across healthcare, social services, law enforcement, and the community, society can foster a culture that rejects violence and supports the safety and well-being of all individuals.

Key Findings

• Prevalence and Severity: NFS is a highly prevalent form of violence, particularly within the context of intimate partner violence and sexual assault. It is a significant predictor of future lethal violence and can have severe and long-lasting physical, neurological, and psychological consequences for victims^8,21,25,28.
• Underreporting and Lack of Recognition: NFS is often underreported and under-recognised, partly due to a lack of external injuries in many cases. This makes it difficult to determine the true incidence and prevalence of NFS^1,6,21.
• Healthcare Professionals' Knowledge Gaps: Studies reveal a concerning lack of knowledge and training among healthcare professionals regarding NFS. Many fail to recognise the signs and symptoms, adequately document the event, or provide appropriate follow-up care^3,8.
• Barriers to Care: Numerous barriers hinder effective healthcare responses to NFS, including stigma, normalisation of violence, fear of not knowing how to respond, time constraints, inadequate screening tools, and limited resources^3,8.

Implications for Policy, Practice, and Future Research

The findings of this dissertation have significant implications for policy, practice, and future research, highlighting the need for:

• Policy Changes: Policies should mandate routine screening for NFS in all healthcare settings, especially emergency departments, and require healthcare professionals to receive specific training on NFS. Legal frameworks should be strengthened to better protect NFS victims and hold perpetrators accountable, recognising NFS as a distinct and serious crime^3,8.
• Improved Practice: Healthcare professionals need access to comprehensive training programmes covering all aspects of NFS, from identification and assessment to documentation, referral, and follow-up care. This training should be integrated into medical and nursing curricula. Additionally, healthcare settings should adopt validated screening and assessment tools specific to NFS, such as those recommended by Clarke et al². Trauma-informed care principles should be universally implemented to create safe and supportive environments for NFS survivors^2,3,8.
• Future Research Directions: Future research should focus on developing and validating more sensitive and specific screening tools for NFS, investigating the long-term health consequences of NFS, particularly neurological and psychological effects, and evaluating the effectiveness of interventions and prevention programmes. Research should also examine the social and economic costs of NFS, providing evidence to support investment in prevention and early intervention. Collaboration with researchers in other countries can contribute to a more comprehensive understanding of NFS and best practices for prevention and management^2,3,9.

Areas for Further Investigation

• Long-Term Health Outcomes: While the long-term effects of NFS are recognised, further research is needed to delve deeper into the specific neurological and psychological consequences. This includes exploring the relationship between NFS and conditions like PTSD, traumatic brain injury, and cognitive impairment. Longitudinal studies can help track the trajectory of these effects over time.
• Effectiveness of Screening Tools: While some authors recommend specific screening tools, research should continue to evaluate their effectiveness in diverse healthcare settings and across different populations. This includes exploring the feasibility and acceptability of implementing these tools in busy clinical environments.
• Culturally Sensitive Interventions: Future research should focus on developing and evaluating culturally sensitive interventions and prevention programmes. This requires understanding the unique needs and experiences of diverse populations, including marginalised communities who may face additional barriers to accessing care.
• Impact of Legal Frameworks: Research should examine the impact of different legal frameworks on the prosecution of NFS cases and the safety of victims. This includes analysing the effectiveness of specific legislation and policies aimed at addressing NFS and holding perpetrators accountable.

Conclusion

The review highlights the urgency of addressing NFS as a serious public health concern. By translating these findings into policy changes, improved practices, and future research initiatives, society can take significant steps toward preventing NFS, supporting survivors, and holding perpetrators accountable.

References:

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