The Coordinated Community Response to Non-Fatal Strangulation in Intimate Partner Violence: A Pilot Program | Categories Utah Women and Violence

A white paper, June 2020

The opinions, findings, and conclusions expressed in this publication are those of the authors and do not necessarily reflect the official position or policies of the University of Utah. Permission to reproduce any portion of this white paper is allowed, on the condition that the author receives credit and is informed of the use of the information. Recommended citation: Fukushima, A.I., Lukasinski, V., & Gonzalez-Pons, K. (2020). The Coordinated Community Response to Non-Fatal Strangulation in Intimate Partner Violence: Pilot Program. A White Paper. Utah: University of Utah. © 2020 Annie Isabel Fukushima

Executive Summary 

This study is an evaluation of the non-fatal strangulation committee that formed in July 2018 as a response to the use of strangulation in intimate partner violence. This study employed mixed methods of quantitative and qualitative data collection. Using mixed methods for this study included quantitative data collection of victims referred to services, engaged with SLCPD advocate, outreached to, the NFS protocol was offered, and victims who declined the protocol (n=72) that occurred between January 2018 and September 2019. This study also analyzed court cases (n=49) where charges were filed, the disposition of the case, and whether or not the exam report was sent to the DA (January 2018 – September 2019). Additionally, data was collected through the analysis of the protective orders filed between January 2018 – December 2019 (n=49). Additionally, the research team conducted semi-structured interviews (N=4) during the month of April 2020. Interviews were transcribed and analyzed utilizing thematic analysis. Overall, there was an increase in numbers of cases that received medical and legal services: an increase in the average person seeking legal aid and medical care per month: 1.25 to 2.8. Although at the end of the 2019, there was a decline in number of cases, this might be due to committee concerns that funds were running out; it was not until December 2019, that funds for NFS forensics were replenished. A majority of the successful legal proceedings charge an abuser with assault. This study offers the following recommendations:  

  1. Increase funding to non-fatal strangulation. All interviewees recommended that there is a need for more financial resources. Funding is essential to responding to the health consequences of domestic violence and intimate partner-violence. Currently, training efforts and social service responses to non-fatal strangulation are underfunded. It is recommended that in addition to creating a long-term plan for funding non-fatal strangulation medical services, which averages $600 per client, that a social services and educational programming is also funded.  
  1. Increase training of key-stakeholders. Training about non-fatal strangulation and local protocols are essential for responding to the physiological effects like non-fatal strangulation. It is recommended that the NFS committee receive funding and support to prioritize training the following: Dispatch 911, new law-enforcement recruits, and medical providers. 
  1. State-wide response. Currently, the response to non-fatal strangulation is funded through the Salt Lake County. This has led to a regionally specific response. However, survivors of intimate partner violence and domestic violence come from across the entire state, and many seek medical services at University of Utah medical. Additionally, borders are fluid where incidents may occur in Salt Lake City, but the victim resides outside of the city or an incident occurs outside of the city jurisdiction, and the victim is a resident of the city. Nonetheless, victims of domestic violence and intimate partner violence come from across the state. A state-wide NFS-Protocol is needed.  
  1. Ongoing research. There is a need to understand the data from 911 dispatch calls, diverse populations that experience strangulation, and law enforcement investigations. This study prioritized evaluating the implementation of the non-fatal strangulation protocol.    

Introduction 

According to the National Coalition Against Domestic Violence, “domestic violence is the willful intimidation, physical assault, battery, sexual assault, and/or other abusive behavior as part of a systematic pattern of power and control perpetrated by one intimate partner against another. It includes physical violence, sexual violence, threats, and emotional abuse” (“NCADV: National Coalition Against Domestic Violence”). Domestic violence, also referred to as intimate partner violence (IPV), is a pertinent issue in the United States affecting 1 in 4 women nationwide. IPV is prevalent in Utah, affecting 1 in 3 women (“Domestic Violence Statistics in Utah”, 2015). Domestic violence is considered a public health issue as it profoundly affects the health outcomes of those who experience it.  

There appears to be a strong correlation between IPV and non-fatal strangulation. In a study of 300 victims of non-fatal strangulation, 89% had experienced domestic violence (Strack et. al, 2001). Strangulation is a “form of asphyxia produced by constant application of pressure to the neck” (International Association of Forensic Nurses 2016). Survivors who experience strangulation may experience voice changes such as hoarseness (dysphonia) or the loss of their voice (aphonia), swallowing changes, tongue swelling, breathing changes, visible injuries such as scratches or bruises, neck swelling, neurological consequences (i.e., Ptsosis, facial droop, unilateral weakness, loss of sensation, paralysis, seizure), lung injuries, miscarriage, acid reflux, among other physiological symptoms related to physical abuse (International Association of Forensic Nurses 2016; Christe et al., 2009; Faugno et al., 2013; Funk & Schuppel, 2003; Strack & McClane, 1999). There are other signs of strangulation that responders might look for including petechiae scalp, eyes, eyelids, face, mouth, or neck, bloody red eyeballs, vision changes, droopy eyelids, ligature marks, and fingernail marks (Strangulation Training Institute n.d). When victims are strangled, “unconsciousness may occur within seconds and death within minutes” (California District Attorneys Association and Training Institute on Strangulation Prevention 2013). 10 Seconds is all that is necessary to cause unconsciousness, and brain death if the strangulation occurs for 4 to 5 minutes (Ibid). Non-fatal strangulation is a common IPV behavior that often leads to traumatic brain injuries due to the deprivation of oxygen to the brain and the likely accompaniment of blunt force trauma to the head (Snyder, 2017). 

Victims of IPV are frequently not screened for strangulation or brain injury, and these patients are often not capable of advocating for themselves as many that have lost consciousness are unable to accurately remember the incident. Oftentimes, the signs of strangulation may be invisible to perceptible eye, where in a study of 300 cases, it was found that 50% had no visible injury (Strack et al., 2001). Strangulation may not be always identified due to what Ellen Taliaferro refers to as the “Pandora Effect,” which is the physiological impacts of NFS long after bruises fade, bones mend, and the physical altercation where strangulation occurred has stopped. In the same study, only 15% of cases had injuries deemed visible enough to take photographic evidence (Strack et. al, 2001). However, many victims suffer internal injuries, and some have died several weeks after their attack due to the brain damage from the strangulation (Douglas & Fitzgerald, 2014). And only in 5% of cases did victims seek out medical attention (Strack et al., 2001). The consequences of repeated strangulation, in addition to the physiological consequences, included depression, nightmares, insomnia, suicidal ideation, anxiety, Post-Traumatic Stress Disorder (Smith et al., 2001). IPV victimization was significantly related to reporting 7 or more poor mental health days, losing 7 or more days of work or other activities, having trouble concentrating or remembering things, binge drinking, being a daily smoker, and reporting overall poorer health (Utah Department of Health, 2017). Non-fatal strangulation in intimate partner violence is also an indicator of later more lethal forms of violence (Manne, 2019). Research shows that the most reliable predictors of future lethality are reports of having been ‘choked out’ (non-fatally) by an intimate partner (Berrios and Grady 1991; Campbell 2002; Douglas & Fitzgerald 2014; Jones 2016; Iverson & Pogoda, 2015; Laughon et al., 2008; Mcquown et al., 2016; Pritchard, et al., 2018; Strack & Gwinn 2011; Strack et al., 2001). The likelihood of a homicide increases 750 percent for victims who have been previously strangled, compared to victims who have never been strangled. It was found in a survey of 237 women who were strangled, 87% were threatened with death, 70% feared death, and 93% lived with their abuser (Wilbur 2001). Given the serious findings, Glass et al., (2008) recommend that all potential first responders to intimate partner violence cases with non-fatal strangulation indications, including law enforcement, emergency medical technicians, and police officers, receive training about the severity of this form of physical violence and direct victims to emergency medical treatment. Concurring, Sheridan and Nash (2007) recommend that healthcare providers query about strangulation if they suspect the patient has experienced intimate partner violence, even if no physical signs are evident.

Utah Legislation

In 2017, the Utah legislature passed HB17, Offenses Against the Persons Amendments, which modified the crime of aggravated assault to include strangulation. These amendments do not include the word “strangulation,” but provide the following definition, “any act that impedes the breathing or the circulation of blood of another person by the actor’s use of unlawful force or violence that is likely to produce a loss of consciousness by: applying pressure to the neck or throat of a person; or obstructing the nose, mouth, or airway of a person.”1 These modifications made non-fatal strangulation a third-degree or second-degree felony depending on the severity of injuries, or the loss of consciousness. 

The Coordinated Community Response to Non-Fatal Strangulation Pilot Program in Utah 

The Coordinated Community Response to Non-Fatal Strangulation Pilot Program Steering Committee (NFS Committee) formed in July 26, 2018. The committee in July 3, 2018, included the Salt Lake Mayor Jackie Biskupski or designee, Salt Lake County Mayors Ben McAdams or designee, the Chief sponsor of HB 17 (2017) Curtis S. Bramble, Salt Lake City Police Department Chief Brown (or designee), the Salt Lake City Police Victim Advocate Wendy Isom (or designee), Salt Lake County Sheriff’s Office Sheriff Rosie Rivera, Salt Lake County District Attorney’s Office Sim Gill (or designee), First Responders from Salt Lake City Fire and Ambulance and Dispatch, Utah Office for Victims of Crime Gary Scheller, University Of Utah Health Care, Family Justice Center Forensic Nurses, Intermountain Healthcare Domestic Violence Committee designee, YWCA Utah, South Valley Sanctuary, Salt Lake Area Family Justice Center, Utah Domestic Violence Coalition, Holy Cross Ministries, and the University of Utah research team (led by Dr. Fukushima). On August 9, 2018, the Family Justice Center organized the “Reducing Domestic Violence Deaths: An Integrated Multi-Disciplinary Approach to Non-Fatal Strangulation Summit Identifying, Investigation, and Prosecuting Domestic Violence Strangulation,” at the Salt Lake County District Attorney’s Office. The summit included presentations from Gael Strack, Bill Smock of the Alliance for Hope International. The goal of the summit was to increase the knowledge and understanding of professionals working with victims of domestic violence and sexual assault who are strangled; improve policy and practice among legal, medical, and advocacy communities; multiply the field’s capacity and expertise; increase offender accountability; and ultimately enhance victim safety. 

In 2018 the YWCA of Utah requested a total of $100,000 from Salt Lake City Mayor’s Office, Salt Lake County, and the District Attorney’s Office to cover the cost of forensic exams for victims of intimate partner strangulation. In 2019, the NFS was able to successfully acquire $99,000 – evenly provided by the Associate Deputy Mayor, Kimi Barnett, the District Attorney’s office and the Salt Lake County. 

In October 2018, the NFS Committee began developing an NFS protocol. The goal of the protocol was to identify victims of non-fatal strangulation, be able to direct to proper medical intervention, and offer education. If the client indicated in any way that they experienced strangulation, NFS committee members would refer the individual on to receive an assessment from a nurse and to also follow-up on the individual’s medical needs. 

To evaluate the project, in December 2018, a research team led by Dr. Annie Isabel Fukushima, Assistant professor with the Ethnic Studies Division, and agreements to formally share data was formalized through the University of Utah’s Center for Technology & Venture Commercialization, which facilitated the formal Material Transfer Agreement. This was in addition to the application for Institutional Review Board approvals (the study was considered exempt, IRB_00117341). 

In February 14, 2019, the FJC, SLC Fire, 911 Dispatch, SLC Victim Advocates, SLC DA, SLC PD, UDVC, University of Utah Trauma Nurse/Forensic Nurse, the FJC Forensic Nurses, and the Administrative Office of Courts conducted a table top exercise of the protocol facilitated by SLC Fire. A final protocol was created (See Appendix A). A flow was created to move responders from identifying strangulation, a process of referral on to a nurse, agreements on the venue of assessment (University Medical or the Family Justice Center) and with a follow-up of care (See Appendix B).  The Non-Fatal Strangulation Committee’s protocol went live on April 1, 2019.  

This research study contributes to a larger effort to evaluate the efficacy of HB17 and the corresponding protocol. Our small research team of Dr. Fukushima and students from the University of Utah is collecting data from various sources to thoroughly examine the outcomes of these procedures in collaboration with the YWCA and the Non-fatal strangulation committee.

Methodology 

This study employed mixed methods of quantitative and qualitative data collection. Quantitative data collection was collected on the victims referred to services, engaged with SLCPD advocate, outreach only, whether or not the NFS protocol was offered, and victims who declined the protocol between January 2018 and September 2019 (n=72). This study also analyzed court cases (n=49) during the same time period where charges were filed with the Salt Lake District Attorney, where data included the disposition of the case and whether or not the exam report was sent to the DA. Additionally, protective orders filed between January 2018 – December 2019 (n=49) was examined. The research team conducted qualitative data collection through semi-structured interviews (N=4). Interviews were approximately 1 hour long. After interviews were conducted the audio recording was immediately transcribed and the audio recording destroyed. This study utilizes thematic analysis of the protocol process. Interviewees included an advocate, a nurse, a service provider, and a 9-1-1 dispatch responder. 

Results

Since the protocol has been in place, the NFS committee saw an increase in the average person seeking legal aid and medical care per month: 1.25 to 2.8. This was a 224% increase in aid for those that experienced NFS. In June 2019, nearly 1,000 first responders were trained in a new screening protocol and in understanding risks and signs of strangulation in order to improve their responsiveness to domestic violence calls (“The Dangers of Strangulation: New Protocol Will Help Save Lives”, 2019). And, between January 2018 – September 2019, a total of 72 cases were identified by the NFS Committee. Education about strangulation has been essential. As described by a social service provider, “strangulation is one of those things that is a misunderstood or minimized risk. And I think what we are learning thanks to a lot of the work that the institute for strangulation prevention is doing… how hard it is to even get somebody to connect with the idea that they’ve been strangled… You use different language like ‘choked’ or ‘you couldn’t breathe,’ cause I don’t think people connect their experience with that word: [strangulation].”

Financial Resources

Medically supporting survivors who have experienced strangulation is costly. Since 2018, the NFS committee has successfully acquired $99,000 – the funds were expected to last the project for two years. By November 14, 2019, the NFS committee reported having completed 145 exams. The cost of the 145 exams was $87,000.  

Although survivors are able to have their medical needs covered, there were bureaucratic challenges. When survivors went to an out-patient clinic, they were given a voucher. However, there were denials to some of these claims, meaning that survivors could face approximately $1,000 bill for their scan. The consequences being under-resourced, as aptly described by an advocated, organizations are currently “understaffed and underfunded,” which means, “people fall through the cracks and don’t get the responses that they need.” 

9-1-1 Dispatch

9-1-1 Dispatch is one of the first responders to domestic violence and intimate partner violence, where incidents of non-fatal strangulation may occur. The dispatch asks questions regarding strangulation as part of their protocol, questions include, “did the perpetrator choke you?” If the caller says, “yes,” a dispatch interviewee conveyed that the response is: “we automatically send medical response.” The perception of the protocol was described by dispatch as follows: 

 “What ends up happening is the police department responds to secure the scene more or less. And then, the fire department responds because they’re the ones – the fire department provides medical services. The fire department responds, and between those first responders, between the police department and the fire department, they have a specific strangulation protocol that they follow. And then they are the ones that reach out and have the victim reach out to the forensic nurse.” 

After a caller hangs-up, the process moves forward where dispatch has no follow-up with a case, where their role ends when the phone call is ended. All dispatch callers were trained on the protocol, to ensure that medical is sent when strangulation is indicated to dispatch. Because 9-1-1 dispatch calls are all recorded – emergency and non-emergency – the recordings themselves also become evidence for a legal case when victims who call 9-1-1 report strangulation.

Social Services

The YWCA Family Justice Center is the primary service provider and shelter provider for victims and survivors of domestic violence and intimate partner violence in Salt Lake City. In collaboration with the Utah Domestic Violence Coalition, victims of domestic violence or intimate partner violence residing in Salt Lake City, may have their shelter needs met, as well as receive support with regards to protective orders, stalking injunctions, substance abuse and mental health services, and a range of other services. Of the 72 cases analyzed between January 2018 and September 2019, 16% of the cases included those in which there was follow-up from victim services to a victim of a strangulation, in which the survivor did not respond. That is, 77% of victims received direct support from social services. It was found that 83% of the victims interacted with Salt Lake City Police Department advocates. The Salt Lake City Police Department’s Advocates work to process victim claims, in particular strangulation claims. The need to support victims is life-and-death. As one advocate stated, “whenever there is strangulation involved, we try not to take anything else into consideration and then just approve those claims because I think… when relationships get to a point where one person is using strangulation to assault someone that maybe they didn’t kill the person this time, but there’s a greater chance that next time–or the next time, that they may.”  

Medical Exams

The creation of an NFS committee has led to an increase in numbers of survivors having a Computerized Tomography (CT) Scan of their injuries. Between January 2018 and September 2019, 72 individuals were identified as being strangled. Of these 72 cases, 66 were assessed by a nurse (91%) with 9% declining being assessed for their medical needs. There are challenges to medical support – even when the treatment is covered. Survivors may spend 4 hours in the hospital, with another 3 hours for their exam. Many survivors do not understand the health implications of strangulation, therefore, consulting with a medical professional is central to their well-being. As one nurse states, “I talk to many, many clients when they are perpetrated upon… I will call and talk to them and work through what happened to them… Many [victims] aren’t willing to go in and seek medical care. That’s the hard part of this all is they do not understand yet how it affects their health.” Some victims seek out medical care, however, are not introduced to a person who is aware of their strangulation history. As a nurse interviewee states, “I’ve read the charting when I’m doing a consultation… They didn’t even mention the word strangulation.” Therefore, there is a need to increase training of medical professionals regarding strangulation indicators. Many victims do not recall being strangulated, having blacked, therefore, asking questions such about “seeing stars,” or “losing time” becomes essential for recommending a victim have their medical needs met. The role of medical assessments due to the NFS protocol has been lifesaving. As one advocate stated, “For those that do go to the hospital… I mean it’s been fortunate because those cases that we’ve seen where, maybe, at first it didn’t look like it was too bad. But then they go in, they get the scans… and they find that there’s like this hematoma2 on the back of their throat or somewhere… and it was more severe than they had originally thought…” The role of forensic nurses has been central to implementing the NFS protocol for serving victim medical needs. Additionally, the forensic assessment can be essential for a legal case. And are perceived of as preventative – preventing future strangulations and possible death. The effectiveness of the role of the forensic exams are far-reaching, where NFS committee members reported being contacted by nurses from other counties (i.e., Davis County).  

Legal Support & Law Enforcement 

Legal support for victims occurs through law enforcement investigations and prosecutions by the District Attorney. In Utah, the Lethality Assessment Program is implemented to assess high lethality cases. Therefore, to meet the legal needs of a survivor whose case may lead to civil and criminal action, requires a partnership with law enforcement and having law enforcement trained. Between January 1, 2018 and December 31, 2018, Utah Domestic Violence Coalition reported that there were 3,626 LAP assessments.3 Although strangulation is known to lead to lethality and the LAP is identified as mitigating the risk for homicide, as one advocate stated, “law enforcement, a lot of the agencies are doing the Lethality Assessment Protocol, but not all of them are. And part of that is either… like in rural areas, I think maybe it’s less.” There are regional differences in how lethality is assessed. In spite of these regional differences, the perception of Salt Lake City Police Department since the NFS Committee created the protocol, is that there is an increase in referring victims on for their medical needs. As one victim advocate stated, the “different responses in the police reports that we’re reading, but most often, we see that they are encouraging their very best to get people who report strangulation of any degree to get medical attention.” Therefore, as the NFS committee implements the strangulation protocols, lessons may be learned from LAP assessment implementation in the state and the role of training law enforcement first responders to refer victims on for their medical needs.  

Some NFS lead to criminal proceedings, with the majority leading to assault charges (71%). Additionally, a majority of the cases utilize a forensic report (91%). In these incidents, the NFS committee member attorneys and nurses educates judges whenever there is a new strangulation case. 48 cases were tracked in the legal system. Strangulation medical assessments can be pivotal to a legal case. As conveyed by a nurse interviewee, “it really does help the attorneys to prosecute a strangulation case because now they’ve gotten all the right answers in order to help teach a jury what happens. So they can say to a jury this is what happens during strangulation.”  

However, generally, the need to train attorneys is ongoing. As described by an advocate, when working with “new prosecutors who don’t really understand the dynamics of domestic violence, who might give contact information for a victim to the defense attorney. We just had a case where I had to get the [legal clinic] involved in that this prosecutor gave contact information for the victim to the defense attorney who then called the victim to let her know if she sought reparations from our office to help with like relocation or other things, that she would be the paying restitution back not the offender.” Misinformation and a lack of knowledge regarding domestic violence and intimate partner violence can be anxiety producing for victims.  

In addition to criminal and civil options, there are safety options for domestic violence and intimate partner violence survivors including protective orders and temporary restraining orders. Of the non-fatal strangulation 49 cases tracked for protective orders between November 2018 and November 2019, 78% resulted in the granting of a protective order for a victim (n=38). Since the protocol has been in place, the NFS committee saw an increase from an average 1.25 to 2.8 persons seeking legal aid and medical care per month. This is a 224% increase in aid for those that experienced non-fatal strangulation. 

Conclusion

Overall it was found that having a Non-fatal strangulation protocol has been essential to increasing effective responses to non-fatal strangulation in intimate partner violence in Salt Lake City County. As illuminated in the above quotes, the NFS protocol facilitates collaboration and improves responses to victim needs. Overall, there was an increase in victims having their legal and medical needs met. 

Limitations

The study was limited in the number of interviews that were conducted. This was due to the interviews occurring during the spring 2020, which also coincided with global pandemic. All of the NFS Committee are front-line workers, of which, many including dispatch, Salt Lake Police Department, forensic nurses, and social services were implementing policy and organizational changes in response to Covid-19. Additional interviews may occur. Quantitative data was collected; to ensure the anonymity of domestic violence victims, data was scraped of identifiable information and quantifiable data was submitted to the lead researcher. Quantitative data came from four different sources: Family Justice Center, Salt Lake City Police Department Victim Advocates, Forensic Nurses, and the District Attorney’s Office. Data varied and it is impossible to cross references between the different data sources. To address these challenges, the committee attempted to collect data by first gathering case numbers from forensic nurses, then providing information with regards to these de-identified cases to the lead researcher. Additionally, all data is based on known cases that came through the NFS committee. The data does not include non-fatal strangulation cases that may have occurred, but did not come through the committee. Therefore, this study the tip of the iceberg. 

Recommendations

“I think the nice thing is we are moving forward. And maybe we’re taking little tiny steps. But we are doing something about [non-fatal strangulation] that eventually I hope our lawmakers, they can help these victims’ way more than they are right now.”  

It is essential to address safety and public health concerns of domestic violence and intimate partner violence, by meeting the medical needs of survivors. The following recommendations are offered: 

  1. Increase funding to non-fatal strangulation. All interviewees recommended that there is a need for more financial resources. Funding is essential to responding to the health consequences of domestic violence and intimate partner-violence. Currently, training efforts and social service responses to non-fatal strangulation are underfunded. It is recommended that in addition to creating a long-term plan for funding non-fatal strangulation medical services, which averages $600 per client, that a social services and educational programming is also funded.  
  1. Increase training of key-stakeholders. Training about non-fatal strangulation and local protocols are essential for responding to the physiological effects like non-fatal strangulation. It is recommended that the NFS committee receive funding and support to prioritize training the following: Dispatch 911, new law-enforcement recruits, and medical providers. 
  1. State-wide response. Currently, the response to non-fatal strangulation is funded through the Salt Lake County. This has led to a regionally specific response. However, survivors of intimate partner violence and domestic violence come from across the entire state, and many seek medical services at University of Utah medical. Additionally, borders are fluid where incidents may occur in Salt Lake City, but the victim resides outside of the city or an incident occurs outside of the city jurisdiction, and the victim is a resident of the city. Nonetheless, victims of domestic violence and intimate partner violence come from across the state. A state-wide NFS-Protocol is needed.  
  1. Ongoing research. There is a need to understand the data from 9-11 dispatch calls, diverse populations that experience strangulation, and law enforcement investigations. This study prioritized evaluating the implementation of the non-fatal strangulation protocol.  

References

Berrios, D.C. and Grady, D. (1991). Domestic violence. Risk factors and outcomes. Western 

Journal Med. 155(2): 133 – 5. 

California District Attorneys Association and Training Institute on Strangulation Prevention (2013). The Investigation and Prosecution of Strangulation Cases, https://www.familyjusticecenter.org/wp-content/uploads/2017/11/The-Investigation-and-Prosecution-of-Strangulation-Cases-Manual-2013.pdf 

Campbell, J.C. (2002). Health consequences of intimate partner violence. Lancet 359(9314): 

1331 – 6.   

Christe, A., Oesterhelweg, L., Ross, S., Spendlove, D., Bolliger, S., Vock, P., & Thali, M. J. (2010). Can MRI of the neck compete with clinical findings in assessing danger to life for survivors of manual strangulation? A statistical analysis. Legal Medicine (Tokyo, Japan), 12(5), 228–232. 

Douglas, H. & Fitzgerald, R. (2014). Strangulation, Domestic Violence and the Legal Response. 

Sydney Law Review 36(2): 14-14. 

Faugno, D., Waszak, D., Strack, G. B., Brooks, M. A., & Gwinn, C. G. (2013). Strangulation forensic examination: Best practice for health care providers. Advanced Emergency Nursing Journal, 35(4), 314–327. 

Funk, M., & Schuppel, J. (2003). Strangulation injuries. WMJ: Official Publication of the State Medical Society of Wisconsin, 102(3), 41–45. 

International Association of Forensic Nurses (2016), “Non-Fatal Strangulation Documentation Toolkit,” https://www.familyjusticecenter.org/wp-content/uploads/2017/11/International-Association-of-Forensic-Nurses-Non-Fatal-Strangulation-Documentation-Toolkit-2016.pdf 

Iverson, M. & Pogoda, K. (2015). Traumatic brain injury among women veterans: An invisible 

wound of intimate partner violence. Medical Care 53 Suppl 4 Suppl 1, p.S112-S119. 

Mcquown, C. Frey, J., Steer, S., Fletcher, G.E., Kinkopf, B., Fakler, M., andn Prulhiere, V. 

(2016). Prevalence of strangulation in survivors of sexual assault and domestic violence. 

American Journal of Emergency Medicine. 34(7): 1281 – 5. 

Pritchard, A., Reckdenwald, A., & Nordham, C. (2015). Nonfatal strangulation as part of 

domestic violence: A review of research. Trauma, Violence, & Abuse, 18(4), 407-424 

doi: 10.1177/1524838015622439 

Smith, D.J., Mills, T., and Taliaferro, E. (2001), The Journal of Emergency Medicine 21(3): pp. 323-329. 

Strack, G.B. & Gwinn, C. (2011). On the Edge of Homicide: Strangulation as a Prelude. 

Criminal Justice 26(3). 

Strack, G. B., & McClane, G. (1999). How to improve your investigation and prosecution of strangulation cases (2nd ed.). D. C. James (Ed.). San Diego, CA. Retrieved May 5, 2016, from http://www.ncdsv.org/images/strangulation_article.pdf

Strangulation Training Institute (n.d.), Signs of Strangulation, https://www.familyjusticecenter.org/wp-content/uploads/2020/04/ONLY-Signs-v3.12.20.pdf 

Utah Department of Health, Office of Public Health Assessment. (2017). Behavioral Risk Factor Surveillance System (BRFSS). Retrieved from https://ibis.health.utah.gov/pdf/opha/publication/hsu/2017/1711_IPV.pdf#HSU 

Wilbur, L., Higley, M., Hatfield, J., Surprenant, Z., Taliaferro, E., Smith, DJ, and Paolo, A. (2001), Survey Results of Women Who Have Been Strangled While in an Abusive Relationship, The Jornal of Emergency Medicine 21 (3): pp. 297 – 302. 

Appendix