Health After Trauma  Newsletter An eZine for survivors of trauma and those who support them
First Quarter 2009 Focus on Manual Strangulation

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Focus on Manual Strangulation

Ellen Taliaferro, MD, FACEP

Prior to ten years ago, few health care and legal professionals had little awareness of the presence and seriousness of strangulation as a form of domestic violence assault. Indeed, the first hint that manual strangulation injuries might be more common than realized appeared in the medical literature in 1985.

In 2001, a landmark series of six articles addressing strangulation as a form of domestic violence assault appeared in the October issue of the Journal of Emergency Medicine. Since then, much has happened as more and more legal and health professionals have been trained in how to recognize and document strangulation assault and in how to care for victims of strangulation.

We now know:

  • Manual strangulation accounts for 97% of all domestic violence strangulation attacks 
  • Of women who present to a busy emergency department for treatment of a domestic violence physical assault, 23% of them have been strangled
  • 50% of women who are examined within a few hours of being strangled have no signs of strangulation injury
  • Strangulation assault is a life-threatening event that takes a major toll on the lives of many of the survivors of the attack
  • Women who have been strangled within the past 24 hours should be admitted or observed in the hospital

This issue of the Health After Trauma eZine is dedicated to the topic of strangulation as a form of DV/IPV assault.

We Used to Call It Choking

Gael B. Strack, JD
CEO & Co-Founder,
Family Justice Center Alliance

In 1995, two teenagers died as a result of domestic violence: Casondra Steward (17) and Tamara Smith (16). Both teenagers were also young mothers. Both had a history of domestic violence and had previously been choked before their deaths. The deaths of these two teenagers were shocking and a sobering reminder of the reality of teen relationship violence. The abrupt deaths also led to an informal death review, a study of existing strangulation cases being prosecuted within the San Diego City Attorney's Office and specialized training for domestic violence professionals.

Fourteen years later, our effort to not let Casondra and Tamara die in vain has grown stronger. Working with professionals from around the country, 26 states have passed felony strangulation statutes. Minnesota even studied the impact of its new law. There are numerous published articles, training videos, sample questions for experts to use in court, brochures for police officers, specialized forms, journals for victims to log their signs and symptoms, improved advocacy and safety planning, and much more.

Through education and awareness, we have gone from calling it a "choking" or "just a misdemeanor" to recognizing in most domestic violence situations we are dealing with a serious, felonious strangulation case. We recognize now that strangulation is serious and one of the most lethal forms of domestic violence: unconsciousness may occur within seconds and death within minutes. Victims may have no visible injuries whatsoever. Yet because of underlying brain damage by lack of oxygen during the strangling, victims may have serious internal injuries or die days or several weeks later. Strangulation may also cause victims to have ...

Expert Witnesses Needed for Prosecution of Strangulation Attack as a Felony

Many states have now deemed a strangulation assault to be a felony. However, jury members often do not understand the seriousness of strangulation. A medical expert witness will help explain strangulation as serious assault

If you are a health care provider preparing to serve as an expert witness for a strangulation case or a prosecutor preparing for trial, these "Questions for Strangulation Experts" developed by Dr. George McClane, Dr. Dean Hawley, and attorney Gael Strack will be a very useful tool for you.

Strangulation: A Lethal Form of Interpersonal Violence
First Strike program 

Ruth I Downing

Strangulation or "choking" has recently become known as a form of interpersonal violence causing serious injury. Patients presenting with no external evidence of trauma can have life-threatening internal injuries as a result of blunt force injury to neck tissues. Recent research describes this form of violence as serious and worthy of higher consideration from health care and legal professionals. Some states have passed laws making nonfatal strangulation a felony offense.

It is important to distinguish...

One State's Story: From Misdemeanor to Felony Charges

Sue Michalski
RN, MS Training and Education Director, Domestic Violence Coordinating Council

I feel extremely fortunate and very grateful to be alive after years of abuse. Over a thirty-year span of time, I've had a unique opportunity as a survivor and as a nurse to take part in the growth process as we care for victims of violence. I've learned to embrace the fact that as we continue moving forward, we must never forget where we've been.

Thirty years ago, the overall response to domestic violence and sexual assault was less than favorable. Advocacy was in its infancy. Victims were often questioned as if they had caused the violence. Domestic violence was considered ...


 Are You Looking for a Speaker?

Finding a speaker for your upcoming events can be a daunting task. Solutions to finding the just-right speaker range from word of mouth to using professional bureaus. If you are looking for a speaker or have a last-minute cancellation in your upcoming event, contact DrT for help. Let her know about your needs, location, etc., by clicking here.

Do you need an expert witness?

If so, contact Dr.T and she will help you find one. Note that the authors of each of the articles found in this eZine can also help you and their contact information is in the articles they contributed.

Other Resources:

Thyroid Storm Induced by Strangulation
Thyrotoxicosis crisis (thyroid storm) occurs when increased circulating thyroid hormones provoke life-threatening dysfunction of multiple organs. This life-threatening condition has now been reported to occur after a strangulation event in a 37 year-old woman.

Authors Jesús I. Ramírez, MD; Patrizio Petrone, MD; Eric J. Kuncir, MD, FACS; Juan A. Asensio, MD, FACS reported such a case in a 2004 issue of the Southern Medical Journal.

To get the article online, click below and then register as a new user of the journal's website

Upcoming Events and Meetings

9th Annual Justice and Hope Domestic Violence Conference

Join us for the 9th annual Justice and Hope Domestic Violence conference on Thursday, March 12, 2009 at the Cowlitz Expo Center in Longview, Washington. Keynote speaker: Dr. Donald Smith, Jr., Child Trauma fellow and co-founder, President, and Executive Director for Generations Center, a non-profit center in Dallas, TX, for the prevention of youth and family violence.

Workshops will include: Impact on Children and Teens Witnessing Violence, Compassion Fatigue, The Healing Power of Humor for People Helpers, In Her Shoes-Why She Stays, and Challenges of DV Intervention in Rural Communities.

Cost for coffee, snacks, lunch and materials: $100. For more information, call conference coordinator, Chere Weiss at (360) 414-7533 or email:

Do you have a conference that you want featured in this eZine?

If so, let Dr T know about your upcoming event by clicking here.

For additional exposure for your event, sign up for a free membership to the Saving Cinderella network and post your event on that website as well.

Wait: Don't Leave Yet

Best friends are where you find them.

Warning: This little video will put a small smile in your heart. If you are trying to work up a good mad about something, best to watch later.

From Dr T 
On my first day of medical school, our anatomy professor told us
that in medicine the questions
were always the same. "It is only
the answers that change," he
admonished us. We all laughed.
Surely he was telling a joke.

Not so. He spoke the truth. The
answers always change.
Yesterday's answers change as
new research emerges.
As the answers change, other
change is called for. Here are two major changes coming from the
Health After Trauma Project:
  • Future eZines will be
    intermittent and focused on specific topics
  • A major overhaul of our
    Health After Trauma
    website is in the works--we look forward to making the
    announcement when the
    "new look" is firmly in place
To further our learning and
understanding of manual
strangulation as a form of DV/IPV
assault, the Health After Trauma
website will add a resource center dedicated to the issue of manual strangulation.

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