Strangulation & Sexual Violence Serious Crimes, Serious Consequences The act of strangulation can be horrifying for victims and cause serious injury, negative future health consequences, or death. Strangulation, which is defined as external compression of the blood vessels of the neck, causing reduced blood flow to or from the brain (Sorenson, 2014), can also lead to increased risk of psychological harm. A common occurrence in intimate partner violence, studies show that strangulation co-occurs with sexual violence in 5 to 25% of cases but the act often goes undetected in sexual assault victims. Due to the serious lethality risks and health impacts, it is vital that first responders know how to detect strangulation and how best to help victims. The Law in Pennsylvania Strangulation was added to the crimes code in 2016. The citation is 18 Pa. Cons. Stat. § 2718 (2016). Here is a summary of law: A person commits the crime of strangulation if the person : -Knowingly or intentionally -Impedes the breathing or circulation of blood Of another person by: -Applying pressure to the throat or neck or -Blocking the nose or mouth The law does not require physical injury to the victim. The law also provides an affirmative defense. If the victim consents to the strangulation, it may be determined that no crime was committed. Modes of strangulation and asphyxia It is important to note that the law covers both strangulation and other acts that may lead to asphyxia, a lack of oxygen to the body. The act of strangulation leads to asphyxia by impeding blood flow to or from the brain and other organs by squeezing the neck. Strangulation can occur manually with the use of hands, arms, or legs. It can also occur by means of a ligature, such as a cable, clothing, or a necklace. However, asphyxia might not involve strangulation. The intake of oxygen can be impeded in other ways. For example, suffocation is the blockage of the nose and mouth by an object, such as a pillow, or body part, like a hand. Signs and symptoms While only about half of victims who have been strangled will have any visible sign of injury (McClane, 2001), it is imperative to take any marks or symptoms of strangulation very seriously. In fact, it takes less pressure to strangle a person than the pressure of an average handshake. It is possible to strangle someone to death and leave no signs or marks on the body (Hawley, 2001). Victims should be encouraged to seek medical care and describe what they experienced so strangulation is not overlooked. Visible Signs of Strangulation Head: -Petechiae (small red or purple spots caused by broken capillaries) often found on face, eyelids, lips, scalp -Subconjunctival hemorrhage (blood in the whites of the eyes) -Bruising behind the ears Neck: -Bruises -Redness -Abrasions -Tenderness/pain -Swelling -Ligature marks Other signs/symptoms: -Slurred speech -Loss of voice -Loss of consciousness -Difficulty swallowing -Urinary or fecal incontinence -Confusion -Headache How to Help Victims Strangulation should be addressed through a multidisciplinary team approach. Training on the topic for sexual assault response team (SART) members is important to make sure all responders are aware of strangulation signs and symptoms and the serious health risks. Screening and assessment for strangulation should be added to protocols and policies in order to make sure the issue is addressed for all victims. SART meetings and case review should incorporate discussion of strangulation and response measures. Teams can assess how strangulation is being charged and the success of prosecution. Lethality assessment processes should be reviewed and evaluated. In addition, each team member can apply specific actions to detect and address strangulation in sexual assault cases. Criminal Justice System Strangulation is a strong predictor of future homicide in intimate partner situations, and sexual assault is frequently a part of those relationships. This strong link to lethality makes the issue important to law enforcement and prosecution. Also, perpetrators of violence who use strangulation to control and injure their victims have shown a greater propensity to kill law enforcement officers than perpetrators who do not strangle their victims (Gwinn, 2014). Tips for Law Enforcement and Prosecution: -Thoroughly document the events, signs and symptoms in the police report -Ask if the victim was strangled or “choked” or if they blacked out or had trouble breathing -Encourage immediate medical care and follow up care -Know the strangulation statute and applicable charges -Become trained on and use the Maryland Lethality -Assessment tool to help assess risk of death for victims of intimate partner violence -Obtain medical records for prosecution if victim sought medical care -Encourage counseling and support from local rape crisis center -Support training and screening on strangulation for community response team members -Help develop expert witnesses in your county Use expert medical witnesses and victim behavior experts for prosecution Healthcare Strangulation has both short and long term health risks for victims of strangulation. In addition to immediate signs and symptoms, victims may experience anxiety, depression, suicidal thoughts, PTSD, memory loss, and even stroke. Victims may have lost consciousness during strangulation and may have trouble recalling details of the sexual assault. They may also be embarrassed by some of their symptoms such as urinary or fecal incontinence. Ask questions in a way that victims will not be ashamed by what happened. An example may be, “It’s common for a person who’s been strangled to wet or soil their pants. Did this happen to you?” Tips for Healthcare Professionals: -Thoroughly assess for health risks in a trauma-informed way -Use protocols and designated documentation tools for medical evaluation and forensic evaluation for all victims -Emphasize importance of follow up medical care -Encourage counseling and support from local rape crisis center -Support training and screening on strangulation for community response team members Rape Crisis Center Advocates Advocates are in a unique position to provide information, education, and support to victims of sexual violence and allied professionals. When meeting a victim in the emergency department, talking on the hotline, or counseling a victim, advocates can incorporate information about the importance of medical care, as well as educate about the law and safety measures. Tips for Advocates: -Stress the seriousness of strangulation and the health impacts -Encourage immediate and follow up medical care -Encourage victims to document symptoms for health and prosecution purposes -Help victims assess their risk and create a safety plan -Assist with victims’ compensation claims and long term disability claims -Support training and screening on strangulation for community response team members Response Team Members In addition to the recommendations above, responders to sexual assault should have sexual assault response team county protocols and policies in place to address strangulation. Strangulation should be addressed in both sexual assault response and domestic violence response protocols. Protocols and templates can be found in the array of resources below. Resources Training Institute on Strangulation Prevention https://www.strangulationtraininginstitute.com/ International Association of Forensic Nurses Non-Fatal Strangulation Documentation Toolkit https://www.forensicnurses.org/page/stoverview?&terms=%22strangulation+and+toolkit%22 American Colllege of Emergency Physicians Evaluation and Management of the Sexually Assaulted or Sexually Abused Patient Second Edition http://www.mncasa.org/assets/PDFs/American%20College%20of%20%20Emergency%20Physicians%20ebook%20Sexual%20Assault.pdf Pennsylvania Coalition Against Domestic Violence Lethality Assessment Program (LAP) http://www.pcadv.org/Learn-More/Domestic-Violence-Topics/Fatalities/LAP/ MD Lethality Assessment Program https://lethalityassessmentprogram.org/ Connections Between Strangulation and Sexual Violence (PCAR webinar) https://www.youtube.com/watch?v=pNzkE7AS-mc&feature=youtu.be References Gwinn, C. (2014). Men who strangle women also kill cops. Domestic Violence Report, 19, 85. Retrieved from End Violence Against Women International: https://www.evawintl.org/ Hawley, D. A., McClane, G. E., & Strack, G. B. (2001). A review of 300 attempted strangulation cases: Part III: Injuries in fatal cases. The Journal of Emergency Medicine, 21, 317-322. doi:10.1016/S0736-4679(01)00401-2 McClane, G. E., Strack, G. B., & Hawley, D. (2001). A review of 300 attempted strangulation cases: Part II: Clinical evaluation of the surviving victim. The Journal of Emergency Medicine, 21, 311-315. doi:10.1016/S0736-4679(01)00400-0 Sorenson, S. B., Joshi, M., & Sivitz, E. (2014). A systematic review of the epidemiology of nonfatal strangulation, a human rights and health concern. American Journal of Public Health,104, e54-61. doi:10.2105/AJPH.2014.302191 Contributors Thank you to Dr. Ralph Riviello for his expertise and contributions with the factsheet. Ralph Riviello, MD, FACEP, MS, is Chairman of Emergency Medicine Crozer-Keystone Health System and Medical Director of the Philadelphia Sexual Assault Response Center. This project was supported by subgrant No. 26420-3 awarded by Pennsylvania Commission on Crime and Delinquency, the state administering office for the SASP and STOP Violence Against Women Formula Grant Programs. The opinions, findings, conclusions, and recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of PCCD or the U.S. Department of Justice, Office on Violence Against Women. © Pennsylvania Coalition Against Rape 2018. All rights reserved. Pennsylvania Coalition Against Rape Help • Hope • Healing Phone: 717-728-9740 Fax: 717-728-9781 Toll-free: 800-692-7445 www.pcar.org