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 victims of this form of trauma, other vulnerable populations cannot be overlooked by health care and law enforcement professionals, including children and the elderly. Professionals providing a response to these vulnerable groups should also consider that these patients may have been injured by forms of smothering or suffocation.
In 44 states and the District of Columbia, health care professionals are obligated to report elder abuse to adult protective services.4 Elder abuse is defined as an intentional act, or failure to act, by a caregiver or another person in a relationship involving an expectation of trust that causes or creates a risk of harm to an older adult. (An older adult is defined as someone age 60 or older.) Forms of elder abuse are recognized to include physical abuse, sexual abuse or abusive sexual contact, emotional or psychological abuse, neglect, and financial abuse or exploitation.5
The incidence of strangulation and subtle nature of associated symptoms and injury are not easily distinguished if health care professionals, law enforcement, and pre-hospital personnel are not exposed to education and training about identification, screening, assessment, and treatment. In addition, forensic nurses have a pivotal role in not only evaluating patients seen after strangulation, but providing in depth evidentiary examinations and accurate medical-forensic documentation. A variety of case studies, best practice recommendations, and tools to support evaluation and documentation are reviewed in the following chapters.
Diana K. Faugno, MSN, RN, CPN, SANE-A SANE-P, FAAFS, DF-IAFN, DF-AFN
Valerie Sievers, MSN, RN, CNS, SANE-A, SANE-P, DF-AFN
Michelle Shores, MSN, RN, MBA-HC, CEN, SANE-A, SANE-P
Bill Smock, MD
Patricia M. Speck, DNSc, CRNP, FNP-BC, DF-IAFN, FAAFS, DF-AFN, FAAN
1.Breiding MJ, Basile KC, Smith SG, Black MC, Mahendra RR. Intimate Partner Violence Surveillance: Uniform Definitions and Recommended Data Elements, Version 2.0. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2015.
2.Strack GB, McClane, GE, Hawley, D. A review of 300 attempted strangulation cases part I: criminal legal issues. J Emerg Med. 2001;21(3):303-309.
3.McClane, GE, Strack, GB, Hawley, D. A review of 300 attempted strangulation cases part II: clinical evaluation ofthe surviving victim. J Emerg Med. 2001;21(3):311-315.
4.Daly