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Strangulation: A Lethal Form of Interpersonal Violence
by Ruth I. Downing MSN RN CNP SANE-A

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.

Strangulation accounts for 10% of all violent deaths in the United States (Funk & Schuppel, 2003; McClane, Strack & Hawley, 2001). It is most common among female victims of intimate partner violence. A survey of battered women revealed that 68% experienced strangulation as a method of violence. Methods used were manual, using rope, clothing, seatbelt, chain, forearms and multiple methods (Wilbur et al., 2001).

It is important to distinguish “choking” from strangulation. Choking occurs when an object, such as a piece of candy, becomes lodged in the airway, preventing normal breathing. Strangulation is defined as “a form of asphyxia characterized by closure of the blood vessels or air passages of the neck as a result of external pressure on the neck” (McClane et al., 2001). Although a patient uses the term “choking”, healthcare and legal professionals should refer to the act as strangulation.

A study of 300 cases of strangulation survivors conducted by the San Diego City Attorney’s Office revealed that in 50% of the cases there were no visible markings to the neck and 35 % had only minor injuries (Strack, McClane & Hawley, 2001). This study demonstrated the need for improved documentation and medical training for law enforcement on strangulation. It also brought strangulation injuries to the attention of medical and legal professionals, and the research that followed demonstrated the seriousness of this form of violence.

Strangulation is a red flag for serious interpersonal violence. One study asked battered women what made them believe they were in danger. The majority of women perceiving a great amount of danger mentioned “choking” as a tactic used against them that made them believe their partner might kill them (Stuart & Campbell, 1989). “Nonfatal strangulation is a risk factor for lethal violence in several studies…These results underscore the need to screen specifically for nonfatal strangulation when assessing abused women.” (Campbell, Glass, Sharps, Laughon, Bloom, 2007)

Depending on the method, force used, and duration of non fatal strangulation, injuries may be visible or internal. Circular or oval contusions on the neck may be caused by fingertips of the assailant’s grasp. There may be bruising behind the ear or on the clavicle, or abrasions on the neck from a ligature. Neck edema may not be visible immediately, but may develop due to internal hemorrhage and injury to underlying neck structures. This edema may progress and compromise the airway, causing delayed death. Also, subcutaneous emphysema may result from laryngeal injury. Petechiae are tiny red dots that may be found above the location of blunt neck trauma, such as the face, eyes or eyelids, scalp or earlobes. Petechiae do not prove strangulation and their absence does not disprove it; they are simply a marker of increased cephalic venous pressure (Ely & Hirsch, 2000; Hawley, McClane & Strack, 2001; Hawley, 2002). Other presentations may include voice changes, hyperventilation, difficulty breathing, vomiting, aspiration, difficulty swallowing and adult respiratory distress syndrome. Hyoid bone fractures occasionally occur, and delayed death has been reported from carotid artery dissection.

The lethality of strangulation may alter prosecution from a misdemeanor to felonious assault or attempted homicide under certain jurisdictions. When healthcare providers and law enforcement understand the serious consequences of strangulation and provide appropriate documentation of injuries, justice can more effectively be served. The result will be improved safety for victims, and perpetrators will be held accountable for their actions.


  1. Funk, M., & Schuppel, J., (2003). Strangulation injuries. Wisconsin Medical Journal, 102(3), 41-45.
  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. Journal of Emergency Medicine, 21(3), 311-315.
  3. Wilbur, L., Hugley, M., Harfield, J., Surprenant, Z., Taliaferro, E., Smith, J., & Paolo, A., (2001). Survey results of women who have been strangled while in an abusive relationship. Journal of Emergency medicine, 21(3), 297-302.
  4. Strack, G. B., McClane, G. E., & Hawley, D. (2001). A review of 300 attempted strangulation cases part I: Criminal legal issues. Journal of Emergency Medicine, 21(2), 303-309.
  5. Stuart, E. P. & Campbell, J. C. (1989). Assessment of patterns of dangerousness with battered women. Issues Mental Health Nursing, 10, 245-260.
  6. Campbell, J. C., Glass, N., Sharps, P. W., Laughon, K., Bloom, T. (2007). Intimate partner homicide: review and implications of research and policy. Trauma, Violence, & Abuse, 8(3), 246-269.
  7. Ely, S.F., & Hirsch, C. S. (2000). Asphyxial deaths and petechiae: A review. Journal of Forensic Science, 45(6), 1274-1277.
  8. Hawley, D. A., McClane, G. E., & Strack, G. (2001). A review of 300 attempted strangulation cases part III: Injuries in fatal cases. Journal of Emergency Medicine, 21(3), 317-322.
  9. Hawley D. A., (2002, June). Death by strangulation. Paper presented at the conference: How to Improve Your Investigation and Prosecution of Domestic Violence and Strangulation Cases. Delaware, OH.

“The more a
man knows,
the more
he forgives.”

—Catherine the Great

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Ruth Downing
Ruth Downing