Hann said domestic violence is still considered taboo, so officers might find a victim unwilling to acknowledge what happened, unsure because she might have blacked out, or did not know strangulation was significant and is not the same as choking, or she may not want to talk about it. She also may want to protect her assailant or is in fear of that person.
“Within the last years, there has been more and more light brought on these issues,” Hann said.
She said there is a “distinct difference” made now between choking and strangulation among authorities.
“There had been a misconception on both sides (police and the people involved in domestic violence incidents), and domestic violence was viewed for many years as a family issue, not a police matter.
“The Domestic Violence Act came forward, and everyone saw domestic violence in a different light,” Hann said. “But there are still some people who don’t want to talk about it. People look at it as an embarrassment. It keeps a lot of people from coming forward, and they downplay it because they don’t want to accept what really happened. The officers (in the past) were going on what they were told if there were no (obvious) physical signs (of strangulation).
“If there are no physical signs, the training is now more advanced, so officers look for other signs,” she said. “We can see other things that might contradict what we are being told.”
“Officers now know that if they document an investigation thoroughly, through photos, video and statements, etc., they can proceed with or without the victim,” Florence police Capt. Brian Boldizar said. “This is important, because a lot of times when it comes time to go to court, the victim does not come to court, or tells the judge that they do not want to proceed with charges.”
Boldizar added, “Some physical injuries may become apparent and visible as many as several days after an incident. So swelling, marks and bruises should be repeatedly photographed to show their evolution over time.”
“Some of the injuries may be self-inflicted, where the victim is struggling to stop the offender’s manual strangulation and/or to remove ligature from around the throat, neck or nose,” he said.
About 30 states have domestic violence by strangulation laws that under certain conditions make it a felony to impede a person’s breathing. New Jersey does not.
“Some have put a special focus on it,” said Sandy Clark said, executive director of the New Jersey Coalition for Battered Women and a member of the New Jersey Domestic Violence Fatality and Near Fatality Review Board, which examines cases provided by police and prosecutors to study how homicides could have been prevented. So there are many new methods used for determining exactly what has occurred when authorities arrive at a scene.
Clark said police also realize now that if a woman is the victim and has been raped, or if some other crime was committed at the same time as the strangulation, the strangulation might now stand out for her.
“Any form of domestic violence is treated very seriously and is prosecuted to the fullest,” Burlington County Prosecutor Robert D. Bernardi said. “We believe that an accusation of strangulation should be met with more severe charges, and have worked with local police departments to make sure they know how to determine when this abuse has occurred.”
Bernardi added, “Symptoms such as raspy speech, difficulty in swallowing or loss of bladder control, among other signs, may be present even if there are no red marks on the throat. It is crucial for the responding officers to be able to document this abuse has taken place, because it can be difficult to prove in front of a jury.”

Rachel, who asked that her real name not be used, lived in Camden County during much of her relationship with her abuser and now resides in Riverside. She is one of a growing number of women who are reporting being strangled during domestic violence incidents nationwide, authorities say.
And while in Burlington County, law enforcement officials and others maintain that the number of these nonlethal strangulation cases have not spiked locally, but they say that awareness of the seriousness of nonlethal strangulation is on the rise and that the response to this type of attack is being handled much differently than in years past.
Domestic violence advocates say the changes are the result of their work, which started slowly about a decade ago when domestic violence began to be viewed more and more seriously and as something that should no longer be considered a private affair that the assailant and victim could eventually work out. They say it is all too common for nonlethal strangulation to be part of these attacks.
A 2008 Journal of Emergency Medicine study found that a woman who experiences nonlethal strangulation — whether by someone’s hands or by ligature or other means — is seven times more likely to be the object of a murder attempt by her assailant. It also found that 43 percent of women killed in domestic violence attacks, and 45 percent of attempted-murder victims, had been strangled by a partner in the previous year.
In 2011, the most recent figures available, there were 380 murders in New Jersey, according to the Uniform Crime Report, compiled by the New Jersey State Police. Strangulation is included in the same category as hanging, drowning and asphyxiation.
But advocates have spread the message to victims as well as police, courts and others involved in these cases — even the attackers — that someone does not have to be killed to be strangled. They start by stressing that “strangling” is not synonymous with “choking,” as traditionally thought, and that strangling can have serious consequences other than death.
From there, they have been pushing for more and more police departments to get special training in how to handle and recognize strangling in domestic violence situations when it might not be apparent that the act has happened, and to charge assailants appropriately.
Burlington County has been making many of these changes.
A form of control and assault
“It’s (nonlethal strangulation) traditionally been a common form of control and assault in domestic violence cases,” said Sandy Clark, executive director of the New Jersey Coalition for Battered Women.
Clark also is on the New Jersey Domestic Violence Fatality and Near Fatality Review Board, which studies domestic violence homicide cases provided by police and prosecutors to see how these deaths could have been prevented.
“We’ve been trying to impress upon law enforcement that this is strangulation and not choking,” Clark said.
“Choking is literally choking on a piece of food, or allergies,” said Karen Hoisington, program director of Providence House Domestic Violence Services of Burlington County, which has a counseling center in Delran and a safe house for victims at an undisclosed location.
Providence House also trains community volunteers to become members of a domestic violence response team that assists victims immediately after an incident at the local police station or hospital.
“Strangulation is an aggressive act that abusers know often when to stop,” Hoisington said.
She said that choking is internal and strangulation is external, and that strangulation is involved in eight out of 10 domestic violence cases.
Clark said of new training and other efforts among those involved in this problem, “What we’re seeing today is the result of advocates working for the past 10 years (to raise this awareness). I don’t think the incidents (of strangulation) are going up (in New Jersey), but the recognition is that it’s not choking.”
“Clients are surprised” when they learn they have actually been strangled and not choked, Hoisington said. “They don’t realize how serious this is and that it can have residual health consequences. It can lead to brain damage because of a lack of oxygen to the brain.”
Voice changes (hoarseness, raspiness or loss of voice); breathing changes (difficulty or inability to breathe); involuntary incontinence and nausea; dizziness; miscarriage; mental status changes (sleep disturbance, amnesia, stress, restlessness or combativeness); fractured bones or injured cartilage in the neck; lung damage; fluid in the lungs; pneumonia; vision or hearing changes, and memory loss are among other results of strangulation.
“In general, you see more education coming out as far as strangulation cases they used to call choking,” Riverton police Chief John Shaw said. “Providence House and the state are pushing training and things to look for.”
Shaw said officers in his department stay up to speed on anything new regarding domestic violence, including attending regular meetings with authorities from the Burlington County Prosecutor’s Office.
“They listen to what prosecutors are encountering in the courtroom,” Shaw said.
Officer training has increased
He said that officers have had basic training in how to handle strangulation cases in the past, but that in the past couple of years the training has increased.
“A lot of times, people think people have to die for it to be strangulation,” Shaw said. “They downplay and think it’s choking if people don’t die. … They see people choke and not die.”
“One of the reasons strangulation has been underreported and underappreciated is there are often no visible injuries,” Clark added. “A black eye might look more serious, although a woman might have lost consciousness (from strangulation).”
“It’s a very high-risk factor for homicide,” she said. “A victim can be killed in five minutes, so in my mind, it’s attempted murder. If you’re strangled for two minutes, you’re half-dead.”
“There should be a red flag that goes up that this person could kill someone. It’s (strangulation) a relatively easy way to kill someone or to send a message that ‘I can very easily kill you if you don’t do what I say.’ ”
Dr. William L. Manion, who is the assistant medical examiner for Burlington County and a part-time assistant medical examiner for Ocean and Atlantic counties, said strangling someone is not only relatively easy but also convenient, because a gun or another weapon isn’t needed to accomplish it. He said it is also an assault that is “up close and personal.”
“When an offender puts their hands around a victim’s throat and squeezes, their intent is to seriously harm the victim,” added Florence police Capt. Brian Boldizar.
Manion explained that in strangulation the assailant usually goes for the jugular (large veins of the neck that drain blood from the head), causing petechial hemorrhaging in the eyes.
“It is easy to press the jugular vein and prevent blood in the head from going back to the heart. When the blood can’t go through the jugular, it builds up and causes small blood vessels to hemorrhage,” he said.
The bleeding is shown as tiny red dots or pinpoints and can appear as small hemorrhages in the whites of the eyes and inside the eyelids. If there is a really intense assault, they can be seen on the bridge of the nose, Manion said.
In addition to bruises on the neck, police will now look for petechial hemorrhaging as well other evidence of strangling that can occur during an attack or afterward.
“Things are more advanced now,” said Pemberton Township police Detective Danielle Hann of the handling of cases involving nonlethal strangulation.
Hann is the department’s domestic violence liaison and the coordinator for the officers’ training through Providence House and coordinator of the domestic violence response teams.
Hann said judges and the Burlington County Prosecutor’s Office are part of the new efforts in addition to police departments.
“There’s a great flow among all the agencies (involved in domestic violence) in Burlington County,” she said.

The Maricopa County Attorney’s Office created a pilot project through the Chandler and Glendale police departments, training officers to look for and document scores of physical indicators of strangulation. Police take the victim to an emergency room or advocacy center, and a trained nurse gets to the victim within an hour.

Through a contract between the county and Scottsdale Healthcare, 26 trained nurses in Scottsdale Healthcare’s forensic-nurse-examiner unit perform a head-to-toe exam, document patients’ history and take swabs or samples that may be used in an investigation. The nurses are on call 24/7 and fill out a six-page medical report. All the evidence gathered by police and nurses can be used when the Maricopa County Attorney’s Office looks to file a felony strangulation case.

“We want to prevent this before this is a homicide. So, I really looked at this project as a domestic-violence homicide prevention,” said Cindi Nannetti, a major-crimes division chief in the County Attorney’s Office, who led the project. “Men who get to the point where they have their hands around someone, taking the life out of them, they’re the most dangerous. If you’re going to triage that population of (domestic violence) offenders, we need to target these people.”

The program began in December 2011. Since then, it has expanded Valley-wide. Fifteen police departments and the Maricopa County Sheriff’s Office have submitted strangulation cases to the County Attorney’s Office.

Nurses performed 720 exams on victims between December 2011 and July 5.

The result: The County Attorney’s Office’s filing rate of felony strangulation cases jumped to 56 percent from 14 percent.

The National Family Justice Center Alliance, which runs the training institute on strangulation prevention for the U.S. Department of Justice, promotes the program as a national model, helping train other jurisdictions.

“Strangulation assaults have been missed by law-enforcement agencies and prosecutors for almost 30 years because there were often few visible injuries. No one thought it was very serious,” said Casey Gwinn, the center’s director. “What’s happening in Phoenix right now is a clarion call for the country. If every community in America were to be doing what Maricopa County was doing, we would save hundreds and hundreds of women’s lives in domestic-violence assaults.”

The first sign of strangulation people think of might be a bruise or redness around the neck.

But there are other subtle signs — visible or not — that can help police strengthen a case against a suspect and increase chances of successful prosecution.

Those signs include bruises behind the ears, blood-red eyes, swollen tongue or neck, and petechiae, which are spots on the body that indicate internal ruptured blood vessels.

Officers also need to ask certain questions and know to look for signs that may be indicators of strangulation. For example, if a woman has a raspy voice, an officer should ask if her voice is normally raspy and take note of how long her voice stays raspy. If a woman has a fresh set of clothes by the time police arrive, the officer should ask if she changed after urinating or defecating when she was strangled to the point of unconsciousness.

“It’s not that this is rocket science, but if you don’t know what you’re looking for, how are you going to find it?” said Scottsdale police Sgt. Dan Rincon, who helped develop the program as well as the checklist of evidence and questions for police to follow.

Nurses in the program also are available throughout investigations of domestic-violence strangulation cases and are available to consult police or go to trial if they are needed. The nurses are trained to look for specific signs and minute details that may not be noted at an emergency room, said Karyn Rasile, forensic-nurse manager at Scottsdale Healthcare.

“You’ve now got this medical component by trained individuals,” Rasile said.

Victims are encouraged to contact their nurse if other symptoms show up in following days after their exam. The advocacy center helps victims connect with shelters or resources for protection, such as obtaining orders of protection or changing a lock.

By Jo Ciavaglia Staff writer/Bucks County Courier Times

Non-lethal strangulation has become more common in domestic abuse cases in the United States over the last decade, but its seriousness has been historically minimized by the legal, law enforcement and medical communities since most victims survive, experts say.

But strangulation is ranked as more dangerous than other forms of physical abuse, and studies suggest that strangulation is often a predictor for homicide. Repeated strangulation can lead to other serious health problems, abuse experts say.

A 2008 study in the Journal of Emergency Medicine suggested that the risks of an attempted homicide increase about sevenfold for women who have been strangled by their partner. The study also found that 43 percent of women murdered in domestic assaults, and 45 percent of victims of attempted murder, had been strangled by a partner in the previous year. “If someone was stabbed and survived, we’d say that was a very close call. If someone says she was strangled and survived we don’t say, you were lucky,” said Gael Strack, CEO of the National Family Justice Center in San Diego, Calif.

LIFE IN YOUR HANDS
At least five women were fatally strangled by intimate partners or spouses between 2007 and last year in Bucks and Montgomery counties, according to the Pennsylvania Coalition Against Domestic Violence. While most domestic violence murder victims are shot or stabbed, strangulation has moved up to the third-most frequent cause of death in Pennsylvania, reflecting about 10 percent of the 110 domestic-related murder victims last year.

Last year, nine people were fatally strangled in the state, and strangulation was listed as a contributing cause in two other deaths, according to the coalition’s annual report. Four of the 76 domestic violence-related victims were killed by strangulation in 2000.

Strangulation was the focus at a coalition education conference last year, legal director Ellen Kramer said. In recent years, the group has worked on raising awareness among law enforcement and legal communities about its dangers, Kramer said. Last year, the coalition worked with the Pennsylvania Chiefs of Police Association to develop an officer training program on strangulation.

Some local domestic abuse experts and law enforcement members say they are seeing strangulation more frequently in domestic incidents.
“This year specifically I have recognized within reports references to abusers’ ‘hands around neck,’ ” said Lower Makefield police Sgt. Gail Jones, who follows domestic abuse cases in the township.

Bucks County’s domestic violence prevention program, A Woman’s Place, doesn’t keep statistics on the types of abuse reported, but it has noted a “definite” increase in clients who report being strangled, said Linda Thomas, the agency’s director of institutional advocacy.
Many women have told Thomas that they saw stars or light before blacking out. She added that many people think once the strangulation stops and they can breathe again, they are not injured. As little as 10 seconds of pressure on the carotid arteries in the neck is enough to deprive the brain of oxygen and cause someone to lose consciousness. If the pressure continues, brain death can occur in as quickly as five minutes, said the National Family Justice Center’s Strack. But even if the pressure is released — and consciousness regained — the person may experience serious, potentially fatal, injuries. Swollen vocal cords can block breathing and lead to death hours or days later. Repeated incidents of strangulation can cause permanent artery and blood vessel damage that can result in an increased risk of early stroke. Blocking the jugular veins prevents de-oxygenated blood from exiting the brain, increasing the risk of brain damage, which can be cumulative.
“No one understands that,” she added.

SERIOUS CRIME
When Lois Fasnacht worked as a domestic abuse advocate, she recalled often hearing victims describe abusers as grabbing them around the throat and shoving them against the wall. “That is a form of strangulation but you don’t think of it that way,” said Fasnacht, who is now a domestic abuse training specialist for the Pennsylvania Coalition Against Domestic Violence. “A lot of other people think strangled means death. A lot of people say when you’re strangled, you’re dead.”
Among the challenges with prosecuting non-lethal strangulation has been that, unlike a black eye or broken nose, the injuries may not be obvious, Strack and others said. A 1995 study found that in half of the strangling cases, people have no immediate signs of external injury, and 35 percent of the time the injuries are too minor for police to photograph. Strangulation presents with more subtle immediate signs, such as redness or scratches around the neck or chest, bloodshot eyes, dizziness, vomiting or loss of consciousness. Hours or days later, bruises also can form around the neck. Without signs of external injury, proving felony assault is difficult for prosecutors. Proving attempted murder is also tough since prosecutors have to prove the defendant intended to kill — not scare or control — the victim, experts say. But police can build a strong case if they know to ask the right questions, such as did the abuser say anything during the strangulation, and the injury signs to look for in suspected victims, Fascnacht said. “Law enforcement and prosecutors are starting to realize that it is a very deadly action, very lethal — I have your life in my hands,” Fasnacht said. “Just because you see the word choking, doesn’t mean this isn’t dangerous.”

The National Family Justice Center Alliance received a $400,000 U.S. Justice Department grant to fund a strangulation training institute, and Strack has traveled the country helping lawmakers draft bills and leading seminars for police. As domestic violence programs have focused more efforts on education and training involving strangulation, police officers are doing a better job at identifying it and charging appropriately, Strack said. As many as 30 states in the last five years have, under certain conditions, made it a felony to intentionally impede someone’s breathing, following cases involving domestic-related murders in which, before being killed, the victim reported nonlethal strangulation incidents.
But Pennsylvania is among the roughly 20 states where nonlethal strangulation is not defined as a crime. It is generally considered an assault that could be graded as a misdemeanor or felony. The Pennsylvania Coalition Against Domestic Violence has pushed for an amendment to the state’s assault statue to break out strangulation as a separate offense, but the bill has not found a sponsor.

Among the nine recent alleged non-lethal strangulation cases in the Lower Bucks area, most suspects were charged with simple assault, and in some instances, recklessly endangering another person.
Three cases included a felony charge of aggravated assault, but earlier this month a district judge dismissed the charge against the boyfriend of the Lower Makefield woman who said she was strangled to the point of vomiting. The man was held for trial on all other charges including simple assault.
Elsewhere, though, over the last five years, prosecutors have increasingly treated domestic cases involving accusations of strangulation more seriously, said Scott Burns, executive director of the National District Attorneys Association in Virginia. When strangulation is involved, it often results in more serious charges against defendants than in the past, he added.
“When I was a DA 10 years ago if we had a boyfriend strangle a girlfriend, he would have been charged with domestic violence. Today I may charge him with aggravated assault or attempt to cause death or serious bodily injury,” Burns said. “I just think it is education and a new heightened concern for that criminal act. It’s like DUI 40 years ago.”