Physical signs of strangulation in cases of domestic violence are not as obvious as we’re led to believe—so victims can suffer lethal related injuries and are seven times likelier to later die of homicide.

By Nicole Wetsman

Yeardley Love, a 22-year-old lacrosse player at the University of Virginia, was murdered by her ex-boyfriend in May 2010. The attack that killed her wasn’t the first—he’d assaulted her before. To Kathryn Laughon, a forensic nurse examiner and professor of nursing at UVA, one detail stands out: During one earlier incident, Love’s ex-boyfriend put his hands around her neck and strangled her. People saw it happen, but didn’t report it at the time—it got lumped in with the other episodes, and wasn’t recognized anything more or less violent than everything else going on.

But strangulation is a particularly dangerous type of abuse: It’s hard to detect, and it’s a major risk factor for homicide. If someone is strangled by an intimate partner and survives, they’re seven times likelier to later be killed by that partner. “Anyone willing and able to cut off someone’s air supply is a highly dangerous person,” said Jaquelyn Campbell, an expert on intimate partner violence and professor at Johns Hopkins University School of Nursing. All abuse is vicious, but most abusers don’t put their hands around their victim’s neck—if someone is inflicting harm in that way, the threat reaches another level. It can kill immediately, and victims can suffer strokes, brain injuries, or aneurysms days or weeks after the initial incident.

On a recent episode of Euphoria, a character, Nate, strangled his girlfriend, Maddy, leaving rings of dark bruises on her neck. Despite how strangulation may be portrayed on TV dramas, where victims immediately have telling dark marks around their throats, it often only leaves small physical signs, and many emergency rooms don’t screen for strangulation. Because the signs are subtle and easily missed if a doctor isn’t looking for them, both victims and law enforcement can minimize the incidents. Some states have policies called lethality assessment programs specifically direct law enforcement to ask victims of domestic violence if they’ve been choked or strangled, to predict cases likely to escalate to homicide, but they’re not universal. That leaves strangulation underrecognized, underreported, and undertreated.

Laughon is in the initial stages of a project to more clearly establish what strangulation looks like, with the goal of helping people working in emergency rooms know what types of physical evidence to look for, and to give expert witnesses stronger credibility when testifying about that evidence in court.

“As a forensic nurse, I’m often balancing a role of being a patient advocate,” Laughon said. “At the same time, I am compelled to go to court to provide an objective testimony—which I want to do in the most scientific way possible. The more objective and evidence-based I can be, the better.”

The more common signs of strangulation are a constellation of both external and internal ones, including hoarseness, swelling and cuts in the mouth, and tiny spots caused by blood under the skin called petechiae. But they can be negligible, which makes them difficult to document. “Whoever does the examination has to really know what they’re looking for,” and many emergency physicians don’t, Campbell said.

When strangulation happens in the context of a larger assault, those specific signs often aren’t pulled out of an overall report, and they’re easy for people who haven’t been specifically trained to miss. The Training Institute on Strangulation Prevention runs sessions for medical professionals, and institute head Gael Strack says that for many, this is the first time they’ve been given this information.

“If your voice is hoarse and your eyes are red and you’re having trouble catching your breath—you’ve probably been screaming, you’re upset, so that doesn’t stand out,” Laughon said. Petechiae can be hidden along the hairline or in the ear. It’s also harder to see some of the physical signs of strangulation on darker skin, particularly without a proper light source—and Black women experience particularly high rates of domestic violence. “Racial equity is a problem, as it is in all areas of the criminal justice system,” Laughton said.

The subtleties of the physical signs make it more challenging for experts like Laughon to link them to strangulation in the courtroom. “All I can do now is talk about what we know from past research from when people are strangled,” she said, “and say that those are consistent with the history someone gave me.”

Laughon is building a database of medical records from victims of domestic violence who did and did not report strangulation. She hopes to achieve more clarity on the physical symptoms that most strongly indicate strangulation by including at least 10,000 cases of domestic violence. The data does not include information about skin tone, just race, so Laughon isn’t sure how much information she’ll be able to pull out about injuries on darker skin—but she said she’ll address that question to whatever degree possible.

“People don’t always tell us that they were strangled, or they might not remember—after a trauma it’s hard to have accurate information,” Laughton said. “If we have a better sense of what’s a strong marker of strangulation, it would help follow up in that way.” That information would bolster the scientific foundation for courtroom testimony. “It adds another layer of evidence. It gives me the ability, when I sit on the stand, to say not just what I saw, but the degree of certainty I have that this is associated with strangulation,” Laughon said.

An emergency room physician who had more information on the physical evidence of strangulation might be able to better identify a case. “It could have an incredible impact,” Campbell said. “Our trauma and emergency departments are waiting for this kind of data. Because [Laughon] is a forensic nurse, she will be able to present the findings in a way that’s persuasive.”

Getting this information into the hands of physicians, law enforcement, and prosecutors is important: in places with lethality assessment programs, rates of intimate partner homicides drop. But increasing awareness of the danger of strangulation in the general population is equally important. Many victims don’t report domestic violence, and many victims don’t realize how dangerous strangulation can be—and how important it is to seek care and be monitored for signs of brain injury or stroke afterwards.

“If someone is strangled, it’s serious. It needs to be taken seriously,” Laughon said. “I always go back to Yeardley Love. He strangled her, and she said she was OK, and no one called the police,” she said, recalling the witnesses. “They were just kids—they didn’t know. People need to know.”

If you or someone you know is a victim of domestic violence, the National Domestic Violence Hotline can provide crisis intervention, information, and referrals to resources. You can contact them via their website or call 1-800-799-7233.

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