Strangulation is one of the most dangerous and most misunderstood domestic violence behaviors. It is a quick and easy way to cause serious harm and death, which very often leaves no external signs of injury. The risk of homicide for victims who have been strangled is 750% higher than for those who haven’t, and the majority of all police officers killed in the line of duty are killed by men who have strangled women. All 50 states, 22 tribes, and 2 US territories have felony assault strangulation laws, and non-fatal strangulation is sometimes considered attempted homicide. Despite the danger, strangulation is used as a form of combat in some martial arts, occasionally as a form of force by military and law enforcement, and quite consensually and enthusiastically by a large portion of the general public as a way to increase sexual pleasure. (TISP Toolkit) This post will delve into the myths and facts of strangulation, signs and symptoms, and potential consequences, as well as some survival strategies and changing perceptions and laws.
Definitions
Strangulation is the external obstruction of blood vessels and/or airflow in the neck resulting in a deficient supply of oxygen (asphyxia). The term “strangulation” is commonly used interchangeably with “suffocation” and “choking”, but these are not actually the same things. Strangulation is the external application of physical force that impedes either air or blood flow to the brain, while choking is an internal obstruction of the airway by a foreign object, such as a piece of food lodged in the throat. (TISP Toolkit) Suffocation is often used as the common term for asphyxia, with definitions ranging from the stoppage of breathing to oxygen deprivation. It typically refers to blocking the nose or mouth to impede breathing. Strangulation can cause asphyxia by cutting off the airway so the victim cannot breathe. Importantly, strangulation can also cause asphyxia while the victim is still able to breathe by blocking the carotid arteries and jugular veins in the neck and disrupting the flow of oxygen to and from the brain via the blood.
“Choking” During Sex
A common kink, especially among younger people, it is widely believed that consensual strangulation during intimacy, commonly (and erroneously) called “choking”, is not dangerous. Choking has been increasingly portrayed in pop culture and on social media as desirable and safe. But however careful the partner doing the choking is, accidental serious harm and death is all too easy as it takes very little pressure (4 pounds per square inch) and a mere few seconds to cause damage. This is not kink-shaming. Even organizations like the National Coalition for Sexual Freedom, a sex-positive advocacy and educational organization, do not condone choking during sex due to the high number of deaths that occur in the BDSM community. In all but four US States, consent is not a defense for strangulation or suffocation. (NCSF).
Even if the choking is genuinely intended by both partners as a pleasurable act and not a form of abuse or control, strangulation in any context is also known to be the biggest predictor of homicide later on by that partner, whether by strangulation or another method (commonly shooting) (DomesticShelters). A 2007 study found that prior non-fatal strangulation by an intimate partner was reported in 43% of homicides and 45% of attempted homicides. Non-fatal strangulation and even consensual autoerotic “choking” is a form of practice, teaching the perpetrator exactly what they are capable of, what it feels like to have someone’s life literally in their hands, and how easy it is to kill.
Signs & Symptoms
Half of strangulation victims have no visible injuries to signal potential problems. However, half do show some visible signs of injury and/or symptoms of potential invisible injuries. Petechiae are pinpoint-sized red spots due to bleeding under skin or membranes. They look like a rash but are actually broken capillaries. Unlike a rash, they will not lighten or pale when pressed and are not itchy or painful. Strangulation can cause petechiae on the eyeballs or eyelids, scalp, earlobes, face, and inside the mouth. The presence of external petechiae almost certainly means there are also internal petechiae, potentially causing permanent brain damage. Other signs of strangulation include bruising, scratch marks, swelling to the neck, face, or chest, bloodshot eyes, vision changes, droopy eyelids, bleeding in the ears, swollen tongue, and other abrasions, redness, and bumps. (TISP Toolkit) Strangulation and suffocation often co-occur, and suffocation (such as by covering the victim’s nose and mouth with hands, a pillow, or a plastic bag, or sitting on their chest to restrict airflow) is even less likely to leave visible signs of injury (DomesticShelters).
Symptoms of strangulation that are not visible but are likely noticeable include difficulty breathing, noisy breathing (stridor), raspy/hoarse voice, loss of voice, difficulty swallowing, pain when swallowing, coughing, sore throat, ringing in the ears, nausea, and drooling. Some neurological symptoms that may be caused by strangulation include loss of sensation, extreme weakness, urination, defecation, vomiting, dizziness, headaches, loss of consciousness, memory loss, difficulty speaking, and behavioral changes. Many of these signs and symptoms may not be present immediately following a strangulation incident but develop later on. This means they are frequently missed, at least at first. It is a good idea for strangulation victims to be around someone they trust for 24 to 72 hours after an incident to help them be on the lookout for signs and symptoms such as these that may indicate a serious issue is developing. (TISP Toolkit)
Common Consequences
Strangulation for any length of time can be exceedingly dangerous. It can cause loss of consciousness within 5 to 10 seconds and death within 1 to 3 minutes. Conversely, death can also occur days to weeks after being strangled due to blood flow complications such as carotid artery dissection (a tear in the artery wall which causes a bulge or blood clot that blocks blood flow) and stroke, or respiratory complications such as pneumonia and acute respiratory distress syndrome (ARDS). As mentioned, only half of strangulation victims have injuries visible to the eye, and of those, only 15% are visible in a photograph, making them difficult to document or even notice. Thus, victims may look and even feel physically fine after being strangled but have internal injuries or delayed complications that are extremely serious and possibly lethal. Potentially non-fatal delayed complications include swelling, hematomas, vocal cord immobility, and displaced laryngeal fractures. (TISP Toolkit)
Strangulation can also cause psychological and neurological injuries, including post-traumatic stress disorder (PTSD), depression, suicidal ideation, memory problems, nightmares, anxiety, severe stress reaction, amnesia, and psychosis. (TISP Toolkit) Another consequence of strangulation could be a traumatic brain injury (TBI). Brain cells start to die after only 10 to 15 seconds without oxygen. A mild TBI, which strangulation more commonly leads to, may not even show up on an MRI and CAT scan, and symptoms like headaches, difficulty thinking, memory problems, attention deficits, mood swings and frustration can be easily overlooked or misdiagnosed. The more often a person is strangled, the higher their risk for brain damage as repeated lack of oxygen to the brain can have a cumulative harmful effect. (DomesticShelters)
Concealed Homicides
Because signs and symptoms of strangulation are frequently delayed, deaths from some of the delayed complications (such as stroke or pneumonia) are often attributed to that issue alone and not the strangulation that caused it. In this way, abusers may get away with murder because the death is not even recognized as murder. The frequent lack of visible injury also means it is all too easy to stage the scene of a strangulation that resulted in immediate death to look like an accident, natural causes, or suicide. This very thing happened to the sister of a DVSN community member, a rare case where the truth eventually came out. Read the details in DVSN’s October 2022 blog post, “Stacy’s Story: Shedding Light on Concealed Homicides”. More training and education on the dangers and signs and symptoms of strangulation can help illuminate some concealed homicides, but not all.
Strangulation Survival Strategies
While loss of consciousness and serious injury can happen extremely rapidly during strangulation, there are a few things victims can do in the moment that may help to save their life. Though the experience may be extremely scary and disorienting, trying to stay calm and think clearly can make a difference in the ability to escape. The “turtle shell technique” is a good way to protect one’s airway. This involves tucking the chin down to the chest as much as possible and raising the shoulders up to help support the neck. If victims are able to keep pressure off at least one side of their neck, they can likely avoid losing consciousness. With some attackers, complying with them may be the best way to survive, while with others, fighting back in whatever way they are able may be the best way for victims to escape. Kicking, pinching, biting, or hitting any part of the attacker’s body one can, with bare hands/feet or any weapon the victim is able to reach, can cause attackers to relax their hold enough to let the victim break free. Wiggling hips and shifting weight can also dislodge attackers who are pinning victims down. For victims who are able to get free, running or moving as quickly as possible away from their attacker and/or finding something with which to defend themselves are important immediate steps to prevent the attack from resuming. Getting to a safe place, calling for help, and seeking medical attention immediately can help save victims’ lives after strangulation. (DomesticShelters & TISP Toolkit)
New Knowledge & Changing Laws
A lot of the information presented here about the dangers of strangulation was only discovered in the past few decades. It is still not common knowledge but is slowly seeping into education, training for law enforcement, medical, and legal professionals, and into the laws themselves. Strangulation and suffocation were added to federal laws with the 2013 reauthorization of the Violence Against Women Act (VAWA) (TISP Fact Sheet). DVSN’s home state of Massachusetts made strangulation and suffocation its own crime in 2014. In 2018, California went as far as to pass a “Duty to Warn” law, requiring law enforcement officers to ask domestic violence survivors if they were strangled, record this information, and inform survivors of the dangers of internal injuries, urging them to seek medical attention. Laws like this can prevent strangulation deaths by helping to track those individuals who strangle and by helping survivors receive the knowledge and medical attention necessary to minimize damage and address further harm due to delayed or unseen injuries. Specifics of laws relating to strangulation for all US states and territories, many tribal codes, and several other countries can be found by using the Training Institute on Strangulation Prevention’s Legislation Map.
More education, research, and consideration of the extreme dangers of strangulation and many myths and misconceptions surrounding it are vital to helping prevent serious and deadly consequences, but understandings are growing and changes being made to increase knowledge and safety.
Resources
Training Institute on Strangulation Prevention (TISP) – offers lots of information, a free online training, and a resource library
TISP Advocacy Toolkit for Survivors of Strangulation/Suffocation – stats and information presented in an easy to understand visual format, plus lots of diagrams, risk assessment tools, and worksheets
TISP Strangulation Safety Plan – safety tips for before, during, and after strangulation and a tracking sheet to monitor symptoms
Defending Yourself 101 – suggestions for moves to escape an attacker in various situations from DomesticShelters.org
DVSN gratefully acknowledges Alliance for HOPE International and the individual authors noted on the three images reproduced here from the Training Institute on Strangulation Prevention for allowing their use.
Please check this monthly blog to read updates about DVSN
and stay informed about domestic violence.
Or, join our mailing list to get the information sent conveniently to your inbox!