By Katheryn Utley

Special to the Tribune

A common but little understood abuse method is partial strangulation, and its long term effects are staggering.

What most victims, and many professionals who deal with domestic violence every day, don’t know is that it can cause brain damage, pneumonitis, miscarriage, heart attacks, and delayed death, days or even weeks after the assault.

Surprisingly, in 50 percent of reported cases, this level of damage can be achieved without leaving noticeable bruises on the outside of the neck. Because external bruising is slight, victims often discount the physically and emotionally traumatic experience, believing “they are not really hurt,” and fail to document the abuse. Even fewer seek medical attention.

In a National Family Justice Center study in which 300 victims reported a strangulation assault, only three victims sought any medical help at the time of the assault. According to chapters regarding medical evidence written by Dr. William Green and Forensic Pathologist Dean Hawley in the CDAA’s (California District Attorneys Association), manual for “The Investigation and Prosecution of Strangulation Cases”, without a continuous supply of oxygen brain cells quickly malfunction and die. Some die immediately, others can take weeks, causing the delayed death of the assault victim.

Even minimal force may cause bleeding and/or swelling inside the neck. The great risk is that both bleeding and swelling can progress (often slowly) and not cause obvious problems until the airway is blocked or a vascular disaster occurs.Anywhere from 5.5 to 22 pounds of pressure can damage the carotid arteries which compromises blood flow to the brain. Delayed findings may include bleeding and damage to the inside of the artery.

As the body tries to heal, blood clots may form inside the artery and block blood flow or break off and travel to the brain, resulting in clinical findings similar to those of a stroke. Only 4.4 pounds of pressure on the jugular veins may cause a back up of oxygen-deficient blood in the brain, resulting in the rupture of internal blood vessels and lack of oxygen to the brain.

Compression of the carotid body, a neurologic structure located in the back of the neck, can result in the slowing of the pulse and progress to cardiac arrest. Strangulation may cause fluid overload in the lungs, (pulmonary edema), up to two weeks after the assault. During the assault, vomit may end up in the victims lungs. The digestive fluids in the vomit may begin to “digest” the victim’s lungs causing pneumonitis.

Other neurologic signs and symptoms may include vision changes, ringing in the ears, facial or eyelids drooping, one-sided weakness, incontinence and miscarriage. Weeks to months after an assault, a victim may have problems sleeping, and experience impairment in memory and concentration.

Mental health problems can include anxiety, depression and dementia. In up to 50 percent of cases, there are no visible bruises.

“Victims really do underestimate the danger of the situation,” said Randi Breager, Domestic Violence/Assault Coordinator for the Alaska State Troopers. Breager gives 20 to 30 domestic violence trainings per year for troopers and police throughout Alaska.

“Training equals recognition,” Breager said. “Because it is so lethal and so subtle, we always bring in strangulation training as a specific component of domestic abuse training. It’s really important that officers ask the right questions and equally important for victims to be medically checked to be sure there’s no internal damage to the throat.”

Forensic Nurse and Coordinator of the Kenai Peninsula SART Program, Colleen James, seconds that opinion.

“There are 50 small muscles in the neck that can be torn, vocal chords can be damaged, causing speech issues, and the brain damage is lifelong,” James said. Victims lose a lot of cognition. They become unable to do any long term planning and grow more dependent on the abuser and less able to compensate for the brain damage as they get older.” Forensic nurses give thorough examinations and look for subtle symptoms that can help treat and document the damage. “We give a head to toe examination and use a questionnaire to assess brain injury.” The more often strangulation is used to control a partner the more likely the partner will suffer brain damage.”

Strangulation is often used by a perpetrator to accomplish a rape or demonstrate how far he is willing to go to establish control in the relationship. Victims can be rendered unconscious in 10 seconds with as little as 4 lbs. of pressure. Once the victim is released, it can take 10 seconds or more to regain consciousness.

“The batterers aren’t strangling to kill their victims, they’re strangling them to show that they can,” Breager said. The act itself desensitizes the batterer to intimate partner murder and is a strong indicator for potential lethality in the relationship. It also succeeds in thoroughly intimidating a partner.

As one domestic violence survivor put it, “Actually, when I came out of that (strangulation incident), I was more submissive, more terrified that the next time I might not come out, I might not make it. So I think I gave him all my power from there because I could see how easy it was for him to just take my life, like he had just given it to me.”

In 2005, Alaska took a leading role in the fight against this particular form of domestic abuse, and became the fifth state in the Union to change their laws to make strangling a felony instead of a misdemeanor.

“It’s a very serious offense, anytime you put your hands around someone’s neck, because it always brings them very close to death,” said John Novak, Assistant Attorney General for the State of Alaska. “This is one of the pieces of legislation in my career I’m most proud of. It astounds me still to know that when I’m sitting at a football game, or in any public space, one out of three women there has experienced domestic abuse or domestic assault.”

Tara Henry, a forensic nurse, was instrumental in getting this law changed in Alaska, Novak said.

“Because people didn’t understand strangulation,” Henry said, “it was being treated as a misdemeanor. Even though there were no bruises, based on my anatomical knowledge I had to ask, ‘What is going on here?’”

Henry looked for and found research about partial strangulation and its effects, as well as new information on how to physically document the abuse, like using special cameras to film bruises that are hidden underneath the skin. She began a campaign to educate first responders, police, prosecutors and politicians.

“One day, I was talking to a prosecutor about the law and said ‘We need to get the law changed.’ We both laughed and she said, ‘Yeah, why don’t you do that!’ And then I thought, why not?”

After some legal research, and a lot of persistence, Henry testified before the Alaska House and the Alaska Senate.

“Once professionals were educated, it passed without opposition,” Novak said. Gael Strack, founder of the National Family Justice Center, said education is key.

“Public education is a weak link in the chain where this health issue is concerned. Many women continue to endure chronic strangulation without realizing it could be slowly handicapping or killing them,” Strack said. “I’ve had women who were attending a workshop on domestic violence stand up and declare they would have left the relationship much earlier had they understood the damage that was being done.”

Because the law changed, training changed and is now ongoing. Homer Police recently completed a Strangulation Training review.

“Officers have a questions check list. Asking the right questions is a matter of protocol,” said Homer Police Sgt. Lary Khuns. “Our top priority is to investigate crimes against persons, and we have a pretty high solve rate. We work as a team with forensic nurses and victims advocates, often making the calls necessary to put victims in touch with advocates while at the scene of the crime.”

“People come to us when they are in crisis. But what we see is just the tip of the iceberg,” Breager said. In 2013, the Council on Domestic Violence did a random survey of over 900 women on the Kenai Peninsula. Forty-three out of 100 had experienced intimate partner violence. Thirty out of every hundred had experienced sexual violence. Partial strangulation occurs in almost two thirds of the relationships affected by domestic violence.

Crisis sometimes brings women to Haven House, a safe house for victims of domestic violence.

“Most of the time, though, it takes planning rather than a crisis to leave an abusive relationship, said Haven House Executive Director, Jessica Lawmaster, “because the highest risk for lethality is when the victim leaves. We have a 24 hour crisis line anyone can call for information, support and planning.”

“Friends, and open, nonjudgmental conversations about domestic violence are more important to battered women than most people realize,” Lawmaster said. “Keeping a public conversation going on domestic violence is one of the most important things all of us can do.”