The following is a guest blog post by Hon. Alan Pendleton, Tenth Judicial District Court Judge in Anoka, Minnesota and Gael B. Strack, JD, CEO and Co-Founder of the Family Justice Center Alliance in San Diego.

The arrests of Ravens running back Ray Rice and San Francisco 49er defensive tackle Ray McDonald have, once again, thrust the ugly specter of domestic violence into the forefront of American consciousness. One of the most terrorizing and lethal forms of violence used by men against their female intimate partners is strangulation. Strangulation is much more common and serious than professionals have realized. Judges and attorneys who deal with perpetrators and victims of domestic violence need to be well-versed in the facts about strangulation; the most effective weapon against domestic violence is education and training.

Here are seven medical-legal facts that judges and attorneys who deal with domestic violence cases need to know about strangulation:

Strangulation defined. Strangulation is a form of asphyxia (lack of oxygen) characterized by closure of the blood vessels and/or air passages of the neck as a result of external pressure on the neck. There’s a widespread lack of understanding about strangulation. Many judicial officers and attorneys don’t understand the medical and psychological severity of the act of strangulation, because in many cases the lack of observable physical injuries to the victim cause judges to minimize its seriousness. To ensure that judges understand the seriousness of strangulation, some prosecutors have asked courts for permission to have an expert in the field of strangulation testify at bail hearings. Strangulation is one of the most terrorizing and lethal forms of violence used by men against their female intimate partners. The act of strangulation symbolizes an abuser’s power and control over the victim, most of whom are female. The sensation of suffocating can be terrifying; the victim is completely overwhelmed by the abuser. A single traumatic experience of strangulation or the threat of it may instill such intense fear that the victim can get trapped in a pattern of control by the abuser and made vulnerable to further abuse. Victims of one episode of strangulation are 7 times more likely to become a homicide victim at the hands of the same partner. Experts across the medical profession now agree that manual or ligature strangulation is “lethal force” and is one of the best predictors of a future homicide in domestic violence cases. The neck is the most vulnerable part of the body. Blood and oxygen all flow from the body to your brain through the neck, which is the most unprotected and vulnerable part of the body. More serious injuries occur from neck trauma than any other part of the body. It takes surprisingly little pressure to strangle someone. The brain needs a continuous supply of oxygen, without which, its cells quickly malfunction and die. Minimal pressure on the neck can prevent blood flow to the brain or prevent the return of blood flow from the brain to the heart. Without sufficient oxygen to the brain, unconsciousness occurs within 10 seconds, brain death within 4 minutes. It takes only 4 pounds of pressure to block the jugular veins, 11 pounds of pressure to block the carotid arteries, and 33 pounds of pressure to block the trachea (air flow). Compare this minimal pressure with opening a can of soda (20 pounds of pressure), an average handshake (80-100 pounds per pressure), or pulling the trigger of a handgun (6 pounds of pressure). Strangulation may leave little evidence on the skin. Lack of visible findings (or minimal injuries) doesn’t exclude a potentially life threatening condition; strangulation—even in fatal cases—often leaves no marks. A study by the San Diego City Attorney’s Office of 300 domestic violence cases involving strangulation revealed that up to 50% of victims had no visible injuries. Strangulation can cause substantial (and often delayed) injuries. Physical injuries short of death may include unconsciousness, fractured trachea/larynx, internal bleeding, artery damage, dizziness, nausea, sore throat, voice changes, throat and lung injuries, swelling of the neck, breathing and swallowing problems, ringing in the ears, vision change, and miscarriage. There can also be neurological injuries, such as facial or eyelid droop, left or right side weakness, loss of sensation, loss of memory, and paralysis. Psychological injuries may include PTSD, depression, suicidal ideation, memory problems, nightmares, anxiety, severe stress reaction, amnesia, and psychosis. Not all injuries are immediately apparent. There’s a possibility of delayed fatality (e.g., death can occur days or weeks after the attack due to carotid artery dissection and respiratory complications such as pneumonia, and the risk of blood clots traveling to the brain.

Historically, strangulation has been minimized by professionals due to the lack of visible injuries and the lack of medical training. Thirty-eight states, including California, have passed statutes in the last ten years to recognize this oversight, increase awareness, and enhance victim safety and offender accountability. The newly re-authorized Violence Against Women Act of 2013 added felony strangulation and suffocation to federal law. In March 2014, the U.S. Department of Justice issued sentencing guidelines and made a finding that “strangulation and suffocation, or an attempt of either, is specific serious conduct that deserves enhanced punishment regardless of injury.”

The Family Justice Center Alliance provides training on strangulation for all professionals, including judges and court staff. Training materials on strangulation are readily available at the Training Institute on Strangulation Prevention. Additional training material on domestic violence is at Judge Pendleton’s Judicial Training Blog.

By judges and attorneys educating themselves on this often misunderstood act, they will be better prepared to intervene appropriately. Effective intervention in non-homicide strangulation cases will increase victim safety, hold offenders accountable for the crimes they commit, and prevent future homicides.

For an easy reference guide to domestic violence law in criminal cases, turn to CEB’s California Judges Benchbook: Domestic Violence Cases in Criminal Court, the book provided to criminal court judges presiding over domestic violence cases.

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