Addressing Strangulation in Florida Courts: A Critical Resource

Published 10/22/25

Addressing Strangulation in Florida Courts: A Critical Resource

Please download the PDF displayed above, which contains footnotes and appendix items.

Written by: Gael Strack and Casey Gwinn for the Office of the State Courts Administrator, Office of Family Courts, Florida Institute on Interpersonal Violence

Contributing Authors/Editors:

The Honorable Lynn Tepper, (Retired) Florida 6th Circuit Court Judge

The Honorable Mary Evans, Florida 20th Circuit Court Judge

The Honorable Stefanie C. Moon, Florida 17th Circuit Court Judge

Ms. Kathleen Tailer, Esquire, Family Courts Operations Manager,

Office of the State Courts Administrator

Mr. Nathan Moon, Senior Attorney II, Office of the State Courts Administrator

Ms. Sophia Akel, J.D., Office of the State Courts Administrator

Sponsored by the Office of the State Courts Administrator,

and the State of Florida, Department of Children and Families.

FOREWORD

The Honorable Lynn Tepper, (Retired) Florida 6th Circuit Court Judge

“Strangulation is deadly force and stranglers are dangerous. Men who strangle women are the most dangerous men on the planet and many professionals continue to miss this truth. The research is clear: If a man strangles a woman one time in an abusive relationship, she is 750% more likely to later be killed by him than a woman who is . . . punched or slapped by her partner. The majority of mass shooters, cop killers, domestic terrorists, and domestic violence killers in this country have two things in common: A history of childhood trauma and a prior history of strangulation assault against women before they kill women or others.”

The significant impact of strangulation on victims and the likelihood the strangler will go on to kill others makes it clear that this extensive resource is needed by all Court partners. Indeed:

“Accountability Matters: Judicial officers should not continue to hear the words “He choked me” and treat this assault as if it were a slap in the face or a punch to the arm. Today, it is understood unequivocally that strangulation is the calling card of a killer; it is one of the most lethal forms of domestic violence and more prevalent than we once realized. Strangulation can have immediate, delayed and long-term consequences, including death. It is most often perpetrated by men against their intimate partners.” The long-term impact of near fatal strangulation on victims can be shockingly devastating. Nonetheless it is stunning to learn that strangulation is potentially more lethal than waterboarding! Above all else, the statistics found throughout this resource are impactful: as judges, we truly have opportunities to reverse those statistics at various stages of court proceedings. Moreover, the numerous links to model resources and tools found throughout this invaluable resource are easily downloaded and truly can change the trajectory of cases within our communities. Indeed, lives can be saved.

The chapters on “Medical Dynamics” and “Understanding the Evidence” contain invaluable information, regardless of whether the case is a bench trial (such as a domestic violence injunction) or a jury trial. The potential positive impacts for victims are numerous and significant.

Once you read those chapters, you may be inclined to encourage local law enforcement and child welfare investigators to read this resource and print out the extensive “Strangulation Assessment Sheet” to serve as a checklist and review as they collect evidence and complete investigations and interviews. The guidance and scientific bases are extensive. Consider just a bit of what may otherwise be missed:

“Body Worn Cameras (BWC) are particularly useful in domestic violence cases given the level of intimidation by offenders and recantation by victims. . . Recent studies show that BWCs are holding offenders more accountable; there are more arrests, fewer cases are being dismissed, and convictions are increasing.”
The use of medical witnesses can be critical in clarifying whether a victim, who may appear to be under the influence of drugs or alcohol, actually has stroke-related symptoms. What may be seen as deficiencies in a victim’s statement may be evidence of the trauma they endured.

This resource makes the connection crystal clear between past stranglers and their history of childhood trauma, which frankly also points the way for members of the Florida Courts to do more upfront so that children do not suffer trauma and those that do, after more thorough investigations, are believed and given every opportunity to heal. Consider this connection to a history of trauma: “Jim Henderson, a former probation officer in Ann Arbor, Michigan, and now a batterers’ intervention program (BIP) coordinator, has been conducting his own research involving his BIP clients. In a small sample, he has discovered that most stranglers have a high ACE (Adverse Childhood Experiences) score.

More significantly, the common factors with the men in his group who strangled included prior child sexual assault (90%) and 80% of them said when they disclosed the sexual assault as a child to their mothers, she did not believe them.”

That should be a stunning wake up call for each of us. I know in my 30 years as a 6th Circuit Court Judge, when I reviewed extensive background reports that included all DCF abuse calls, regardless of whether they were “founded” or not, it was not uncommon that calls of child sex abuse resulted in no action because of a “recantation” or claim by a parent that “it never happened.” In time I would learn that indeed it did. Further, I presided over cases involving men convicted of murder but were spared a jury recommendation of death after it was disclosed during the penalty phases that they endured a childhood of hideous and long-term unmitigated child abuse.

Understanding the devastating impact of strangulation in all cases is critical. However, judges and those in the justice system who are involved in any aspect of child abuse must understand that we actually have the ability to reduce the staggering number of stranglers from coming into existence at all: if we can stop one child who was sexually assaulted from being silenced, and suffering as a result; provide safety and judicial intervention; provide healing and evidence-based trauma therapy, we truly can expect that another strangler, high risk offender, or police killer will not evolve. If we are to assure that justice is done, and actually assist in reduction of the “creation” of perpetrators of fatal and near fatal strangulation, it is absolutely essential that in every case, judicial officers assure the following practices are in place:

Trauma assessments by qualified providers are done in all dependency cases;
Local law enforcement and child welfare, in conducting investigations of allegations of child sex abuse, follow best practices:
- Utilize local Children Advocacy Centers6 to conduct forensic exams and interviews,
- Follow protocols to assure that the alleged victim is not being manipulated or intimidated,
- The alleged perpetrator does not have any form of access to the alleged victim during the investigation and any prosecution.

The significant role of judges: scrutinize the history of men who strangle women.

“Whether that history is documented or provided to the court by the victim or others familiar with the defendant’s prior conduct, it is imperative that judges probe deeply into the potential risk of a strangler to the current victim, future partners, or the public. There is more than enough research to now suggest that stranglers are high risk offenders with the potential for lethal violence.” Florida judges: this is not about “something else to try.” The established protocols in this resource are effective. It’s about saving lives. Be part of it.

CHAPTER 1: Introduction and Overview of Strangulation and Suffocation Assaults

“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 given it to me.”

Survivor of Strangulation (2010)

INTRODUCTION

This is the most comprehensive guide ever prepared for judges to evaluate and adjudicate strangulation assaults. We now know enough about strangulation assaults to write an entire guide to help assist judges, magistrates, and other court personnel in their role in the administration of justice in handling these complex cases.

The research is indisputable; men who strangle women are the most dangerous men on the planet and many professionals continue to miss this truth. The majority of mass shooters, cop killers, domestic terrorists, and domestic violence killers in this country have two things in common: a history of unmitigated childhood trauma, and a prior history of strangulation assault against women before they kill women or others. We often say in our trainings, when the stranglers of America apply pressure to a woman’s neck, they are raising their hand and identifying themselves as killers. Why? What is the connection between strangulation and the mass shooters and cop killers of America?

The reasons are complex, but the rage of stranglers, soaked in misogyny, appears to produce what we now refer to as a “loaded God-complex.” Stranglers want their victims to know that they have complete control over whether their victims live or die. Stranglers literally hold victims’ lives in their hands. It makes sense that such rage-filled entitlement increases the likelihood that a strangler will kill a police officer or attack others when his power is questioned or challenged.

In failing to understand these complex connections, law enforcement officers, women, mass shooting victims, and many in the general public are dying because of our failed interventions with stranglers. The courtroom is where justice keeps its promise. Court professionals cannot continue to hear the words “He choked me” and treat this assault like we would a slap or a punch. The difference between life and death in most strangulation assaults is only a matter of seconds. We have an opportunity to stop most stranglers before they kill, but to do so, we must recognize strangulation assaults as a precursor to homicide.

Prosecutors are filing more non-fatal and near-fatal strangulation assaults as felony offenses even with little or no external visible injuries. Allegations of strangulation assault are regularly being presented in family, civil, and juvenile court cases. The challenge, then, in this guide is not to understand whether stranglers are dangerous; the challenge is to properly evaluate and adjudicate these cases even where the evidence is nuanced and subtle. The challenge is to ask the proper questions with self-represented litigants and rule thoughtfully on evidentiary issues when admissibility must be determined. As criminal cases begin to go forward with or without victim participation or testimony, judges must have the right tools and adequate guidance in adjudicating these cases. See Appendix 1 : Florida Bench Card and Appendix 2: The Family Court Judicial Checklist - Virginia.

The goal of this guide is to provide Florida judges and court personnel with the most current information, research, case law, and resources available at this time to enhance their practice, hold offenders accountable, and increase victim safety. Recently, we have seen tremendous progress with new statutory laws, research, case law, resources, protocols, and the development of multi-disciplinary response teams in the handling of strangulation and suffocation cases. Our rapidly expanding understanding has produced the need for more specialization, advanced training, and more experts to testify in strangulation cases. We encourage judicial officers and stakeholders alike to dive in and learn more about this deadly crime to effectively handle these cases in any courtroom.

OVERVIEW: THE SCOPE OF STRANGULATION

Strangulation impacts all professionals working on sexual assault, domestic violence, child abuse, elder abuse, animal abuse, and human trafficking cases. Strangulation is external pressure to the neck, by any means, that impedes air flow or blood flow, or both. Suffocation is the obstruction of air flow to and from the lungs making it difficult to breathe. Continuous pressure and obstruction of blood flow and/or air flow can lead to unconsciousness within seconds and death within minutes. See Appendix 3: Strangulation Infographic and Appendix 4: Five Myths About Strangulation.

Terminology: Some use the terms “strangulation” and “suffocation” interchangeably, but they are distinctively different. While many victims call it “choking,” it is not “choking.” Choking is usually accidental, most often the result of food lodged in the throat. Strangulation is intentional, lethal, and deadly. The term “strangulation” should always be used when external pressure is applied to the neck, even when a victim’s statement describes it as being “choked.”

Prevalence: One in three women will experience intimate partner violence in their lifetime. The prevalence of non-fatal strangulation by their partners varies between 68% to 80% for high-risk victims. Strangulation is common among high-risk survivors who call the police, seek shelter, go to court for protection orders, or access services at a Family Justice Center or Domestic Violence Center. Strangulation is also a gendered crime with virtually all perpetrators being male (299/300). Most women will be manually strangled with hands or arms; 38% report losing consciousness, and between 70% to 99% of strangled women believed they would die.

Inherently Dangerous: Strangulation is one of the most lethal forms of domestic violence. Victims may have no visible injuries—but because of underlying brain damage or other internal injuries due to the lack of oxygen during the strangulation assault—they may sustain serious internal injuries. They may even die days or weeks after the attack due to a stroke, suffer a traumatic brain injury, or experience other long-term physical and mental health consequences. Strangulation is also considered deadly force by law enforcement. Many states have now banned the use of neck restraints by law enforcement and in many states, it is a felony to apply a neck restraint on a criminal suspect.

Predictor of a Homicide: When a victim is strangled, she is at the edge of a homicide. Strangulation is one of the most accurate predictors of the subsequent homicide of victims of domestic violence. One study showed that “the odds of becoming an attempted homicide victim increased by about seven-fold for women who had been strangled by their partner.” Women who are strangled multiple times are at even higher risk. Another qualitative study, found that 100% of murdered domestic violence victims were strangled before they were killed, making strangulation often “the last warning” before a homicide occurs. See Appendix 5: Power and Control Wheel and Appendix 10: Danger Assessment 11.

Deadly Link to Other Crimes: Strangulation has also been linked to officer-involved critical incidents, officers killed in the line of duty in intentional homicides, and mass murders. The research shows the need for all professionals to improve their screening and documentation of strangulation cases. When working with a known strangled victim, it is imperative to make good use of risk assessment tools, encourage medical treatment, create personalized safety plans, and offer long-term follow-up.

Power and Control: Strangulation is also a form of power and control that can have devastating psychological effects on victims in addition to potentially fatal outcomes, including suicide. While most abusers do not strangle to kill their partner, they want them to know that they can kill them at any time. Most victims who survived being strangled believed they were going die and at least 31% of those victims later contemplated suicide. The inability to breathe is one of the most terrifying events a person can endure. Survivors of non-fatal strangulation have known for years what many professionals are only recently learning–many domestic violence perpetrators use strangulation and suffocation to silence their victims, gain control, torture, and kill them. Strangulation has now been recognized as the equivalent of waterboarding. The unique nature of non-fatal strangulation assault makes it a particularly effective tool of coercive control. With non-fatal strangulation, it is possible to bring someone to the point of believing death is imminent, but then stop, either before or immediately after they lose consciousness. In doing so, the strangler conveys a very powerful and credible threat of imminent death, which is an essential element of establishing and maintaining coercive control. Evan Stark has described coercive control as resulting in a “condition of unfreedom and a feeling of entrapment for survivors.” Strangulation survivors learn to comply with their abusive partner’s subsequent demands as a survival strategy, while abusers realize they can get away with it and it soon becomes their weapon of choice.

Health Consequences: Repeated injuries, concussions, and anoxic brain injuries will eventually take their toll.18 It is estimated that one in five victims of domestic violence has threatened or attempted suicide during their lifetime.19 The Centers for Disease Control estimates suicide is among the ten leading causes of death among women aged 10 to 54 in the United States (CDC, 2009). But why does a survivor of strangulation assault become suicidal after living through the scariest ordeal of their lives? The near-death experience of strangulation robs victims of hope.

Robber of Hope: Hope is the belief that the future can be brighter than the past and that an individual plays a role in making it happen. Hope is a future orientation with goal setting, motivation to pursue those goals, and the strategic thinking skills to overcome obstacles to achieve those goals. The opposite of hope is apathy. Apathy occurs when we feel as though we cannot control anything in our lives, and we begin to feel that “nothing will ever change” or “nothing that I want in life can happen.” A woman being strangled by the person she loves, realizing that the man on top of her with his hand or hands around her neck holds all the power over her life has been robbed of all hope, of any ability to set goals, of the ability to have dreams for the future, or to think strategically about ways to achieve her dreams. Robbed of all hope, survivors often begin to feel there is no way out and suicide becomes a way to stop the pain and end the terrifying reality of living with a strangler. Strangulation adds a life and death terror unparalleled in most other types of domestic and sexual violence assaults, which is why judges need to take strangulation cases more seriously.

A Gendered Crime Filled with Rage: Strangulation is most often perpetrated by men against their intimate partners. In our original 1995 San Diego Study, 99% of perpetrators were men. For the rage-filled, “loaded God-complex” man, strangulation is the weapon of choice. The experienced batterer knows that without visible injury, an untrained officer is less likely to find probable cause to arrest; and therefore, the chance of being arrested goes down dramatically. Indeed, most visible injuries may end up on the perpetrator as the victim fights for her life, increasing the odds that the victim is the one who will be arrested when untrained officers arrive. Who is going to believe a potentially hypoxic victim who appears hostile and combative victim with no visible injuries, especially if the batterer has scratch marks and bite marks from the victim trying to defend herself? Domestic violence perpetrators who use strangulation to silence their victims to the point of unconsciousness not only commit a felonious assault but should be charged for an attempted murder and even torture.

Need for Accountability: Given the lethality and seriousness of non-fatal strangulation, it is critical that courts hold the most dangerous offenders accountable for the felonious crimes they commit and pay special attention to victim safety issues from the bail hearing, to sentencing, and through the entire period of probation and/or parole. Stranglers are different. They pose a higher risk to their victim and the public in general. Reducing strangulation charges to misdemeanors or allowing stranglers to divert out of the criminal justice system sends the wrong message to offenders, victims, and the public.

WHAT HAPPENS WHEN A VICTIM IS STRANGLED?

Physiology of Strangulation/Suffocation: When a victim is strangled, unconsciousness can occur within seconds and death within minutes. Victims may lose consciousness by any of the following methods: blocking of the carotid arteries in the neck (depriving the brain of oxygen), blocking of the jugular veins (preventing deoxygenated blood from exiting the brain), or closing off the airway (making breathing impossible). With continuous pressure after unconsciousness, urination has been reported to occur within 15 seconds, and defecation within 30 seconds. Seizures have also been reported after pressure has been released, as well as during the application of pressure. See Appendix 12: Timeline of Physiological Consequences of Strangulation.

Anatomy: The neck is extremely vulnerable. Very little pressure on both carotid arteries for less than 10 seconds is all that is necessary to cause unconsciousness. If the veins are compressed while the arteries are open and pumping blood, little red spots called petechiae may result from build-up of venous pressure. Petechiae is evidence of obstruction of blood flow. Petechiae are smooth to the touch and provide evidence of internal injuries even though most visible petechiae will be on the surface of the skin—above the pressure of the chokehold (and even in the eyes). They form immediately or within seconds. If the pressure is immediately released, consciousness will be regained within 10 seconds. To completely close off the trachea (windpipe), more pressure is required. Brain death will occur in minutes if strangulation persists. It is important to remember that often in strangulation cases there are no visible external injuries, even in fatal cases. See Appendix 11: Vital Neck Structures.

HOW DID WE ALL MISS THE SERIOUSNESS OF STRANGULATION?

For many years, medical training to identify domestic violence injuries—including strangulation—for law enforcement officers, judges, prosecutors, advocates, and court professionals—was not included in core training. It wasn’t until the deaths of 17-yearold Cassondra Stewart and 16-year-old Tamara Smith in 1995 that the San Diego criminal justice system first began to understand the lethality and seriousness of “choking” cases. The deaths of these two teenagers were a sobering reminder of the reality of interpersonal violence, prompting the San Diego City Attorney’s Office to study existing “choking” cases being prosecuted within the office. Our published study revealed that, on a regular basis, victims had reported being “choked,” and, in many of those cases, there was very little visible injury or evidence to corroborate the “choking” incident. The lack of physical evidence caused the criminal and civil justice systems to treat many “choking” cases as minor incidents, much like a slap to the face where only redness may appear. These two horrific deaths ultimately changed the course of history and launched an aggressive national awareness and education campaign to recruit experts and improve the criminal justice system’s response to the handling of “choking” cases, which are now referred to as “non-fatal” or “near-fatal strangulation” cases. The momentum for specialized training has now spread around the country, including within the Florida court system.

Legal Reform: As a result of those early efforts, many strangulation cases are now being elevated to felony-level prosecution due to professionals understanding the lethality of strangulation. The momentum for change has spread nationwide, and even worldwide. As of May 2025, all 50 U.S. states have passed some form of a felony strangulation and suffocation law. There are strangulation and suffocation statutes in federal law and the Uniform Code of Military Justice, three U.S. territories (Guam, Virgin Islands, and Puerto Rico) and at least 20 Tribal Codes. Australia, New Zealand, Canada, the UK/ Wales, and Ireland have also passed new strangulation laws, with other countries not far behind. For a complete and updated list of existing strangulation laws and related case law, visit strangulationtraininginstitute.com and review the site’s Legislative Map of Strangulation Statutes.

In 2017, California passed one of the most life-saving statutes in America. Penal Code Section 13701 now mandates law enforcement officers to warn victims that strangulation can cause serious internal injuries and urge them to seek immediate medical attention and contact an advocate (Duty to Warn). PC13730 also requires law enforcement agencies to modify their reporting forms to document when strangulation and/or suffocation has occurred during a domestic violence incident (Duty to Track).

These new laws, protocols, and practices have created a demand for further specialization and expert witnesses. There are many more research articles, publications, resolutions, and published and unpublished cases on strangulation to assist professionals in their practice. Doctors, forensic nurses, and detectives are regularly being utilized as experts and testify in court about strangulation. Communities are now implementing countywide or state-wide protocols and use forensic nurses to assess and document signs and symptoms of strangulation. Despite dramatic changes in law, policy, and practice, however, there is still much more communities can do to improve their response to this deadly and devastating crime. There is no doubt that strangulation laws are important, but training and implementation is vital.

Need for Training: Strangulation training for all professionals (including judges) is provided at state and national conferences, some regional police training academies, and in hospital grand rounds. Further training is also available via webinars and online programs in the resource library at strangulationtraininginstitute.com. The Training Institute on Strangulation Prevention was launched in October 2011, as a program of the Alliance for HOPE International (Alliance). The Alliance serves as the comprehensive training and technical assistance provider for the United States Department of Justice for Office on Violence Against Women (OVW) grantees. The Training Institute provides training, technical assistance, web-based education programs, an online directory of national trainers and experts, and serves as a clearinghouse for all research related to domestic violence and sexual assault strangulation crimes.

The goals of the Training Institute on Strangulation Prevention are to: (1) enhance the knowledge and understanding of professionals working with victims of domestic and sexual violence who are strangled; (2) improve policy and practice among the legal, medical, and advocacy communities; (3) maximize capacity and expertise; (4) increase offender accountability; and (5) ultimately enhance victim safety.

Many professionals, including judges and court personnel, working with victims of violent crime rarely receive medical training concerning the identification and documentation of injuries or the signs and symptoms associated with strangulation. Providing these trainings on a regular basis will help institutionalize our understanding of strangulation, increase the capacity of professionals to handle these cases effectively, and ultimately save lives.

CONCLUSION

This guide covers key topics that judges and court personnel need to know to properly evaluate and adjudicate cases involving allegations of strangulation and/or suffocation assaults. This Chapter (Chapter 1) provides an introduction and overview of strangulation and suffocation assaults. Chapter 2 covers strangulation and the law, including case law in Florida and rulings from other states, which may assist judges in handling cases of first impression in Florida. Chapter 3 provides an overview of the physiology of strangulation, including what judges need to know in evaluating medical testimony. Chapter 4 focuses on understanding the evidence and being aware of the types of evidence which may exist in cases, particularly if prosecutors are seeking to prove cases without the victim’s participation. Chapter 5 focuses on survivor considerations with a particular focus on victim recantation. Chapter 6 delves into court considerations regarding bail and risk assessment processes, potential defenses, sentencing, and victim restitution.

Chapter 7 focuses on the use of expert witnesses and what judges should expect to hear from expert witnesses. Chapter 8 delves into the rage and anger of stranglers and what judges may be likely to hear and observe when evaluating those charged with strangulation offenses in the criminal context, and considerations of in-custody matters when strangulation is alleged and proven. Chapter 9 focuses on emerging issues including children witnessing strangulation, pediatric strangulation, the rough sex defense, and suspicious death cases. Chapter 10 focuses on promising or inspiring practices in addressing strangulation cases that could be implemented in Florida with judicial leadership. Chapter 11, written by The Honorable Mary Evans, Florida 20th Circuit Court Judge, focuses on strangulation dynamics in the context of parenting and family law. The sixteen items in the Appendices supplement the information provided in each chapter of the guide and their relevance is noted in each chapter.

Cassondra Stewart and Tamara Smith did not die in vain in San Diego in 1995. Their tragic deaths have clearly led to measurable changes in California, across the country, and around the world. Unfortunately, their cases never made it to the courtroom where the escalating violence could have been stopped, and homicides prevented. But now judges have a role to play in addressing victim safety and offender accountability. With strangulation laws on the books and more aggressive enforcement in Florida and across the country, the court system must be aware of the issues to be evaluated and the complex dynamics of strangulation assault cases.

CHAPTER 2: Strangulation and the Law

“Every survivor will tell you the same story. The inability to breathe is terrifying. It is fundamentally terrifying. It is so basic to our ability to survive. Being hit is bad but losing the ability to breathe (because of strangulation) is worse in a whole host of ways. I urge you to understand what those who are subjected to this behavior go through…and move forward with this bill to protect all of us who have been and will be victims of strangulation.”

- Former Oregon State Senator Elizabeth Steiner Hayward (Survivor of Strangulation and a Physician), Advocating for a Felony Strangulation Statute in Oregon, SB 1562, Feb 2018

INTRODUCTION

For many years, professionals across the nation have failed to treat non-fatal strangulation assaults as serious crimes. The lack of physical evidence, experts, training, laws, and protocols caused well-meaning professionals to unintentionally minimize one of the most lethal forms of domestic violence. Often, strangulation cases were not prosecuted at all and even if they were, they were treated as low-level misdemeanors due to the lack of visible injuries. In the civil context, allegations of strangulation were relegated to “he said, she said” allegations and minimized and ignored. Thirty years after the deaths of two teenagers in San Diego, the criminal and civil justice response has made tremendous progress.

While this chapter will mainly focus on understanding Florida’s strangulation law, it also provides a national and global overview of strangulation statutes and case law to assist judges in making informed decisions where there are gaps. This chapter summarizes the key points on why suffocation, non-fatal and near-fatal strangulation are now considered a felony. See Appendix 16: Strangulation Fact Sheet.

Evolution of Strangulation Laws: The first strangulation stand-alone law in the United States was passed in 2000 in Missouri. By 2014, 37 states and one U.S. Territory (Virgin Islands) had passed some form of a felony strangulation and suffocation law. Today, all 50 states, DC, and three U.S. Territories (Virgin Islands, Guam, and Puerto Rico) have added strangulation and/or suffocation assaults to their criminal codes, including the federal and Uniform Code of Military Justice (UCMJ). Most states have simply added strangulation and suffocation to their existing aggravated assault statutes.

Sixteen states have passed separate stand-alone strangulation and suffocation statutes. A few states have changed their definition of bodily injury or added a definition of strangulation and suffocation under a separate code section, thereby allowing prosecutors to charge strangulation as a felony. Most strangulation statutes protect any person while others limit strangulation laws to family members and/or a dating relationship. Strangulation has been recognized as a general intent crime. Visible injury is explicitly not required to prove the crime in the federal Violence Against Women Act (VAWA), the UCMJ, Delaware, Hawaii, Idaho, Nebraska, Pennsylvania, and Tennessee.

Federal law has one of the most comprehensive definitions of strangulation and suffocation. Under Federal law, Title 18 USC § 113, strangling, suffocating, or attempting to strangle or suffocate, means “intentionally, knowingly, or recklessly impeding the normal breathing or circulation of the blood of a person by applying pressure to the throat or neck, regardless of whether that conduct results in any visible injury or whether there is any intent to kill or protractedly injure the victim.” A violation of this code section is a felony and punishable up to 10 years. Only five states include consent as an element in their strangulation statute: Florida, Virginia, Pennsylvania, West Virginia, and Kentucky. Even in states that have included consent as an element, including Florida, an individual still cannot legally consent to an act that is considered an aggravated battery, can cause serious injury, or poses a risk of death or causes death, such as strangulation. The effort to understand the significance of strangulation and suffocation in the United States didn’t go unnoticed by other countries. Countries such as Australia (2016), New Zealand (2018), Canada (2019), the United Kingdom (2021), and Ireland (2023) have all passed similar stand-alone strangulation laws.

FLORIDA LAW

In 2007, Florida passed its own felony strangulation and suffocation law without any legislative findings. Section 784.041(2)(a), Fla. Stat., “felony battery: domestic battery by strangulation” reads:

A person commits domestic battery by strangulation if the person knowingly and intentionally, against the will of another, impedes the normal breathing or circulation of the blood of a family or household member or of a person with whom he or she is in a dating relationship so as to create a risk of or cause great bodily harm by applying pressure on the throat or neck of the other person or by blocking the nose or mouth of the other person. This paragraph does not apply to any act of medical diagnosis, treatment, or prescription which is authorized under the laws of this state.

Under § 784.041(2)(b)1., Fla. Stat., a “family or household member” has the same meaning as in § 741.28, Fla. Stat.

Under § 784.041(2)(b)2., Fla. Stat., a “dating relationship” is defined as “a continuing and significant relationship of a romantic or intimate nature.”

Under § 784.041(3), Fla. Stat., a person who commits felony battery or domestic battery commits a felony of the third degree, punishable as provided in §§ 775.082, 775.083, or 775.084, Fla. Stat.

There are two available jury instructions for these code sections: Jury Instruction 8.5(a) Domestic Battery by Strangulation and 8.5(b) Battery by Strangulation.

There are two published cases under this statute that provide guidance. In Lopez-Macaya v. State, 278 So.3d 248 (Fla. 3d DCA 2019), the Appellate Court held that the state need not prove great bodily harm to establish the crime of domestic battery by strangulation. The state can prove this crime by establishing that the defendant’s actions created a risk of great bodily harm.

In Dennis v. State, 338 So.3d 279 (Fla. 4th DCA 2022), the Appellate Court held there was sufficient evidence to show the defendant intentionally impeded the victim’s breath, as required to prove the offense of battery by strangulation. The felony-battery statute merely required that the defendant impede the victim’s breath, not cut it off entirely. In this case, the defendant suspended the victim’s entire body weight off the ground by holding her in the crook of his arm. The victim testified that she was trying to get a breath.

In 2023, Florida passed “Battery by Strangulation.” Under § 784.031(1), Fla. Stat., a person commits battery by strangulation if he or she knowingly and intentionally, against the will of another person, impedes the normal breathing or circulation of the blood of that person so as to create a risk of or cause great bodily harm by applying pressure on the throat or neck of the other person or by blocking the nose or mouth of the other person. This subsection does not apply to any act of medical diagnosis, treatment, or prescription which is authorized under the laws of this state.

Under section (2), a person who violates subsection (1) commits a felony of the third degree, punishable as provided in §§ 775.082, 775.083, or 775.084.

There are no published cases under this statute. Under these circumstances, it is important to look to legislative intent, jury instructions, other case law from Florida, and case law from other states, including unpublished cases. Since 2007, Florida courts have recognized the seriousness of strangulation. In Johnson v. State, 969 So. 2d 938, 956–957 (Fla. 2007), the Florida Supreme Court held that the strangulation of a conscious victim is prima facie evidence that a murder is “heinous, atrocious, or cruel,” and is an aggravating factor supporting the imposition of the death penalty. The Court also held that a murder victim’s statement to the defendant, made while she was being strangled, that she “wanted her children,” was admissible under the excited utterance hearsay exception. See Appendix 1: Florida Bench Card on Strangulation.

Legislative Findings from Other Jurisdictions

The Florida legislature did not include any legislative findings when it passed “Domestic Battery by Strangulation,” however, there is guidance from New York, Washington, Hawaii, and federal case law. State legislatures have played a profound role by adding legislative intent to their strangulation statutes. It helps professionals determine why this law is necessary, the goals for the new law, as well as provides guidance to professionals on the elements or evidence needed to prosecute to achieve their goals of homicide prevention and prevention of harm to individuals. For non-fatal strangulation, laws have been passed mostly to bring awareness, prevent future harm, and prevent homicides.

New York: In People v. Figueroa, 968 N.Y.S.2d 866 (N.Y. City Ct. 2013), the Appellate Court discussed the rationale for New York’s new strangulation law by stating: “The intentional obstruction of a person’s breathing or circulation is among the most potentially lethal forms of domestic violence. These acts send a message to the victim that the batterer holds the power to take the victim’s life, with little effort, in a short period of time, and in a manner that may leave little evidence of an altercation. The suffering endured by these victims often includes torment caused by the blocking of blood flow or near asphyxiation. It is not necessarily limited to pain alone. The law’s purpose was to increase penalties for intentional impeding or impairing of another person’s breathing, including but not limited to circumstances where such conduct leads to unconsciousness for any period or any other physical injury or impairment.”

Washington: The Washington legislature found “Assault by strangulation may result in immobilization of a victim, may cause a loss of consciousness, injury, or even death, and has been a factor in a significant number of domestic violence fatalities.” Strangulation is one of the most lethal forms of domestic violence. The particular cruelty of this offense and its potential effects upon a victim, both physically and psychologically, merits its categorization as a ranked felony offense.

Federal Case Law: In US v. Lamont, 831 F. 3d 1153 (9th Cir. 2016), the United States Court of Appeals for the Ninth Circuit carefully reviewed the legislative intent and cited to three reasons for its holding that assault by strangulation was a general intent crime. It also held that Defendant’s intoxication was irrelevant. The three reasons included: 1) Congress intended assault by strangulation to be a general intent statute in part to “decrease the incidence of violent crimes against Indian women.” Compared to all other groups in the United States, Native American women experience the highest rates of domestic violence. 2) Congress was concerned with the gradual escalation of seriousness associated with domestic violence offenses and sought to protect Native women from an epidemic of domestic violence by allowing federal prosecutors to seek tougher sentences for perpetrators who strangle or suffocate their spouses or partners. 3) Congress was focused broadly on the act of domestic violence against Native women, not on the mindset of defendants.11 The Court also stated “Many domestic violence offenders and rapists do not strangle their partners to kill them. They strangle them to let them know they can kill them at any time they wish.”

Hawaii: Then in 2019, the Hawaii legislature found that “Strangulation is a highly dangerous and potentially deadly form of abuse that frequently precedes other acts of violence. In addition, successfully prosecuting perpetrators of strangulation can be difficult because only fifty percent of strangulation victims have visible injuries. The legislature noted that although Act 175 explicitly provided that bodily injury need not be visible to establish the offense, it was not the intention of the legislature that other offenses that include bodily injury as an element be construed to require visible bodily injury.”

The Importance of Unpublished Cases: Florida’s strangulation law was passed in 2007, yet there are very few published strangulation cases under felony domestic battery, which is typical across the country when new laws pass. However, there are many helpful unpublished cases in Florida and across the United States that could assist judges in making important rulings and decisions. It is well understood that most courts disfavor the citation of unpublished cases unless the party believes the unpublished opinion persuasively addresses a material issue in the appeal and no published opinion from the court adequately addresses the issue. As such, it may be helpful to track unpublished strangulation cases and consider requesting publication in the furtherance of justice, consistency, and clarification.

Why Non-Fatal Strangulation Cases Should Be Treated as Felonies: There are clear reasons why strangulation assaults in domestic violence cases should be treated as felonies and not as misdemeanor offenses. These reasons have been articulated during legislative hearings across the country as statutes have been passed over the last 25 years, as well as in numerous published and unpublished cases. Court professionals should be familiar with the arguments that led to Florida’s strangulation and suffocation law. Those arguments are listed in the Appendix 16: Why Non-fatal Strangulation Cases Should be Treated as Felonies (2021). This document can be used in various hearings and reports to help professionals understand the seriousness and lethality of strangulation assaults. Key points are separated into bullet points to make it easy for professionals to use. Since the publication of this document, additional and compelling position statements have been published:

The American College of Emergency Physicians Policy Statement on Strangulation and Neck Compression of 2021 recognized the seriousness of strangulation and neck compression, particularly in cases of violence. The policy statement emphasized the need for emergency physicians to assess for strangulation in victims of intimate partner violence, child and elder abuse, and other contexts. It also called for increased education and training on strangulation recognition, assessment, and intervention within emergency medical services, medical schools, and emergency medicine residency programs.
Also in 2021, the American Academy of Neurology (AAN) issued a new policy statement on the use of neck restraints in law enforcement. "Because there is no amount of training or method of application of neck restraints that can mitigate the risk of death or permanent profound neurologic damage with this maneuver," the AAN recommends prohibiting the use of neck restraints. AAN further stated that the medical literature and the cumulative experience of neurologists clearly indicate that restricting cerebral blood flow or oxygen delivery, even briefly, can cause permanent injury to the brain, including stroke, cognitive impairment, and even death. Unconsciousness resulting from such maneuvers is a manifestation of catastrophic global brain dysfunction.

Rarely are victims just strangled, many are beaten, raped, and stalked: In addition to being strangled and/or suffocated, many victims are also threatened with death and believe they are going to die. The act of strangulation itself is a way to exert power and control over the victim. Such attempts to coercively control the victim are also exhibited by stalking perpetrators. Stalking generally is defined as a behavior in which a person repeatedly contacts, follows, or intrudes on a victim, leading to the victim feeling fear or distress because of the repetitive intrusion. In Florida, stalking means willfully, maliciously, and repeatedly following, harassing, or cyberstalking another person, § 784.048(2), Fla. Stat.

The link between domestic violence and stalking is well established. Researchers from Australia analyzed close to 10,000 cases of domestic violence that involved stalking and found that at least 16.6% (or 1,634) of those victims also experienced non-fatal strangulation. They recognized that this may be a low number, as often, strangulation is missed due to a lack of training, visible injuries, and/or reporting. Strangulation victims are also physically or sexually assaulted, restrained, kidnapped, intimidated to not call the police nor participate in the prosecution of the case. In the Oklahoma Study, victims reported severe violence by their abusive partners (63.39%), sexual abuse (17.66%), and/or sexual assault (29.46%). There may also be other victims and other crimes such as use of firearms or deadly weapons, animal abuse, child endangerment, and other related crimes.

Strangulation as Attempted Murder: Recently, statutes, case law, and researchers have come to recognize that strangulation cases should be charged as attempted murder in certain circumstances. In 2021, researchers reviewed 130 cases of non-fatal strangulation cases to determine whether case characteristics and themes across survivors’ on-scene statements can help prosecutors combat common legal defenses raised when victims are unavailable. Researchers found that only 6% of the perpetrators stopped strangling victims on their own, which suggested that non-fatal strangulation complaints should be investigated as attempted homicide until the evidence suggests otherwise.

In 2023, the Tennessee legislature added a new subdivision to their penal code, allowing prosecutors to charge attempted first-degree murder when the victim loses consciousness due to strangulation under § 39-13-202, or attempted second-degree murder under § 39-13-210. The difference between strangulation as an aggravated assault and strangulation as attempted murder is that strangulation is a general intent crime and attempted murder is a specific intent crime. However, when a victim is threatened with death, strangled multiple times, whether manually and/or with a ligature, and loses consciousness, prosecutors should consider charging for attempted murder. There is no reason to continue applying pressure to a limp and unconscious individual unless the intent is to cause death. Continuing to apply pressure after loss of consciousness significantly increases the chances of brain damage and/or death.

In People v. Vicary, D063404, 2014 LEXIS 3602, (Cal. App. 2014),the Defendant was onvicted of attempted murder of his wife under PC166/187 where the victim was strangled to the point of unconsciousness, not breathing, mouth open, and eyes rolled back into her head. Defendant did not let go until an independent witness yelled at the Defendant, at which point he said, “She was going to leave.” He then ran off. The witness, in an attempt to resuscitate the victim, repeatedly shook her until she started coughing and breathing again. The victim was then transported to the hospital. The victim also presented with petechiae, slight bruising on her neck, redness in her eyes, and neck and throat pain.

In People v. McCann, 126 A.D.3d 1031 (N.Y. App. Div. 2015), the Appellate Court found sufficient evidence of attempted murder in the second degree where the victim testified that the defendant choked her for two to three minutes, causing her to black out. The strangulation left her unable to lift her head or swallow, caused hematomas in her eyes, impaired her vision for several days, caused chronic neck pain, and an altered voice. The pathologist testified that the victim lost consciousness because the blood supply to her brain had been cut off from choking and that, had the defendant not released her, she would have died a minute or two later.

In Witham v. State, 49 N.E.3d 162, 168 (Ind. Ct. App. 2015), the defendant strangled the victim with a ligature until she passed out. The prosecutor argued there is only one reason a person would put a ligature around someone’s neck and that’s to kill them. It was not an accident. The defendant was acting with a conscious object to kill and to “close the deal.”

In State v. Fox, 184 So.3d 886 (La. App. 3 Cir. 2016), the act of choking someone after the point of unconsciousness was a disproportionate use of force that went beyond self-defense. The act of choking another person was indicative of a specific intent to kill.

In People v. Ryder, 44 N.Y.S.3d 598 (N.Y. App. Div. 2017), attempted murder was upheld where the defendant strangled his mother while she begged for her life and until she lost consciousness. The defendant also threatened he was going to get a gun and kill her. The victim testified she saw black spots and lights flashing before “it all went black.” She lost bladder function and thought she was going to die. The absence of long-term serious injury to the mother did not preclude the finding of life-threatening actions by the defendant. The court found that the defendant’s actions demonstrated an intent to kill.

In State v. Diaz, 410 So.3d 188 (La. App. 4 Cir. 2017), strangulation was upheld as attempted manslaughter where the victim was strangled twice, lost consciousness, had a garbage bag stuffed into her throat, and was threatened with death.

In State v. Pacheco, A-5042-16T4, 2019 WL 1567812 (N.J. Super. App. Div. 2019), the Appellate Court found there was sufficient evidence to prove attempted murder where the defendant told the victim “to die, to die already” and “die, die” while choking her twice to the point that she had difficulty breathing. He also repeatedly punched and kicked the victim. The Appellate Court held that the defendant’s words combined with the prolonged period of intense choking demonstrated the defendant’s intent to kill the victim.

In addition the victim begged the defendant not to kill her. “Please don’t kill me. Look atmy boy that is right there. Take anything you want, but don’t kill me. I have children.”

In People v. Sotomayor-Quan, Ill. App. (1st) 181617-U (unpublished), Defendant’s conviction for attempted first-degree murder was affirmed. The victim testified she had been dating the Defendant. They had been arguing for three days. On the day of the incident, the defendant had a “look of anger” she had never seen before. Defendant strangled the victim twice causing everything to “get blurry, go black, and her body go limp.” She repeatedly tried to break free, while the defendant repeatedly told her he was going to kill her, that she deserved to die, and that she was going to die that day. The victim was eventually able to escape and ran a block and a half. The defendant followed her in his car. The victim was able to ask a woman to call her mother, meanwhile she hid until her mother arrived. Her mother then took her to the hospital and took pictures of her. At the hospital, the victim spoke to police.

The defendant also testified. He denied most of the victim’s statements, claimed selfdefense, and said he had no intent to kill the victim. The Trial Court, in a bench trial, found the defendant guilty. The Court stated, regarding the attempted first degree murder charge, “[i]t is probably the hardest crime to prove, because one has to prove an intentional desire and intent to kill another person.” The Court found that the State had proved that intent beyond a reasonable doubt.

In making this finding, the Court explained that it relied on the combination of the defendant’s actions and words. Specifically, the Court highlighted that the defendant put his hands around the victim’s throat and strangled her while repeatedly stating that he wanted to kill her, “I’m going to kill you, you deserve to die, you’re going to die today,” repeatedly saying “you are going to die,” during a lengthy ordeal. Court also stated “When you put your hands on another human being’s throat and squeeze, that’s intent. When you grab somebody around the throat, you are making a statement. When you keep your hands around the throat, you are making a stronger statement, and then when you throw in and add to the mix the language that was used here, which demonstrated an intent to take the victim’s life, it’s not an accident.” The Court also observed that the defendant may not have had the constant intent to kill the victim “every single one of those moments” through the “lengthy ordeal that the the complaining witness endured” but explained that this was not necessary for a finding of intent.

The Appellate Court upheld the defendant’s conviction, finding the defendant’s intent to kill can be inferred from his conduct through the attack. Once the elements of attempted murder are completed, abandonment of the criminal purpose is no defense. “Suffocation is different. Choking someone with one’s hands is a continuous act with an indeterminate point at which death may occur. Whether the assailant completely blocks the airway or only partially does so, how long the victim can survive without oxygen–it is impossible to be certain when death will result. And we know from the victim’s testimony that she was on the verge of death or at least blacked out twice. So, unlike the irreversible decision to shoot someone, for example, intending to kill someone by choking is reversible—one can intend to suffocate someone but then later change one’s mind before it’s too late. The Trial Court, considering all the evidence, found that the defendant did, in fact, intend to kill the victim at some point in time while he waffled between rage and restraint, though he obviously later retreated from that decision.”

IMPLEMENTATION OF STRANGULATION LAWS–RELIANCE ON VICTIM PARTICIPATION

Even with the passage of new laws, felony convictions have proven challenging. Many states have difficulties in effectively implementing their laws (New York Times, 2013; Massachusetts, 2015; Texas, 2016; Iowa, 2017). In some jurisdictions, prosecutors outright refuse to prosecute serious cases of domestic violence and non-fatal strangulation unless the victim fully agrees to prosecute, regardless of the evidence obtained by police investigations (Pinellas County Domestic Violence Task Force, Tampa, Florida). Why is this happening after laws have passed, protocols have been written, and thousands of professionals have been trained? Communities fail to develop an implementation plan. Implementation is one of the most critical steps to affect change which takes leadership, teamwork, and a lot of hard work.

Local researchers from the University of Florida recognize that legal outcomes in domestic violence and non-fatal strangulation incidents are complicated by a multitude of factors. For strangulation cases, the challenges include the lack of: external visible injuries, medical treatment, forensic evidence, training, county-wide protocols, forensic nurses to conduct forensic exams, experts to testify in court, and victim participation.

Victim recantation also includes a multitude of reasons and factors: fear, intimidation, coercion, brain injury, lack of trust in the criminal justice system, continuances in the criminal case, suspect released from custody after arrest due to no bail or low bail, lack of victim support and services, housing, and/or overall safety concerns. Yet, when protocols are in place, professionals are trained, and evidence is collected by law enforcement or forensic nurses, prosecution and accountability does increase.

CONCLUSION

Florida judges do not currently have many published cases to rely upon in adjudicating issues in strangulation assault cases, but there are many cases, both published and unpublished across the country, which may provide guidance and assistance. Cases of first impression are to be expected in states where strangulation training is raising awareness for law enforcement professionals and prosecutors, as is currently happening in Florida.

Chapter 3: The Medical and Physiological Dynamics of Strangulation

“There are fundamentally two kinds of strangulation victims–dead ones and near misses.”

Dr. William Green

Introduction

Strangulation is a very dangerous and potentially lethal form of domestic and sexual violence. Unfortunately, it is also common. The rate of strangulation in domestic violence cases is estimated to range from 27-68%, depending on the study. Sexual assault victims report being strangled by their assailants at rates of 13-18%, though this number may be much higher. If the sexual assault occurs in the context of an abusive relationship, the strangulation rate climbs to 23-28.5%. Minimal pressure on the neck can cause serious injury, but even in fatal cases of strangulation, there are no visible external injuries in 40% of homicides. While a great deal of research has been done to understand the physiological dynamics of strangulation, there is no way to safely do studies where pressure is applied to the neck of human beings, and the impacts studied.

One study, the Rossen Study from 1944, yields data that is invaluable to experts in the field of strangulation assaults, but it can never be replicated. It is regularly cited in court to help educate judges and juries on the average time to unconsciousness from strangulation (6.8 seconds) and other signs and symptoms experienced by strangulation assault victims.

Judges should expect to hear from experts in strangulation assault cases, whether fatal or non-fatal. Experts can provide a wealth of information to the court and trier of fact given the large body of published research now available on strangulation assaults. This chapter is designed to provide judges with the most basic, minimal, medical, and physiological dynamics of strangulation. The full medical chapter spans more than 80 pages, but the fundamentals—and the key points an expert witness should be able to address in court—remain essential for judges to understand.

There are two types of strangulation—manual and ligature. Manual strangulation is generally done with an arm, hand (one hand or two), leg, or other body part. Ligature strangulation is generally done with a rope, cord, piece of jewelry, article of clothing, or other object. Judges should ensure that the jury gets adequate information to determine what type of strangulation has occurred and if external pressure was applied to the neck of another person that blocked air flow, blood flow, or both.

Not All Injuries Are Visible: Strangulation is a form of asphyxia characterized by external pressure to the neck, by any means, that occludes blood vessels and/or air passages of the neck. Judges often must make determinations about guilt or innocence as triers of fact, and must make rulings related to appropriate testimony from experts in strangulation cases. When someone has a gunshot or knife wound, the injuries are obvious. When someone has been strangled, it may be much more complicated. A victim can be strangled to death and have no external visible injuries. This means a person can be strangled almost to death and have no external visible injuries. If the victim fights back while thinking she is going to die, the injuries often include scratches, bite marks, or other injuries on the strangler. This can mislead police officers, prosecutors, judges, and juries. As a result, clinical forensic evaluation is important in most non-fatal strangulation cases.

Health care providers working the field of clinical forensic medicine commonly examine victims who were assaulted either by domestic violence, sexual assault, and/or strangulation. In some communities, this will simply be an emergency room physician or nurse, or perhaps a police officer or detective. The strangled patient presents multiple challenges and questions. Some of these questions relate directly to the medical care of the strangled patient. Other questions are directed to the needs of the criminal justice system. Did strangulation occur? Can the forensic examination help confirm the identity of the assailant? What was the intensity and duration of the assault? Was the strangulation assault a life-threatening event? Any professional, whether in health care or the criminal justice system, that interacts with the strangled patient/victim, must keep these basic concepts in mind:

Strangulation is a very dangerous (and often life-threatening) form of interpersonal violence.
Strangulation always includes both medical and forensic aspects.
Victims may not remember a chronology of events.
Victims may have major brain impacts along with trauma impacts.
Lack of memory may be evidence of internal injuries to the brain.
Lack of memory may be evidence of major trauma to the body.
Strangulation requires careful medical evaluation. Documentation must be thorough
and complete.

A clarification of terms is important for the purposes of context in this discussion. The term “forensic,” refers to the interface between the law and medicine. “Forensic pathology” is the medical discipline that deals with the evaluation of dead victims. This differs from “clinical forensic medicine,” which is the medical discipline that deals with the evaluation and care (both medical and forensic) of living victims. Clinical forensic medicine includes attention to patient care needs, while forensic pathology does not.

The term “clinical” refers to any information or activity related to patient care. Both “victim”and “patient” will be used to describe the individual who has been strangled. “Victim” has a criminal justice system connotation and “patient” is appropriate in a medical context.

Signs and symptoms are both important in documentation of a strangulation assault, though a victim may have been strangled and still have very few, if any, signs or symptoms. Signs are objective, observable, visible injuries and symptoms are subjective experiences reported by the victim. Photographic evidence gathered by law enforcement officers, medical professionals, the victim, or friends of the victim are often helpful in the evaluation of strangulation cases in court. Often visible injuries may take hours or days to appear after a strangulation assault. Even in a serious, life-threatening assault, visible injuries may not be present at the time of the assault in as many as 50% of cases. Many victims do not seek medical attention, making the documentation of signs and symptoms more difficult even if a case is later filed.

Judges should not minimize the seriousness of a strangulation case simply because there were no visible injuries immediately after the assault. Observable signs may include:

Strangulation 101 – The Medical Basics

Whether evaluating a strangled patient, investigating a strangulation case, or prosecuting a strangulation assault, everyone involved, including the jury, needs to understand the fundamental nature of strangulation, including:

basic physiology and anatomy;
medical terminology;
definitions and mechanisms;
pathophysiology (abnormal functioning);
clinical; and
clinical findings and signs.

This starts with basic anatomy (structure of the body) and physiology (bodily functioning).

Answering the Fundamental Questions

Signs Supporting Strangulation	Signs That May Be Consistent With Strangulation
Scratches on the victim	Venous Congestion
Fingertip bruises	Aspiration (vomiting)
Petechiae (small red dots)	Rope/Ligature Marks
Bite marks on the perpetrator	Abrasions
Scratches on the perpetrator	Bruising behind the ear(s)
Facial palsy	Central clearing on the neck
General bruising or erythema on the neck	Petechiae (on other parts of the body if offender was sitting on the victim while the assault occurred)
Incontinence (urination or defecation)

See Appendix 6: Signs and Symptoms of Strangulation and Appendix 13: Strangulation Assessment Sheet.

Answering the Fundamental Questions

Symptoms Supporting Strangulation	Symptoms That May Be Consistent With Strangulation
Neck pain or sore throat	Nausea and/or vomiting
Breathing changes or difficulties	Coughing
Voice changes (raspy) or inability to speak	Headache
Swallowing difficulties or pain	Changes in hearing (ringing or deafness)
Incontinence	Fear of death
Vision changes/blurred vision	Venous congestion (bloodshot eyes)
Focal neurologic weakness	Memory loss
Altered mental status or loss of consciousness	Feeling of generalized weakness or profound fatigue

The brain needs a continuous supply of oxygen. Without it, brain cells quickly malfunction and die. The brain is the most sensitive organ in the body when deprived of oxygen.

Within the brain, there is a spectrum of vulnerability with some areas being extremely sensitive and others more robust. When brain cells die, they do not regenerate, and the function they supported is permanently gone. To ensure continuous oxygen supply, two vital bodily systems must work perfectly and in unison: the respiratory (breathing) system and the cardiovascular (blood flow) system. Multiple areas of vulnerability exist in both of these systems, and the compromise of a single area can rapidly produce a very bad outcome.

Oxygenation is the process in the lungs that shifts oxygen gas from inhaled air into the bloodstream. Oxygen in the blood is then delivered to the brain cells. Once the oxygen is transferred to the cells, the blood is devoid of oxygen or deoxygenated. Carbon dioxide gas is the main waste product of respiration that is transferred from the cells into the bloodstream. The deoxygenated blood is now not only devoid of oxygen, but full of carbon dioxide. The carbon dioxide waste must now be removed from the body. Respiration delivers oxygen into the bloodstream. For the respiratory system to function normally, air must pass freely through the nose and mouth, through the upper air passages, through the upper and lower throat (pharynx and hypopharynx), through the voice box (larynx), into the windpipe (trachea), and finally into the lungs. Air must also pass freely out of the lungs, which allows the carbon dioxide gas to shift from the blood into air in the lungs and then be exhaled into the atmosphere. Normal breathing is the unobstructed in and out of air flow. The bones and muscles of the rib cage work with the diaphragm (large dome-shaped muscle between the chest cavity and the abdominal cavity) to create the mechanical “bellows” action that moves the air in and out. Cardiovascular refers to the system that includes the heart, arteries, and veins. The heart provides the pumping action that moves the blood through the lungs (for oxygenation and carbon dioxide removal) and to and from bodily tissues and organs. Arteries move blood away from the heart and veins move blood back toward the heart.

Carotid arteries (right and left) are the two main blood vessels in the neck that transport about 85% of the oxygenated blood to most of the brain cells. At the angle of the jaw, each common carotid artery divides into an internal carotid and an external carotid branch. Jugular veins (right and left; also with internal and external branches) are the thin-walled blood vessels in the neck that transport the oxygen—depleted, carbon dioxide-rich blood from the brain back to the lungs. Vertebral arteries (right and left) travel through bony passages in the bones of the neck (cervical vertebrae) to supply about 15% of the oxygenated blood to brain cells, mainly to the back (posterior) parts of the brain.

Medical Terms in the Courtroom in Strangulation Cases

The most common medical terms judges will hear in a courtroom in strangulation cases include:

Hypoxia is an oxygen deficiency in body tissue.
Anoxia is the absence or lack of oxygen in body tissues.
Abrasion refers to common visible injury in strangulation where the force applied damages superficial skin tissue and may remove layers of skin.
Asphyxia is a broad term defined in forensic situations where a body does not receive or utilize adequate amounts of oxygen. In the context of strangulation, asphyxia occurs when brain cells do not receive adequate oxygen for normal functioning. This may result from respiration compromise (the lungs being deprived of oxygen) or cardiovascular compromise (the brain being deprived of blood flow). Asphyxia may result from a combination of problems in both systems.
Carotid Dissection is vascular injury where the artery tears either internally or externally. Once a person experiences a dissection, the body forms a blood clot to stop the internal bleeding. This clot, once formed, has an immediate risk of breaking off and going to the brain, causing a stroke. Bilateral carotid dissections are also common in strangulation assaults, where the victim ends up with tears in both carotid arteries—creating a high risk of stroke without medical intervention. A stroke may lead to permanent disability or death.
Petechiae are small, tiny capillaries that burst when arterial flow continues but venous return of the blood is blocked by external pressure. In a strangulation case, petechiae will always be above where pressure is applied to the neck. They can be visible on the surface of the skin but may also be inside the brain (not visible even with imaging in the surviving victim). One small dot is referred to as “petechia.” Multiple burst capillaries are referred to as “petechiae.” If both carotid arteries are simultaneously compressed (by any mechanism) to the point that all carotid blood flow to the brain is stopped, neurologic dysfunction will begin very quickly. Lightheadedness and dizziness will give way to loss of consciousness within 10 seconds or less. If the carotid arteries are flowing and the jugular veins are blocked, petechiae will begin after approximately 15 seconds of pressure.
Hippocampus is the complex brain structure deep in the limbic system of the brain that plays a critical role in forming, organizing, and storing memories. The hippocampus is the most sensitive part of the brain to oxygen deprivation. Strangulation can damage cells in the hippocampus making it very difficult for a victim to recall events during the assault.
Ecchymosis is the medical term for a bruise which occurs when blood leaks from damaged blood vessels into the skin causing discoloration.
Venous Congestion refers to the swelling of tissues caused by increased blood flow and pressure in the veins. In strangulation assaults, it is often a precursor to petechial hemorrhages.
Erythema is redness of the skin or mucous membranes caused by hyperemia in the superficial capillaries under the skin. In a strangulation assault, erythema may disappear within minutes after the assault or may later turn into a bruise.
Tinnitus is the perception of sound in the absence of acoustic stimuli and is commonly called “ringing in the ears.” Tinnitus has been mentioned as a symptom in strangulation literature and may be due to transient lack of oxygen to the acoustic structures, but it has many causes.
Traumatic/Acquired Brain Injury can be long or short-term damage to the brain which results from the death of synapses and neurons in the brain due to trauma including blunt force and asphyxia trauma (such as strangulation). If brain cells die, they do not regenerate. This means there is a permanent damage to the brain which may or may not affect function, but brain injuries are also cumulative, so they can have profound long-term impacts on a victim.
Suffocation is a broad term encompassing different causes of asphyxia associated with oxygen deprivation.
Smothering is asphyxia by obstruction of air flow into the upper air passages including the nose, mouth, and pharynx (e.g., putting a pillow or hand over the victim’s nose and mouth, stuffing a rag into the victim’s throat).
Choking is asphyxia by obstruction of air flow into the lungs at the level of the voice box (larynx) or windpipe (trachea). This occurs when an object (e.g. piece of food or other object) mechanically blocks the air flow internally. Victims in strangulation cases will refer to being “choked” but the trier of fact must learn or ask what exactly “choking” means to the person testifying. In common parlance, some will call strangulation “choking” when in fact they mean strangulation.
Mechanical or positional asphyxia occurs when either external compression of the chest or abnormal body position stops or compromises normal breathing. If a strangler is sitting on the victim while applying neck pressure this can result in positional asphyxia and compromises normal breathing and blood flow to the lower extremities of the body.
Pulmonary edema is a rare but medically significant cause of post-strangulation shortness of breath, which occurs when fluid gets into the small air sacks (alveoli) and surrounding tissue of the lungs. This problem develops because complete airway compression instinctively causes the victim to attempt repeated, forceful inspirations (efforts to breathe). These attempts generate significant negative pressure within the lungs. After the obstruction is relieved, fluid from the capillaries in the lungs is drawn into lung tissue, which compromises normal oxygenation.
CTA Imaging refers to computed tomography angiography imaging and is the gold standard for evaluating a strangulation victim for vascular injuries (such as a carotid dissection).
MRI Imaging refers to magnetic resonance imaging and is a technique used in radiology to generate pictures inside the body. MRI scans are used more to evaluate strangulation injuries in Europe than in the United States. MRI scans identify more internal damage than CTA Imaging, but are considered more forensic in nature and are seldom used in forensic examinations in the United States.

Experts in strangulation assaults should be able to define each of these terms though appropriate language may vary depending on the expert’s background. A police officer with expertise might describe petechial hemorrhages as “tiny red spots” while a doctor or nurse may use more medical language such as referencing damage to capillaries from arterial flow and venous occlusion. Both descriptions are medically accurate but based on an expert’s background, their language may be different.

The Life-Threatening Nature of Strangulation Assaults

Strangulation assaults often produce life-threatening impacts. Strangulation is the type of offense where if the offender continues the act for 1-2 minutes, the victim will die. Carotid dissections appear to be much more common than originally believed, leaving researchers to call for CTA Imaging for all strangulation victims in order to rule out vascular injuries. Brain damage is also likely happening once victims experience unconsciousness from strangulation. Much of the data regarding brain injury is verified in the large body of stroke literature related to what happens to the brain once adequate blood flow is being reduced to the brain. See Appendix 15: HELPS.

Answering the Basic Forensic Questions in a Strangulation Case

Following the medical/forensic examination of the strangled patient, judges and other criminal and civil justice professionals should anticipate answers to the forensic questions posed in the introduction. Part of that anticipation is the expectation that the forensic examiner will be able to testify in court, using evidence-based answers to the questions, to help the jury understand what happened to the victim and the magnitude of the risks involved in the incident.

Did Strangulation Occur?

The subjective information will come from what the victim said to professionals involved in the response (e.g., the 911 dispatcher, law enforcement, emergency response personnel, the hospital nurses, the emergency physician, the forensic examiner).

The more consistent the documentation from each interview, statement, or history, the more credible and powerful the impact. The symptoms reported to medical providers offer consistency with the history of strangulation described by the victim. Some symptoms are more supportive of strangulation than others that are less specific. The thoroughness and accuracy of medical documentation also affects impact.

The most persuasive information supporting a recent strangulation event will be objective medical data. Traumatic physical exam findings (via written description and forensic photos) directly related to the documented mechanism(s) of injury are powerful. If visible findings are absent or minor, the examiner must be prepared to explain the statistics related to the lack of findings and the medical dangers of over-reliance on visible findings to confirm strangulation. The most compelling data to substantiate strangulation are injuries found on direct imaging, if available. See Appendix 14: Medical Radiographic Recommendations.

Who Was the Assailant?

In the context of sexual assault, about 80 percent of victims know their assailant. In domestic violence, virtually all the assailants are known. In the event of an unknown assailant, the identity issue falls on the law enforcement investigation and crime scene evidence. In strangulation, the victim’s body is technically part of the “crime scene” and DNA recovered from the victim (especially the neck) may provide a full profile. Investigators are always looking to see if that profile is in DNA database(s) and matches an individual. Generally, the identity of the assailant is not an issue in most strangulation cases handled in the context of domestic or sexual violence.

Was the Neck Compression Brief or Prolonged?

Expert witnesses and well-trained investigators may be able to assist the court and/or trier of fact in answering this question. Forensic science has provided some reliable benchmarks based on physical findings:

If there is petechiae above where pressure was applied, a minimum of 15 seconds of pressure was applied to occlude the jugular veins before capillaries began to burst
If loss of consciousness occurred during the strangulation assault, then bilateral, simultaneous pressure occluded both carotid arteries for at least 7-10 seconds
If the victim urinated or defecated, then bilateral, simultaneous pressure occluded both carotid arteries for at least 15 seconds for urination to occur and 30 seconds for defecation to occur.
Based on the Rossen Study, an expert is likely to testify that pressure was still being applied after the victim lost consciousness. See Appendix 12: Timeline of Physiological Consequences of Strangulation.

Was This a Life-Threatening Event?

This is usually the most important question for the criminal justice system and the jury. The victim has survived a strangulation assault. The fundamental issues are:

Was there a mechanism of injury present that could create a lethal outcome?
Were there symptoms or findings present that confirm the patient was on the path
to death?

There are two basic lines of inquiry. First is the presence of geographic petechiae. Petechiae above the pressure of the neck compression confirm that bilateral, simultaneous occlusion pressure was present for at least 15-30 seconds. This is the requisite mechanism for the path to stagnant hypoxia and, if sustained, to death.

The next avenue is more complicated with wider possibilities. The final common pathway to death is asphyxia of the brain. Sustained asphyxia will lead to death. There are two mechanisms that lead from a normal state, to cerebral hypoxia, to fatal asphyxia:

First is impairment of arterial blood flow to the brain. Without adequate arterial blood flow, there will be inadequate oxygen for normal brain cell activity and cells will begin to malfunction.

Manifestations of brain cell malfunction include:

Altered mental status (lightheadedness, dizziness, confusion, or hallucinatory phenomena)
Loss of consciousness
Incontinence (bladder and/or bowel)
Vision loss or visual disturbance

These findings, individually or in combination, indicate the path toward death has begun. If the arterial blood flow interruption continues, death will follow.

The second mechanism to brain asphyxia is airway compromise that interrupts arterial oxygenation. Impaired oxygenation will eventually lead to the final common pathway of brain asphyxia with the same findings just described. But before that point, airway compromise has unique symptoms that indicate the mechanism is in place:

inability to breathe;
inability to speak;
hoarseness or change in voice; and
shortness of breath or difficulty breathing.

If airway compromise is sustained, oxygenation will fail, brain asphyxia will progress, and death will ensue. There are fundamentally only two kinds of strangulation victims: dead ones and near misses. The line between survival and death rests on the degree of force applied and the duration of that force.

Special Note: Sexual Choking/Erotic Asphyxia

As this Benchbook goes to publication, there is strong evidence of a growing trend in today’s culture known as “sexual choking” or erotic asphyxia—which is strangulation during intimacy or sexual intercourse in intimate relationships. Medical experts in strangulation cases in court where “consent” or “agreement” to sexual choking is alleged should be able to testify that there is no physiological difference between erotic asphyxia and strangulation during violent assaults. The potential short and long-term medical consequences are identical.

The newest study by Dr. Debbie Herbenick and colleagues has found brain changes in women experiencing strangulation during sex compared to sexually active women not being strangled during sex. Courts across the country are finding, based on law and public policy, that a person cannot legally consent to something that can cause serious bodily injury, poses a substantial risk of death, or ultimately kills them. Medical professionals are finding no physiological differences between a violent, rage-filled strangulation assault and a so-called “consensual” sexual choking or erotic compression of the neck.

Conclusion

Expert witnesses in strangulation cases in Florida should be able to testify in court to the physiological and psychological impacts of strangulation assaults. Judges should be prepared to ask questions of self-represented litigants and even ask clarifying questions in criminal cases related to the physiology of strangulation assaults when presiding over jury trials or functioning as the trier of fact. There are a host of myths and misconceptions about strangulation that judges and juries must be able to evaluate in order to ensure informed decision making in these cases. Some of those myths are identified in Appendix 4: Five Myths about Strangulation.

Chapter 4: Understanding the Evidence

“He choked me.”

“He grabbed my neck.”

“He pinned me against the wall.”

“He wouldn’t let me go.”

“He grabbed my face.”

“I couldn’t breathe.”

“I felt dizzy.”

“I thought I was going to pass out.”

“I wet my pants.”

“Everything went dark.”

“I saw stars.”

“He said he was going to kill me.”

“I thought I was going to die.”

“I thought of my kids.”

Quotes from the San Diego Strangulation Study

Introduction

This chapter focuses on understanding the evidence collected by first responders, medical professionals, or detectives conducting follow-up investigation. It also discusses the evidence that can be identified by court personnel even without legal or medical intervention. Many victims of domestic violence do not call the police, nor do they seek medical attention. It is common for victims of strangulation to be unrepresented, pro se litigants at family court hearings. As such, it is important for judges to know the kinds of evidence they can ask about with or without lawyers present in court. This chapter also discusses important terminology, the use of specialized forms, protocols and bench cards as well as key questions to ask to identify the signs and symptoms previously discussed in the medical chapter.

Language Is Important: Special attention should be paid to vocabulary. While most victims will continue to report they were “choked” or grabbed by the neck—and it is important to use words the victim is most comfortable using—responders and court personnel need to acknowledge the seriousness of the abuse that occurred. “Cahoking” is accidental. Strangulation is intentional. Choking can be intentional when a suspect forcibly lodges an object down a victim’s throat such as a plastic bag, telephone, a fist or other objects. Choking means having the windpipe blocked entirely or partly by some foreign object, such as food. Strangulation means to obstruct the normal breathing of a person or to inhibit the circulation of blood into, or out of, the brain by applying external pressure to the person’s neck. Suffocation refers to obstruction of the airway at the nose or mouth and can occur accidentally or intentionally. Suffocation can even include applying weight or pressure on someone’s torso/chest such as positional asphyxia. The word “choking” minimizes the severity of non-fatal strangulation for victims and all professionals working in the justice system.

For many years, medical experts and researchers referred to strangulation assaults as “attempted strangulation.” This represented an inadequate understanding of the nature of the assault. Indeed, even in our seminal San Diego Strangulation Study, we used “Attempted Strangulation” language. The belief, though unstated in most research, was that strangulation meant death. If a victim survived, it must not have been strangulation; it must have only been “attempted strangulation.” Sadly, this language is still used by some courts, professionals, media outlets and/or even in statutes. Based on the current state of the law and research, any intentional effort to apply pressure to the neck, by any means, should be viewed as a strangulation assault, not merely a “choking.” It takes very little pressure to impede/occlude air or blood flow or airflow. Both signs and/or symptoms can corroborate a strangulation assault. As such, the perpetrator does not “attempt” the assault. The act of strangulation is completed it at the time pressure is applied and there is evidence of obstruction of airflow or blood flow. For court purposes and report writing, professionals should correctly memorialize the words used by the victim, preferably noting their words in direct quotes. Professionals should consider asking a few questions included in the Florida Bench Card on Strangulation. See Appendix 1: Florida’s Bench Card. By asking the victim questions related to strangulation, the victim’s statement could go from “He choked me” to this sample police report from San Diego, after training:

“The victim told me she was choked. She said her husband applied continuous pressure to her neck. He used both of his hands. She didn’t know how long, but it felt like forever. She saw his eyes were black and he was full of rage. He had the eyes of a demon. She reported she could not breathe, felt dizzy and thought she was going to die. The next thing she remembers is waking up and her pants were wet. She doesn’t remember how she got from the kitchen, where the argument started, to the bedroom where she woke up. The victim said she had no visible injuries to her neck, but when she looked in the mirror; her eyes were red and stayed red for days. Based on the victim’s description of the assault, I concluded that her signs and symptoms were consistent with strangulation.”

In addition to using the term “strangulation,” it may be appropriate to use “suffocation,” “near-fatal strangulation,” and “non-fatal strangulation” depending on the circumstances. When there is evidence of unconsciousness, petechiae, urination and/or defecation, near-fatal strangulation would more accurately describe the assault.

Use of Specialized Forms, Protocols, Manuals and Bench Cards: Today most law enforcement agencies have developed specialized domestic violence reporting forms, checklists and protocols to investigate domestic violence cases. It is expected that officers arriving at the scene of a domestic violence case will conduct a thorough investigation and prepare written reports describing all incidents of domestic violence involving the victim and perpetrator, as well as documenting all crimes committed by the perpetrator.

Over the last 13 years, countywide protocols in the handling of strangulation and suffocation cases were first adopted in communities starting with Maricopa County, Arizona (2012), Brevard County, Florida (2015) and San Diego, California (2017). These jurisdictions are not only using specialized reporting forms for domestic violence cases, but they are also utilizing specialized reporting forms for strangulation cases. Some jurisdictions have included questions about strangulation and suffocation into their domestic violence or sexual assault forms. Strangulation/suffocation protocols are spreading across the United States. Most recently in 2023, statewide strangulation protocols have emerged in the states of Indiana, Delaware, and New Jersey.

To enhance statewide implementation of strangulation laws, multiple states have published manuals on the handling of strangulation cases in collaboration with our Training Institute on Strangulation Prevention including California (2014, 2020), Alaska (2015), and Kentucky (2024). Judicial Bench Cards on strangulation and suffocation have also been developed across the United States in various states including Minnesota, Virginia, Florida, Arizona, and Ohio. Florida’s Bench card contains 18 things judges need to know. See Appendix 1: Florida Bench Card. As part of Florida’s Bench card, Section 16 lists 15 Questions to Consider Asking in Court, judges should consider asking victims in evaluating a strangulation case. Many more questions are available in various manuals. See Appendix 6: Signs and Symptoms of Strangulation.

Did anyone apply pressure to your neck, by any means?
Did the attacker use one hand or two?
Did the attacker use something other than his hands?
Did the attack take place from the front, behind, or both?
How long did it last? (Trauma may impact a victim’s ability to tell time.)
Did you have marks or bruises on your neck at the time of assault or after?
Did you have trouble breathing?
Did you have trouble swallowing?
Did you have a sore throat?
Did your voice change?
Did you have trouble speaking?
How did you feel when pressure was being applied?
Is it possible you may have lost consciousness? Any vision changes?
Did you see stars or spots? (But be aware, the victim may not know.)

Recently, in Larson v. Gibson, No. 344, 2024, 2025 WL 1554872 (Del. 202, the Appellate Court found it was appropriate for a Family Court Commissioner to use questions from a bench card related to coercion, strangulation and oral sex to examine the respondent’s expert witness.

The Signs and Symptoms of Strangulation: Learning how to identify, document, and understand these signs and symptoms of strangulation and/or suffocation requires special training and special consideration. Without training for all professionals handling these assaults, very few criminal cases will ever make it to the courtroom. Recently, Florida researchers analyzed 63 non-fatal strangulation cases by reviewing law enforcement reports, forensic medical examinations and legal outcomes. They concluded less than 50% were ever charged. Knowing which questions to ask will assist in identifying evidence consistent with strangulation starting from the 911 call, to body worn cameras, to the statements of the victim, the suspect, and other witnesses. Evidence of strangulation can also be found at the scene, documented in photos, impounded evidence, medical documentation, the prior history of abuse, follow-up interviews with victims and witnesses, and jail calls by the offender. Forensic evidence collected by specially trained forensic nurses and physicians can corroborate non and near-fatal strangulation cases and dramatically increase the prosecution of such cases.

Understanding Symptoms of Strangulation: As discussed in Chapter 3, The Medical and Physiological Dynamics of Strangulation, the signs of strangulation injuries are not always visible; however, most victims will have at least one or more symptoms of strangulation which includes neurological, voice, swallowing and breathing changes. Symptoms provide corroborating evidence of strangulation and/or suffocation. Symptoms of strangulation can be revealed in 911 calls, body worn camera footage, paramedic reports, medical records, law enforcement investigations, statements from friends, family members, coworkers, neighbors, in petitions for restraining orders, conversations with child protection service workers, observations from the court and from the victim herself. Knowing what to look and/or listen for will help the court understand the severity of the crime. Strangulation is a type of crime that is often missed, minimized and/or misunderstood.

The Emergency 911 Call: Emergency 911 recordings provide key evidence and corroboration to strangulation assaults. 911 calls capture the victim’s emotional state and often include: (1) statements about the incident; (2) the domestic violence history in the relationship; (3) the victim’s physical condition; (4) the victim’s and/or suspect’s level of intoxication and/or use of drugs; (5) the presence of witnesses; (6) the presence of weapons; (7) the existence of protective orders and other corroborating evidence. The 911 call is a microphone into the violent incident and often records statements from children, witnesses, and/or the abuser. Here is a 911 call from the original San Diego Study:

Caller: Hello?

911: Yeah, Michelle. This is Lynn at San Diego Police Department. Is this your husband or boyfriend?

Caller: My husband.

911: It’s your husband?

Caller: Yes.

911: Okay. Does he have any weapons at all?

Caller: No.

911: What did he do to you?

Caller: He—

911: Okay, I want you to try to take a deep breath and calm down.

Caller: He tried to break my neck.

911: He did what?

Caller: He tried to break my neck and suffocated me. And he— (unclear speech)

911: Okay, do you need a paramedic? Okay, Michelle, do you need a paramedic?

Caller: No.

911: Are you sure?

Caller: Yes, I’m sure.

911: Okay. He’s inside your house alright. He’s not there with you?

Caller: He might have taken off in the car right now.

911: What kind of car would it be? Hey, Michelle, I want you to take a deep breath and try to calm down, okay? He’s not right there, so he- (audio cuts out)

Caller: He— (unclear speech)

911: Okay, Michelle?

Caller: Yeah?

911: Okay.

Caller: I—I—I’m not crying. I just can’t breathe very well.

911: Alright. Do you want a paramedic?

Caller: No, I’m o— I’m okay.

911: Are you sure? If you can’t breathe...

Caller: How come I can’t—How come I can’t breathe? How come I can’t—I can’t—

This 911 call provides critical information about the strangulation assault and the need for medical attention. The call demonstrates why training dispatchers and other professionals on the medical signs and symptoms of strangulation is imperative. First responders can explain to victims the need for medical attention. Otherwise, many victims tend not to seek medical attention. There are many reasons why injured victims decline medical attention: fear of retaliation, to protect her abuser, lack of childcare, potential involvement of the Department of Children and Families, work obligations, financial limitations, more concern for immediate safety than health, not wanting to disclose the abuse, not trusting that anyone can or would help and/or a perceived lack of time. In many cases, victims simply do not understand the need for medical care. Victims tend to underestimate the seriousness of non-fatal strangulation and the need for medical care. In the San Diego Study, only 5% of the victims who called 911 for help sought medical attention. Nationally today, with training and encouragement from professionals, more victims are seeking medical attention with ranges from 50% to 69% depending on the study.

911 calls often contain spontaneous and/or excited utterances from the victim. Under Florida Evidence Code s. 90.803 (1) and (2), Fla.Stat., spontaneous statements and excited utterances are exceptions to the hearsay rule as these statements are made by victims or witnesses at and/or shortly after witnessing an assault or being assaulted. Courts view spontaneous statements or excited utterances as trustworthy, reliable, and admissible as an exception to the hearsay rule. A computer-aided dispatch (CAD) printout of the 911 call will also show when the call was made, who made the call, where the call was made from, when and how many officers were dispatched, when officers arrived at the scene, whether or not paramedics were also dispatched, and if the situation escalated to the point hostage negotiators and/or the SWAT team were called to the scene. Approximately 50% of strangulation victims experience voice changes, which is another reason to obtain a copy of the 911 recording. If the victim called 911 to report the incident, the recording may contain evidence of a voice change or evidence concerning the victim’s other signs and symptoms.

Body Worn Cameras: The use of a body worn camera (BWC) by law enforcement officers is a powerful tool to collect evidence, analyze the evidence, corroborate victim and witness statements and/or the conduct of a police officer in responding to 911 calls. A BWC allows officers to document the crime scene, record video and audio statements of involved parties, and record the actions of all officers at the scene. Judges and jurors can objectively see the scene through the eyes of responding officers from the moment they arrive, exit their police vehicle, view the interactions between all of those involved, and hear the emotional statements of survivors, suspects, children, and witnesses. Because everything is recorded, BWCs are of immense value to the civil and criminal justice system.

BWCs are particularly useful in domestic violence cases given the level of intimidation by offenders and recantation by victims. The use of BWCs in domestic violence investigations has allowed many cases to proceed even where victims have recanted or have been too afraid to testify. BWCs can also capture the subtle signs and symptoms of strangulation such as redness to face and neck, voice changes, and/or difficulty breathing that is nearly impossible to document without an audio recording. It is also a perfect tool to accurately document the entire scene of the incident as an officer walks around each room of the crime scene, views it from different angles, captures the layout and distances between rooms, and appreciates the relative level of violence.

Recent studies show that BWCs are helping courts hold offenders more accountable. There are more arrests, fewer cases are being dismissed, and convictions are increasing. It may even relieve the pressure and stress of victims having to testify in court and ultimately enhance victim safety. In State v. Richards, 928 N.W.2d 158 (Iowa Ct. App. 2019), the body camera recording of the strangled victim, recorded two hours after the actual incident, was ruled admissible as a spontaneous statement and made during an ongoing emergency. The Victim stated, “He tried to choke me again, but I felt like I could breathe this time.” The Appellate Court held the Iowa strangulation statute does not require the state to prove the victim’s breathing stopped or that she lost consciousness. Rather, it requires the state to prove the defendant impeded the victims normal breathing by applying pressure to the throat or neck citing to State v. Kimbrough, No. 16-1280, 2017 WL 2876244 (Iowa Ct. App. 2017). The evidence in Richards showed the defendant caused some level of blood flow or breathing to be impeded, though it may have only been momentary or slight.

Victim Statements: Victims who have been strangled, suffocated, assaulted, raped and/or traumatized may not be able to remember all the details of an assault. They could have difficulty describing distance and time and difficulty describing the assault in chronological order. This is normal and expected for several reasons. In strangulation cases, a lack of memory could be related to the mechanism of the strangulation assault that inhibited blood flow to the victim’s brain, altered consciousness or rendered the victim entirely unconscious, thereby unable to form memories. The body needs a constant flow of oxygen to survive. Airway from the mouth and nose allows oxygen to travel to lungs for oxygenated blood supply. Oxygen-rich blood is delivered to the brain by the arteries and the veins return de-oxygenated blood back to the lungs for more oxygen. The brain needs a continuous flow of oxygenated blood to function properly. A lack of blood flow and/or airflow can cause hypoxia or anoxia and lead to unconsciousness, brain damage and/or death.

“I could hear my heartbeat in my head. I couldn’t breathe. Everything started going black. There was pressure to both sides of my neck…It felt like I was drowning without water. I think I lost consciousness, but I cannot say for sure. The next thing I remember is that I’m on the ground, on my knees, bleeding and gasping for air. I could feel the deck shaking." Dawson v. Commonwealth, 758 S.E.2d 94 (Va. App. 2014).

Unconsciousness Can Happen Quickly: Experts can also provide evidence on the physiology of strangulation. When a victim is strangled, unconsciousness may occur within seconds and death within minutes. Victims may lose consciousness by any of the following methods: blocking of the carotid arteries in the neck (depriving the brain of oxygen), blocking of the jugular veins (preventing deoxygenated blood from exiting the brain), or closing off the airway (making breathing impossible). When blood flow is obstructed, loss of consciousness generally happens under 10 seconds. When air flow is obstructed, like drowning, it can take longer to pass out. If obstruction of air flow and blood flow occur simultaneously, loss of consciousness will likely happen quickly. But it will depend on the amount of pressure applied, where the pressure is applied, how pressure is applied (method) and how long pressure is applied. As discussed in the Medical Chapter, it does not take much pressure to obstruct vital neck structures. To completely close off the vein(s), only 4 pounds of pressure is required. The carotid arteries require a little more, approximately 11 pounds of pressure. The trachea (windpipe) requires 33 pounds of pressure. However, this is not much pressure when you consider the average handshake is 80-100 pounds of pressure per square inch which explains why the neck is vulnerable to injury. Unconsciousness is a sign of an anoxic brain injury and a life-threatening injury. It is common for strangled victims to have anoxic seizures because of lack of oxygen to the brain. The body has an automatic reaction to being deprived of oxygen and blood to the brain. It knows when it is about to die. If pressure is immediately released, consciousness will be regained within 10 seconds. If pressure is not released, urination may occur within 15 seconds and defecation may occur within 30 seconds. Brain death will occur within minutes depending on the method
of strangulation. See Appendix 12: Timeline of Physiological Consequences of Strangulation.

Evidence of Unconsciousness: There is no definitive test to determine unconsciousness. Evidence of unconsciousness is generally determined by victim statements, witness statements, medical evaluation and/or other corroborating evidence. It is an evaluation of the collective evidence of unconsciousness. It may also include what the victim remembers as well as what the victim doesn’t remember. The first step is to look for symptoms of hypoxia (a lack of oxygen to the brain) or asphyxia (the result of having no oxygen to the brain or body). Because unconsciousness can happen quickly, it is important to look for evidence of altered state of conscious.

Evidence of Altered State of Consciousness: Altered state of consciousness may cause vision changes such as seeing stars or spots, going from color to black and white or everything going dark. Victims may experience feeling dizzy, nauseous or like they are going to pass out. It may also include hearing changes or changes in behavior. Lack of oxygen to the brain may cause the victim to be restless or hostile at the scene. The victim may appear to be under the influence of drugs or alcohol, but it may be stroke-related symptoms. The victim may have urinated or defecated, changed her clothes or even failed to mention urination or defecation to anyone due to embarrassment. Petechiae is evidence of blood obstruction which generally takes 20 to 30 seconds and likely means there is also evidence of unconsciousness. If a victim does in fact lose consciousness, she may not remember having passed out. As discussed in the Medical Chapter, the hippocampus, a part of the brain important to the formation of memories, is particularly sensitive to hypoxia and anoxia. As a result, formation of memories may be impaired by these conditions, even if the victim is not rendered wholly unconscious.

Denial of Loss of Consciousness: In a recent study, researchers found that even when 50% of the victims denied loss of consciousness, they nevertheless reported hypoxia symptoms followed by amnesia. Leading them to conclude their patients most likely lost consciousness and suffered an anoxic brain injury and didn’t know it. In Time is Brain, an anoxic brain injury results in the death of 1.9 million neurons and 14 billion synapses per minute. Brain cells located within the hippocampus (in the limbic system of the brain) and prefrontal cortex are particularly susceptible to damage due to their location and high metabolic demand Non-fatal strangulation can result in pathological, neurological, cognitive, psychological and behavioral outcomes. Pathological changes include arterial dissection and stroke. Neurological consequences include loss of consciousness, indicating at least mild acquired brain injury, seizures, motor and speech disorders and paralysis. Psychological outcomes include PTSD, depression, suicidality and dissociation. Cognitive and behavioral outcomes include memory loss, increased aggression, compliance and lack of help-seeking. Pregnant victims who were strangled have also reported miscarriages. Experts in the physiology of strangulation can often provide evidence on all of this.

The Inability to Breathe is Terrifying and Traumatic: The experience of being strangled will most likely traumatize the victim. Studies show that victims who have been strangled often believe they were going to die, between 44% and 99% depending on the study. When the human brain senses significant stress or danger, the ability of a person to voluntarily focus their attention may be reduced as the brain’s defense circuitry takes control. For years, researchers have understood that trauma memories are often fragmentary and generally contain more emotional and sensory information. Professionals need to understand the survivor may have no memory of some parts of the incident. This lack of memory may be evidence of the trauma endured, rather than a sign the subject is lying or uncooperative. These factors can dramatically impact how the victim tells their story. It is common in such situations for the victim’s story to be jumbled or confused. Victim advocates or experts in domestic violence dynamics with specialized training in strangulation can often provide testimony on these issues.

Trauma-Informed Interview Techniques: Professionals who interact with traumatized individuals should remember stress and trauma can change the way a person’s brain operates and processes information. The questions and way professionals interact with trauma victims must be informed by research on this subject to improve the quality of information obtained during interviews and to foster an understanding of why trauma survivors exhibit certain behaviors. Trauma changes brain function during a traumatic event, impacting future recall and potentially even the nature of the memories that are formed. In response to significant stress or a traumatic event, the automatic defense circuitry of the brain often affects the way a person can focus their attention, whether they are able to engage in logical decision-making and planning, and how their memories are integrated into coherent narratives or “stories.” Each of these changes has implications for the way a victim or witness will experience and recall an event. It is not uncommon for an individual exposed to significant stress or a traumatic experience to be challenged by questions that focus on the timeline of the assault or on details that seem germane to a police report or criminal justice proceedings, but were entirely irrelevant to the experience of a victim gripped by mind-shattering fear and engaged in a desperate struggle to stay alive.

Presence of External Injuries: As we discussed in Chapter 3, on the physiology of strangulation, experts can testify to the significance of injuries whether minor or major. Even when victims exhibit injuries from strangulation, the injuries will likely appear minor and limited to the point at which pressure was applied. The reference guide below provides a summary of the locations on the body where professionals may find signs of strangulation and/or suffocation and what they can testify to in court.

Face	Eyes & Eyelids	Nose	Ear	Mouth
Red or flushed Pinpoint red spots Scratch marks	Petechiae to R and/or L eyeball (circle one) Petechiae to R and/or eyelid (circle one) Bloody red eyeball(s)	Bloody noseBroken nose (ancillary finding) Petechiae	Petechiae (external and/or ear canal) Bleeding from ear canal	Bruising Swollen tongue Swollen lips Cuts/abrasions (ancillary finding)

Under Chin

Chest

Shoulders

Neck

Head

Redness
Scratch marks
Bruises
Abrasions

Redness
Scratch marks
Bruise(s)
Abrasions

Redness
Scratch marks
Bruise(s)
Abrasions

Redness
Scratch marks
Fingernail impressions
Bruise(s)
Swelling
Ligature mark

Petechiae (on scalp)

Ancillary findings:

Hair pulled
Bump
Skull fracture
Concussion

Internal Injuries/Symptoms: In a 2016 study involving 1,064 victims of sexual assault and intimate partner violence, researchers found that 67% of strangulation victims reported at least one symptom of strangulation. The reference guide below provides a summary of what symptoms to look for when seeking to identify any symptoms of internal injury on a victim who has reported being strangled or who is believed to have been strangled. Generally, if a forensic examination was completed, experts can testify to all of this.

Breathing	Voice	Swallowing	Behavioral	Other
Difficulty breathing Hyperventilation Unable to breathe	Raspy voice Hoarse voice Coughing Unable to speak	Trouble swallowing Painful to swallow Neck pain Nausea/vomiting Drooling	Agitation Amnesia PTSD Hallucinations Combativeness	Dizzy Headaches Fainted Urination Defecation

Note: Victims may say they could not breathe but this may or may not mean their airway was blocked. Without adequate blood supply to the brain, victims may feel like they could not breathe even if their airway itself is still open and only partially obstructed.

Suspect Statements: Obtaining statements from everyone at the scene, including the suspect, will always help sort out the truth. Most suspects involved in domestic violence want the opportunity to tell their side of what happened and be heard. The more they talk, the more information any professional will get to help sort out the truth. Suspects should feel that you want to listen to what they have to say. Some suspects will deny everything and claim nothing happened at all—in which case eliminating self-defense. Other suspects will minimize what they did, make partial admissions, and/or claim self-defense. Only a small number of suspects admit to everything they did. Suspect interviews are always recommended and the fair course of action.

Witness Interviews: 78% of intimate partner strangulations occur inside the home, whichmay lead many to believe that there are few, if any witnesses. Yet research shows that adult witnesses will be present in these situations up to 39% of the time of the time, and children may be present between 50–75% of the time. In domestic violence cases, witnesses may include every person and/or child living or visiting the home who can provide some corroborating information. There could be witnesses who were present in the home but left. There could be witnesses who saw the victim before she was injured and after the assault.

Neighbors are often witnesses and are often the ones who call 911. Neighbors may have heard loud voices, people arguing, or the victim screaming for help. Neighbors may be aware of a history of arguments or violence. The neighbor may even be the person the victim ran to for help. Victims often call friends, family members, or co-workers before and/or after the incident occurred. Victims who do call 911 first may call family, friends, or co-workers while waiting for law enforcement to arrive, and these witnesses typically hear the victim’s demeanor and voice as they explain what happened. Children are often present during the assault and may even have called 911 or a relative for help. Children should always be interviewed. Letting children talk about what happened and acknowledging them can assist them in dealing with this traumatic event.

Talking with witnesses as soon as possible after the incident is imperative because their memory is fresh and there is less time for the witness to have talked with other parties, which may affect their statements. Friends and family of the parties often have the best information of prior violence in this relationship and are willing to share to protect the victim. Some will have electronic messages or notes from the victim. Some will have photos on their phones of prior injuries to the victim that the victim may have sent for safekeeping.

Other witnesses include emergency medical technicians (EMTs) and paramedics who were called to the scene shortly after the incident. The victim may have been transported to a local hospital. Statements made to medical professionals concerning the incident, how they are feeling, and what caused their injury for purposes of medical treatment are considered exceptions to hearsay and admissible under the medical diagnosis exception.

In strangulation cases, most victims will not have visible injuries at the time law enforcement responds. Victims may or may not be aware, appreciate, or understand any symptoms they may be experiencing. Identifying witnesses after the incident occurred who may be able to corroborate visible injuries, voice changes, problems swallowing, or changes in behavior will provide corroborating evidence. While the victim is cooperative, ask who she saw or talked to about the incident after the incident occurred. Did the victim try to get a protection order? Did she stay with anyone? Did she see friends, family members, or coworkers when she had visible injuries? Did she talk to a victim-witness advocate at the district attorney’s office to get the charges dropped or to the suspect’s probation officer? Did she see subsequent medical attention? Did she talk to anyone from Child Welfare Services (CWS)? Did you talk to or see anyone else after the incident occurred?

Medical Examination and Documentation: Without question, strangled victims need medical attention and when examined by trained professionals, their medical examination, assessment, documentation, and treatment can provide persuasive forensic evidence to confirm that an assault took place. Assuming the victim is examined by a paramedic, a forensic nurse or a medical professional at an Emergency Room or by a primary care physician, the quality and the extent of the documentation will depend on the training of that individual, protocols in place in that jurisdiction and/or assessment tools that are available and/or being used by that practitioner. The Training Institute on Strangulation Prevention has developed a tool for first responders both in English and Spanish called the Strangulation Assessment Sheet. See Appendix 13: Strangulation Assessment Sheet. Medical examinations and related documentation provide impactful evidence in court.

The Strangulation Assessment Sheet: This sheet was designed by first responders for first responders and approved by the Medical Advisory Committee of the Training Institute on Strangulation Prevention, which is made up of the leading forensic medical experts in the United States. See Appendix 13: Strangulation Assessment Sheet. It provides a quick review of the signs and symptoms of strangulation, a checklist of what to do at the scene, recommendations for when to transport a strangled victim to the hospital, information about delayed consequences, discharge information for the victim/patient, and a notice to the medical provider about properly assessing a strangled patient, including a recommendation for medical providers to order a CTA of the neck to assess for internal injuries. There are also medical documentation forms for strangulation and/or suffocation that are available.

Imaging Recommendations: Imaging is also highly recommended for the strangled patient given the prevalence rate between 2% and up to 15%. The imaging that is typically recommended is the computed tomography angiography (CTA), the magnetic resonance angiography (MRA) or magnetic resonance imaging (MRI). The CTA is the imaging of choice identified by the medical committee as part of their Imaging Recommendations. See Appendix 14: Medical/Radiographic Recommendations. The CTA tends to be more accurate in detecting damage to the arteries or veins, more readily available than an MRI and less expensive. However, recent studies show the benefit of MRIs. An MRI of the neck and/or head tends to find more relevant injuries of the assault than a CTA. In a recent study conducted in Switzerland, researchers found approximately 7% of patients who reported being strangled had suffered potentially dangerous injuries such as fractures, carotid dissections and/or hypoxic brain injury, higher than most previous studies causing them to believe that the true prevalence of internal injuries from strangulation is unknown.

Some strangulation protocols require paramedics to be summoned to a scene if: (1) the victim requests medical attention (whether the officer believes EMS should be summoned or not) or (2) if it appears that strangulation has occurred. Reports from responding paramedics and emergency room records should be reviewed for statements by the victim describing internal and external injuries. The treating paramedics and emergency room personnel can also testify about the extent and treatment of the victim’s injuries. Statements made by victims to medical professionals are generally considered an exception to the hearsay rule as a medical diagnosis exception.

In one case prosecuted by the San Diego City Attorney’s Office, the police officer indicated in his report that the victim had “red abrasions to the neck.” He encouraged the victim to seek medical attention, which she did. In reviewing the medical records, the treating physician indicated the patient had “multiple linear contusions to both sides of her neck with overlying redness, mild edema, and tenderness.” The medical description of the victim’s injuries provided dramatic medical corroboration which tremendously enhanced the case, allowing the prosecutor to obtain a quick guilty plea in court. None of the witnesses or the victim had to come to court to testify. Even if the victim is unable or unwilling to testify in court, the victim’s statements to a medical professional is generally deemed trustworthy and provided for medical purposes, as opposed to trial testimony and is not considered a violation of the confrontation clause.

Medical Diagnosis Exception: Under s. 90.803(4), Fla. Stat., statements made for the purposes of medical diagnosis or treatment by a person seeking the diagnosis or treatment or made by an individual who has knowledge of the facts and is legally responsible for the person who is unable to communicate the facts, which statements describe the medical history, past or present symptoms, pain, or sensations, or the inception or general character of the cause or external source thereof, insofar, as reasonably pertinent to diagnosis or treatment. Though Florida courts have not allowed identity of the perpetrator to be proven by the medical diagnosis exception to date, recent case law in other states has found that the identity of the perpetrator is admissible as pertinent of diagnosis and treatment and relevant to ensuring the safety of the victim.

Forensic Exams for the Strangled Victim/Patient: Many jurisdictions now utilize forensic investigators and nurses who are specially trained to gather evidence using various techniques and photographic equipment either by policy or by law. The following states have now passed laws allowing for free forensic medical examinations for victims of strangulation: Colorado, Washington, California, Nevada, Oregon and/or Virginia. Once these examinations are regularly performed in Florida, this evidence will begin appearing in more Florida trials.

Forensic nurses are proficient in follow-up examinations, taking photographs, and interpreting medical records. Many sexual assault nurses have expanded their scope of practice to include the forensic examination of strangulation victims. In 2016, the International Association of Forensic Nurses, in partnership with our Institute, developed the first Toolkit for Forensic Nurses for this examination. Forensic nurses play a critical role in the clinical examination and comprehensive documentation of the strangled victim. They can assist police and prosecutors interpret medical records; understand offensive, defensive, accidental, and/or intentional injuries; document follow-up injuries; and/or testify in court as experts. Few victims are getting forensic examinations in Florida at the present time but with comprehensive training of professionals across the state, these types of witnesses will become more prevalent in the years to come. Forensic examinations provide powerful evidence corroborating a victim’s statement or allowing prosecutors to go forward with prosecution even if the victim is too terrified to testify against her abuser.

Conclusion

Florida judges and juries currently may not see much of the evidence being gathered in strangulation cases as in other parts of the country. This is a result of inadequate training for law enforcement officers, prosecutors, and medical professionals. The Training Institute on Strangulation Prevention is currently doing more training in Florida than it has historically. We anticipate judges and juries having access to much more evidence in their fact-finding process in the future. It is crucial that the evidence be gathered and that judges and juries then have the tools and information necessary to evaluate and understand the evidence.

Related Resources

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Addressing Strangulation in Florida Courts: A Critical Resource

Addressing Strangulation in Florida Courts: A Critical Resource

FOREWORD

The Honorable Lynn Tepper, (Retired) Florida 6th Circuit Court Judge

The significant role of judges: scrutinize the history of men who strangle women.

CHAPTER 1: Introduction and Overview of Strangulation and Suffocation Assaults

INTRODUCTION

OVERVIEW: THE SCOPE OF STRANGULATION

WHAT HAPPENS WHEN A VICTIM IS STRANGLED?

HOW DID WE ALL MISS THE SERIOUSNESS OF STRANGULATION?

CONCLUSION

CHAPTER 2: Strangulation and the Law

INTRODUCTION

FLORIDA LAW

Legislative Findings from Other Jurisdictions

IMPLEMENTATION OF STRANGULATION LAWS–RELIANCE ON VICTIM PARTICIPATION

CONCLUSION

Chapter 3: The Medical and Physiological Dynamics of Strangulation

Introduction

Strangulation 101 – The Medical Basics

Answering the Fundamental Questions

Answering the Fundamental Questions

Medical Terms in the Courtroom in Strangulation Cases

The Life-Threatening Nature of Strangulation Assaults

Answering the Basic Forensic Questions in a Strangulation Case

Did Strangulation Occur?

Who Was the Assailant?

Was This a Life-Threatening Event?

Special Note: Sexual Choking/Erotic Asphyxia

Conclusion

Chapter 4: Understanding the Evidence

Conclusion

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What Judges and Court Staff Need to Know About Strangulation

Evaluation of Efforts to Implement No-Drop Policies – Two Central Values in Conflict, Final Report

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CDAA Investigation and Prosecution of Strangulation Cases Manual