All Abusers are Not Equal

IPV Research Reveals that Nonfatal Strangulation is an Indicator of Deadly Abuse

The numbers are familiar but never fail to shock. One in four women will experience violence at the hands of their partner. Homicide is a leading cause of death for women younger than 44 years old, and nearly half of female homicide victims are killed by a current or former partner.

African American and American Indian/Alaska Native women are at even greater risk than others, and women who have experienced intimate partner violence (also known as IPV or a subcategory of domestic violence) are more in danger of being killed by their partner. These horrifying statistics are not new, but what you may not know is that researchers have recently identified an important predictor of increased violent behavior in perpetrators of IPV.

Blue graphic depicting strangulation of a victim of intimate partner violence.

“The most dangerous domestic violence offenders strangle their victims. The most violent rapists strangle their victims.

We used to think all abusers were equal. They are not.

Our research has now made clear that when a man puts his hands around a woman’s neck, he has just raised his hand and said, ‘I’M A KILLER.’ They are more likely to kill police officers, to kill children, and to later kill their partners. So, when you hear ‘He choked me,’ now we know.


 —CASEY GWINN, Co-Founder, Training Institute on Strangulation Prevention

Strangulation as a Warning Sign

According to the Training Institute on Strangulation Prevention, “A woman who has suffered a nonfatal strangulation incident with her intimate partner is 750% more likely to be killed by the same perpetrator…with a gun.” That is a staggering number, and it’s not a coincidence. Researchers and law enforcement professionals have determined that nonfatal strangulation is a leading indicator of escalating violence in a relationship and an important risk factor for homicide in women.

Why is strangulation different than other types of IPV?

One reason that strangulation is a particularly concerning warning sign in IPV is because of what it represents: Control, taken from the victim and placed in the hands of the perpetrator, who, in the moment of violence, has the power to literally take the breath of the victim. It can take only seconds to lose consciousness during a strangulation incident, and the line between fatal and nonfatal strangulation is perilously thin. And “if a perpetrator is willing to move towards taking the life of a loved one with his bare hands…killing others does not seem to be a stretch.”

Identifying and Treating Victims of Nonfatal Strangulation

Identifying victims of nonfatal strangulation when they present for medical treatment or interact with law enforcement is crucial, but it’s not as simple as it might seem. Despite the lingering terror it can inflict on victims, strangulation, even in fatal cases, often does not leave a visible mark. In fact, researchers report that only half of strangulation victims have visible injuries, and only 15% have injuries that can be photographed. According to Gael Strack, co-founder of the Training Institute on Strangulation Prevention, “Our original study…proved it—most victims of strangulation WILL NOT HAVE VISIBLE EXTERNAL INJURIES and will not understand the danger. The lack of injuries and the lack of training caused the criminal justice system to minimize strangulation. We failed victims. But now we know—NONFATAL STRANGULATION CASES ARE LETHAL and have serious immediate and long-term health consequences.”

In addition, victims often do not use the term “strangulation,” but rather will describe “choking,” which can have the effect, for victims themselves and for health care providers, law enforcement, and friends and family of the victim, of minimizing the very real danger of being a victim of strangulation.

This makes it even more important that health care providers recognize strangulation victims when they present for treatment. “When a victim of nonfatal strangulation presents to the emergency department it is critical for the medical provider to rule out potential life-threatening injuries,” said William Smock, M.D., police surgeon for the Louisville Metro Police Department and the chair of the Strangulation Institute’s Medical Advisory Board. Evaluation should include assessment for neck and spine injuries, as well as head trauma, and ordering a computed tomographic angiogram is essential, says Smock. In addition, death can occur days or weeks after strangulation as a result of carotid artery dissection, respiratory complications, or blood clots, so patient education and follow-up are crucial.

For more information on identifying and treating strangulation, as well as downloadable resources for patient education and discharge planning, visit the Training Institute on Strangulation Prevention’s website at

Dr. Smock is a coauthor on STM Learning’s Domestic Violence and Nonfatal Strangulation Assessment. This workbook addresses cases of nonfatal strangulation in the context of intimate partner violence and is available in our bookstore.

This blog was written by STM Learning’s editorial staff for educational purposes only. It is not intended to give specific medical or legal advice. For expert information on the discussed subjects, please refer to STM Learning’s publications


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