If there’s one thing Sarah Alley, a forensic nurse at Mary Washington Hospital, could tell people in the community who are assigned jury duty, it’s this—there is no such thing as “attempted strangulation.”
“ ‘Attempted strangulation’ would be this,” Alley said, pretending to lunge at the neck of another person in the room and then absurdly veering past her.
Alley’s job—and that of the three other nurses in the forensic nursing program—is to examine survivors of domestic violence and document their injuries.
The exams can take two to four hours, Alley said. When it comes to survivors of strangulation—which is the reduction of air flow or blood flow to the brain by external compression of the throat or neck—the injuries can be difficult to document.
While there might be marks left on the neck by the perpetrator’s hands or by a ligature—something used for tying or binding—often there are no immediately visible injuries.
“That’s how the majority of [survivors] appear,” Alley said. “[Strangulation] is more an event of obstruction than physical trauma.”
Alley’s trained eyes might document pinpoint red spots—called “petichiae”—in the woman’s eyeball, the tips of her ears or her scalp. These are small bleeds caused by burst capillary blood vessels.
She might see faint, circular bruises on the survivor’s fingertips or note that her voice sounds hoarse or raspy.
“I’ve listened to 911 calls where the voice sounds so scratchy, like they smoke a pack a day,” Alley said.
She’ll ask if the survivor has trouble swallowing, a sore throat, difficulty breathing, a headache or vision changes.
But sometimes, the only injuries are self-inflicted. The survivor might have a few scratches on her neck from her own fingernails as she tried to pry her abuser’s hands away. Or her sole injuries might be internal and only visible in an MRI or CAT scan.
What will never go away, and what she can’t document, Alley said, is the terror of someone looking you in the eye and bringing you to the brink of death.
“If it were me, I’d much rather be punched in the face or kicked down the stairs,” Alley said.

A public safety issue

October is Domestic Violence Awareness Month, and strangulation is one of the most lethal forms of domestic violence.
“It’s extremely dangerous and it has short-term and long-term impacts,” said Susan Sigmon, a court advocate with Empowerhouse.
According to the National Training Institute on Strangulation Prevention, one in four women will experience intimate partner violence in their lifetime and of those, 10 percent will experience strangulation.
“At Empowerhouse last year, out of 2,472 adult victims, 490 disclosed that their abusive partner intentionally blocked or obstructed their breathing,” Empowerhouse Executive Director Kathy Anderson said.
Alley said she has seen 12 people this year specifically for strangulation and 30 since 2014.
In a strangulation event, external pressure on the neck interferes with the normal flow of blood through the body, either through compressing the carotid arteries, which carry oxygenated blood to the brain, or the jugular vein, which takes deoxygenated blood to the heart.
Strangulation can also compress the larynx or trachea, which causes suffocation.
Unconsciousness from any or all of these methods can occur within 10 seconds and death will occur in four or five minutes.
“Once they’re unconscious, it’s a crapshoot whether they’re going to wake up or not,” Alley said.
Victims may regain consciousness, but that doesn’t mean they’re OK. Brain cells will have died from the loss of oxygen, which can result in memory loss, behavioral changes, mood changes, dizziness or chronic headache.
And death has been reported up to two weeks after strangulation, Sigmon said.
Once a woman has been strangled, she is extremely likely to become a victim of homicide.
“If you’ve been strangled even one time, you’re 750 percent more likely to be killed,” said Gael Strack, who oversees the Training Institute on Strangulation Prevention.
In a 2014 issue of “Domestic Violence Report” that focuses on strangulation, Strack and co-authors Casey Gwinn and Melissa Mack wrote, “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—anytime they wish. Once victims know this truth, they live under the power and control of their abusers day in and day out.”
Empowerhouse is working with community partners to protect survivors of strangulation, who are at high risk for homicide. The organization was recently awarded a grant from the federal Office of Violence Against Women amounting to $450,000 over three years.
Anderson said the funds will be used specifically to support the hiring of an additional forensic nurse examiner at Mary Washington Healthcare—for a total of five—and an Empowerhouse domestic violence advocate to be stationed at the Stafford Sheriff’s Office.
The grant will also train all Stafford deputies on the Lethality Assessment Protocol, a strategy to prevent domestic violence homicides, and train MWH emergency room doctors and nurses on strangulation identification and the high risk of intimate partner violence homicides.
Strangulation is not only dangerous to its immediate victims.
“It’s a public safety issue, too,” Sigmon said.
The Training Institute on Strangulation Prevention cites research that found a majority of law enforcement officers who were killed in the line of duty were killed by men with a history of strangulation assaults against women.
“[A person who strangles] is a person with no impulse control,” Alley said.
There is also a link between mass shootings and domestic violence in general, and strangulation in particular. The men who committed the 2017 Sutherland Springs church shooting that killed 27 and the 2016 Pulse nightclub shooting that killed 49 were both reported to have strangled their wives.

Defining the crime

Despite the dangerous and potentially lethal effects of strangulation, survivors can have a tendency to minimize the assault.
“They’ll say, ‘He choked me for a minute,’” Alley, the forensic nurse, said. “But police are not allowed to put someone in a choke hold—that’s considered lethal force.”
“Choking” is the term most victims use, Strack said.
“It’s hard for them to get to strangulation because everybody thinks, if you’ve been strangled, you’re dead, and if you survived, you’re fine,” she said.
The terms are often used interchangeably, but they are different events, and domestic violence advocates say it is important for the community to understand the distinction.
Choking is the accidental internal obstruction of the airway, while strangulation uses external force by hands, arms, legs or ligature and is not accidental.
Alley said she thinks juries also have trouble recognizing the lethal nature of strangulation if the victim survives.
“I think because of shows like ‘CSI’ and ‘SVU,’ juries expect to see photos of horrible injuries,” she said. “To see photos of just a few scratches is not what they expect. They might think the victim wasn’t really strangled because she’s still alive.”
Besides examining domestic violence victims when they come to the emergency room, Alley’s job involves documenting their injuries and writing reports about the event. The reports, and the testimony of forensic nurses like Alley, can be used in the prosecution of strangulation crimes.
Until fairly recently, strangulation was prosecuted across the country as a misdemeanor, placing it on the same level as petty theft or vandalism. Starting in the mid-2000s, states started making it a felony offense. In 2013, it was added to the federal assault statute.
“The federal statute has up to a 10-year maximum prison sentence and it specifically says no visible injury is required, which is really good,” Strack said.
In Virginia, strangulation became a class 6 felony—the lowest felony class—in 2012. Stafford Commonwealth’s Attorney Eric Olsen said this achievement was part of a multi-year lobbying effort by members of the Virginia Association of Commonwealth’s Attorneys and a coalition of law enforcement and domestic violence advocates.
“Prior to the statute, in order to be a felony, you would have to prove that it was assault with an intent to kill,” Olsen said. “That’s a very high burden. If you had a serious physical assault, but couldn’t prove malicious wounding, the punishment would be the same as if I slapped you or pushed you. That was frustrating.”
If convicted of felony strangulation in Virginia, offenders can be punished by a fine of up to $2,500 that may or may not be combined with up to 12 months in jail, or by a prison sentence of one to five years, Olsen said.
But according to Virginia code, to be punishable as a felony, the strangulation has to result in “wounding or bodily injury.” That can be difficult to prove since strangulation injuries are often internal.
“Proof is certainly an issue,” Olsen said. “It’s not an easy case to prove.”

Proving ‘bodily injury’

In the Stafford Sheriff’s Office, crime scene investigators make use of alternate light sources—sources that emit light in different wavelengths, as opposed to white light—to identify bruising that might be hard or impossible to see with the naked eye.
Stafford Deputy Benjamin Woodson said he and his partner use an intense blue light with an orange filter to make visible and photograph subclinical bruising on a victim’s neck, usually 48 to 72 hours after the incident, although he said he has been able to see bruises under the alternate light source up to 14 days after the injury was inflicted.
A neck that in visible light appears to be unharmed becomes almost totally discolored under the alternate light source, save for a strip just under the chin that the perpetrator’s hands didn’t cover during the strangulation.
The alternate light source can also make evident wound or bruise patterns that help corroborate the victim’s testimony, Woodson said.
“I’m not diagnosing,” he said. “We’re going on their verbal testimony and it enhances their verbal testimony when we see discoloration.”
Using the alternate light source to document injuries requires knowledge of photography as well as the light source itself, and principles of crime scene investigation.
Woodson said surrounding jurisdictions “either have this capability or are continuing to work on bettering their knowledge of it.”
“This is where having dedicated crime scene investigation and forensic science departments is so important,” he said. “So staff are not having to wear so many different hats and we’re more likely to bring these victims justice in court.”
In strangulation cases, testimony by forensic nurses such as Alley is also crucial, domestic violence advocates say.
“I can argue the health ramifications [of strangulation] much easier than I can sexual assaults,” Alley said. “I can say that in the years I’ve been doing this, [since 2013] I have never had an acquittal. I’ve had several convictions.”

A landmark case

But many strangulation cases don’t make it to court.
“When someone calls the police, they need help,” Olsens aid. “Unfortunately, the dynamic changes once the threat is gone and the immediate fear goes away.”
Intimate partner violence tends to go in a cycle, with a physically violent episode followed by a “honeymoon” phase. During this phase, many survivors decide they don’t want to press charges or are pressured not to by their partners.
“All the things that lead DV victims to drop charges are heightened if it’s a felony offense: fear of the offender because of the consequences to him, fear for the children,” Olsen said.. There’s more on the line for the offender, so there’s more pressure from him.”
A case called Commonwealth of Virginia v. Kevin Cody that was decided in February in Loudoun County and upheld in April by the Virginia Court of Appeals may help the prosecution of abusers when the victim recants or refuses to testify.
“I think it’s going to be a landmark case,” Strack said.
Cody was convicted in February of strangulation and five counts of violation of a protective order. The victim—the mother of Cody’s two children—told law enforcement officers and a forensic nurse that Cody had punched her, stepped on her and strangled her to the point of unconsciousness.
He was arrested and held without bond, but called the victim repeatedly from jail, violating a no-contact order, and successfully pressured her to refuse to testify against him.
Usually, out-of-court statements such as those the victim made to the nurse and to law enforcement would be inadmissible, Olsen explained, because it violates the defendant’s right of confrontation—the right to cross-examine a witness.
But in the case of Cody, Olsen said, the prosecution used the theory of “forfeiture by wrongdoing” to argue that the right of confrontation didn’t apply to Cody since he was the cause of the victim being unavailable—by intimidating her into silence. This allowed her out-of-court statements to the nurse and to law enforcement to be admitted as evidence and led to Cody’s conviction.
“So for DV cases, if the influence of the abuser—physically or emotionally— makes the victim unavailable at trial, then we have the ability to bring hearsay evidence,” Olsen said. “I think prosecutors are seeing and understanding how [forfeiture by wrongdoing] can be used and the Cody case helps frame the issue.”
He said one of his attorneys is preparing a brief on forfeiture by wrongdoing to be used in an upcoming domestic violence case in Stafford.

Dignity and respect

Because victims of strangulation teeter on the edge of unconsciousness and many do pass out, their memories surrounding the event can be cloudy and dark.
Sometimes, they lose control of their bladder or bowels. When they regain consciousness and realize this has happened, they’ll change clothes before they call 911.
“They want to maintain some dignity,” Sigmon said.
So when law enforcement does come, they might find a woman in clean clothes with no marks on her and a fuzzy recollection of what happened to her.
Alley said she does see the same women multiple times for strangulation attacks.
“We have had so much training in the cycle of domestic violence that they don’t have to feel shame sitting with us,” she said. “They don’t have to explain to us why they didn’t leave immediately.
“I enjoy being here with people when its literally the worst day of their life and making [the examination] a comfortable, dignified event and giving them the dignity and respect they deserve,” she continued.
Her job can be grim and stressful. But she said everything she does is worth it when a survivor sees her in court and says to her, “Thank you. You were so nice to me that day.”
“That’s all the self-care I need,” Alley said.

Many domestic violence offenders … do not strangle their partners to kill them; they strangle them to let them know they can kill them—anytime they wish. GAEL STRACK,
WRITING IN ‘DOMESTIC VIOLENCE REPORT’

Adele Uphaus–Conner: 540/735-1973 auphaus@freelancestar.com @flsadele

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