A Cry For Justice

Awakening the Evangelical Church to Domestic Violence and Abuse in its Midst

Most victims of strangulation will not have visible external injuries

Non-fatal strangulations point to future homicides.

Victims of non-fatal strangulation often relate to being “choked” and though this terminology is commonly used among victims and police officers alike, the word is often used incorrectly.

Choking is an internal blocking of the airway by an object. In contrast, strangulation is a form of asphyxiation characterized by closure or restriction of the airway or vessels in the neck by external pressure. The key words to focus on are “external” and “neck.” The closure of a single structure of the neck that supplies oxygen to the brain is all that is required to kill a person.

An idea was promulgated for decades that there must be external signs of injury such as marks on the neck and/or petechial hemorrhage in the eyes when strangulation occurred. It was believed that without those injuries the assault could not be proven and likely did not occur. This idea is far from the truth. Gael Strack, former prosecutor and chief executive of the Institute on Strangulation Prevention states, “Our study proves it—most victims of strangulation will not have visible external injuries. Lack of injuries and lack of training caused the criminal justice system to minimize strangulation.”

This image represents a raw photograph showing little to no signs of harm.

This image was taken with a i3 Thermal Expert, showing clear signs of hand print heat signatures on the victim’s neck.

This image was taken with a i3 Thermal Expert and shows heat signatures on the victim’s neck. Infrared cameras enable uses to capture high resolution thermal images.

Injuries from strangulation can be delayed so that victims may not exhibit any signs immediately after the assault, however, they may exhibit signs hours or days later. Take for example an athlete that sprains their ankle, but can finish the game only to wake up the next day with an ankle so swollen and injured that it cannot be walked on. This can be observed in some strangulation victims who can talk and breathe normally one minute and be near death in the hospital the next. Research on strangulation in the medical field and in case studies now clearly shows that injuries can also be immediate, they will likely be permanent and they are absolutely life threatening.

It can take as little as five pounds of pressure for six to ten seconds to render a person unconscious. This is less pressure than opening a can of soda or pulling the trigger on most law enforcement pistols. One can understand why there may be no external signs or injuries on the victim when considering how little pressure is needed to render them unconscious. Signs and symptoms known to be associated with strangulation now include a raspy or hoarse voice, difficulty breathing, vision changes, fluid in the lungs, vomiting and involuntary loss of bladder / bowel control.

Look to the signs

Although many organs in the body may be affected, it is the brain that is most affected by lack of oxygen. If a person loses consciousness because the brain has been starved of oxygen then there is permanent brain damage. Loss of consciousness also means lack of memory since the hippocampus—the part of the brain that stores memory—is most affected by lack of oxygen. All too often the lack of detail from victims is associated with lack of credibility. With regard to strangulation, however, lack of detail and memory points directly to an indicator there was loss of consciousness. Proper trauma-informed interviewing of a victim is key when there is loss of consciousness.

In instances where there is no loss of consciousness, it is possible that arteries/veins in the neck can tear internally, causing blood clots. These clots left alone and without immediate medical treatment can lead to stroke and death even weeks later. Brain death can occur within two minutes or less when the brain is deprived of oxygen. Delayed death can occur hours, weeks or months later due to internal injuries as mentioned previously. Unfortunately, victims only seek medical attention about three percent of the time. Therefore, it is important for law enforcement to take the lead on getting victims medical help as soon as possible.

In reality, the act of strangulation itself is a lethal act regardless of an offender’s intent. It tells us that the offender has a propensity to use lethal violence and I would argue also demonstrates a mindset that lethal violence is justifiable against anyone. If an offender is willing to harm their intimate partner, child, vulnerable adult or anyone using strangulation, then they can kill anyone. Many studies have shown this to be true. A study of 300 “choking” cases by the Family Justice Center Alliance in San Diego and Institute on Strangulation Prevention showed that a woman who is strangled even once is 750 percent more likely to be strangled again and 800 percent more likely to be killed later. Domestic violence victims often suffer repeated strangulations because law enforcement has not been informed of the subtle signs or the victim has delayed reporting to law enforcement.

A study by the same group on risks to law enforcement showed that 80 percent of critical incidents where officers were shot or had to shoot an attacker involved offenders with a history of domestic violence. Many of these offenders also had a background of strangulation assaults. As if the dangers to officers were not enough, the general public is now at increased risk. Research is showing that many of the domestic mass shooters in the U.S. also had a history of domestic violence and strangulation prior to their mass killings.

Church shooter Devin Kelley killed 26 people in Sutherland Springs, Texas. He had a known history of strangling his wife and fracturing his stepson’s skull, but the authorities in that case filed charges as misdemeanors.

Esteban Santiago killed five in a Fort Lauderdale, Florida airport and his past history was that of strangling his girlfriend in Alaska. He, however, was allowed to sign a sentencing agreement to have his charges reduced, which ultimately allowed him to own and transport a gun into the airport.

Omar Mateen killed 49 at the Orlando Pulse night club. It is reported he had strangled two of his past wives but was never charged or prosecuted.

As Casey Gwinn, cofounder of the Institute for Strangulation Prevention states, “Men who strangle women might as well be raising their hand and saying I am a killer.” Gwinn also refers to strangulation as a “warning shot” that gives every indication that lethal violence is sure to follow.

Tools to aid investigation

Though domestic violence and/or intimate partner violence are the crimes most often associated with strangulation, it goes far beyond intimate partner violence and must be extended to other crimes and victim types. Strangulation assaults are seen in abuse of vulnerable adults, child abuse, sexual assault, kidnappings and even robberies.

There are tools available to help raise the level of awareness and to increase the frequency of charges and successful prosecution for non-fatal strangulation assaults:

First: The Training Institute for Strangulation Prevention provides many online training courses and webinars free of charge. A good entry level course is a 25 minute fully interactive video on strangulation. It can be taken by going to the Institute’s website at www.strangulationtraininginstitute.com and looking under the training tab. Officers may also look under the resources tab to print investigative checklists, signs/symptoms information sheets, pamphlets for victims and investigation manuals. I’d like to emphasize the use of the investigative checklists as these can help prove a non-fatal strangulation case when there is little physical evidence of external injury.

Second: We all know that photo documentation of any assault is extremely important because it can speak for the unwilling or unavailable victim. It can be very difficult to document injuries with pictures when little to no external signs of strangulation are present on a victim. Research has shown that of observable strangulation injuries less than 15 percent are actually able to be photographed.

SDFI Camera with ring flash

When taking photographs, make sure you use an approved camera or imaging device. It is generally not a good practice to use a cellphone to take pictures since a discovery motion by a defense attorney may require it to be turned over for full examination of its contents.  Also, have adequate lighting to show the injuries you are trying to document.  Using a flash is not always appropriate and in other instances a flash has to be used.  Camera flashes are often offset from the lens and at times can create shadows that distort what we need to see.  Perhaps a better option is to use what is called a “ring flash” that surrounds the camera lens to provide even light.  This can enhance pictures of injuries taken at very close distances.  Companies such as Secure Digital Forensic Imaging (SDFI) have special cameras that include a ring flash and proprietary software that can enhance hard to see injuries.  These images can often be admitted as evidence in court because of SDFI’s chain of custody and secure storage software.  There is an interest in using thermal imaging for assault investigations, too.  A new camera to note is made by Thermal Expert and can be attached to mobile devices and tables.  Initial examination shows it tends to offer better resolution and more diversity in image capture than similar products.  Research to validate thermal imaging is still being conducted; therefore, officers should consult with their legal staff prior to utilizing such devices for evidence collection.

We must raise awareness of non-fatal strangulations and recognize that this knowledge benefits not just the crime victim but the public and law enforcement as well. The victims we respond to, the citizens we protect and even the fellow officers we serve with are all at risk if we fail to recognize that non-fatal strangulation is a sign of future lethal violence.


A Cry For Justice thanks Brian Bennett, the author of this article, for pointing us to and giving us permission to repost his article. His original article is Subtle Signs Of A Killer.  ACFJ removed the first two paragraphs in this reblog and we retitled the article because most of our readers are victims of abuse, not law-enforcement officers.

Brian Bennett

Brian Bennett has 20 years of law enforcement experience and serves as an instructor at the South Carolina Criminal Justice Academy. His is skilled in various law enforcement disciplines and is court qualified as an expert in police training. Areas of expertise include domestic violence, vulnerable adult victimization and strangulation. He can be reached at Bkbennett@sccja.sc.gov.

For further reading:  Have you been strangled? Or smothered so you couldn’t breath?


  1. Anon

    I’m really interested to know if the same statistics apply to suffocation? If a victim has been suffocated with a pillow or hand over mouth and nose….is this also an indicator of possible future homicide? Thanks.

    • Hi Anon, at the bottom of the post it gives Brian Bennett’s email address. Why don’t you email him and ask him that question. And then you can let us know his answer. 🙂

    • Song of Joy

      Just my personal belief (solely based on gut feeling and not scientific statistics) is that suffocation is similar in intent to strangulation. ….Suffocation from a pillow, a hand, and I would include holding someone’s head under water (attempted drowning). Denying someone oxygen is a very sinister and terrifying kind of assault. I too would be very interested to know if there are any statistics on these other DV methods.

      In my family of origin, my dad strangled my mom with his hands (non-lethal) early in the marriage and decades later we did indeed suffer an intra-family homicide (complicated family tragedy orchestrated by my father). However, my dear mom is alive! She was not the final victim….although my dad stalked her, followed her, tracked her activities for years after the divorce, stalked her at night and while even carrying a firearm. He had a successful career and a generous reputation with outsiders, while behind closed doors he was always very dangerous and knew exactly how to destroy people.

    • anonymous

      Smothering and suffocation seem to be just as severe, if not more so, because the victim doesn’t lose consciousness as quickly since the neck arteries are not being constricted — so the perp is really committed to harming the victim in order to render the victim unconscious via smothering and suffocation.

      [Trigger Warning]

      It’s terrorizing and life-changing. It’s torture. And the perp knows it. From that moment on, everything becomes a question of ‘do you want to die?’ which the perp verbally and nonverbally communicates to the victim again and again. Great tactic to obtain and maintain total control, like holding a gun to the victim’s head all the time, but such is made invisible to all outsiders, which is not accidental. Perps willing to render the victim unconscious, threaten her with death, and so much more are very, very dangerous. And most of the time, the victim is alone in this knowledge and the perp looks ‘normal’ to outsiders and the victim looks ‘abnormal’ to outsiders in her very reasonable fear of the perp.

      There are videos on the internet where people have hung themselves in front of the camera and even when they’ve been rendered unconscious, their body still thrashes about, and that’s strangulation, with the constriction of neck arteries, so it’s even more violent and prolonged when one factors in what is needed in terms of time and technique in rendering a victim unconscious from smothering or suffocation.

      Gunshot wounds are taken super seriously but I’d rather be shot than be suffocated again. Plus, anyone can pull a trigger, not many can manually smother someone to death (or unconsciousness), which shows just how evil these abusers are.

      Thanks, Barb, for all of these articles. This whole website is phenomenal and life-saving.

      • twbtc


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  2. TBD

    Hi. I am relatively new to this blog, but am commenting to verify that indeed strangulation without marks can ~ and does ~ happen. It is from personal experience of which I speak.

    • twbtc

      Hi TBD,

      Thank you for your comment and Welcome to the blog!

      As you may know we like to encourage new commenters to check out our New Users’ Info page as it gives tips for how to guard your safety while commenting on the blog.

      And after reading the New Users’ Info page, you may like to look at our FAQ page.

      Again Welcome!

    • Thanks TBD.

      I hope you have not suffered long term health problems from the strangulation.

      And feel free to not say any more, if you don’t want to or don’t feel safe to do so, but If you do want to share here with a bit more, I would be interested to hear more of your experience about this.

      Did you report the strangulation to any authorities? (e.g. police, or doctors)
      If you did report it, how did the authorities respond to you? How much did they investigate it?

      Are you still at risk from the perpetrator? If so, you might like to look at our Safety Planning page.

      • tbd

        Thank you for sharing your words of wisdom, Barbara Roberts. Yes, indeed, I am still at risk from the perpetrator and recently decided I need to take him back to court: against all odds. Legal abuse has been a major issue in my case, for sure and certain. But I’ve literally exhausted all other avenues.

        The strangulation in my case was brief and just designed to “put me in my place” many years ago. It worked back then. Prior to my post, I did review the information and do know the risk I am taking right now. Yes, it’s worth it.

        Long story and I need to stay off the details for now.

      • 🙂

  3. Mel

    I told my dv worker how I was never physically abused except for being strangled once nearly 20 years ago. She told me strangulation is symbolic of him saying “I own your life”. He was doing it to take my car keys from me as well, and she said that is symbolic of “I own your freedom”.

    This is why I still fear him after all these years. I get PTSD whenever I sense he isn’t happy and I find myself trying to appease him. I’m still fighting my survival instinct around him. I’m still fighting to know who I am and what my wants and needs are rather than just thinking about him. Can I ever heal from this and feel safe around him again?

    • I don’t think you can ever feel safe around him again. And why should you feel safe around him? Who is expecting that you ought to feel safe around him?

      He is not a safe person. He is a very unsafe person.

      Your fears are sensible. You are not crazy.

      Have you read my Don Hennessy series? If not, I suggest you dig into it. It will help you understand how your perp got into your head and how he continues to make you feel afraid of him and to make you doubt and blame yourself.

      Also, I think you would probably find it helpful to read Don Hennessy’s latest book Steps to Freedom. He wrote it specially for victims who are still living with their abusers.

      Bless you, and (((hugs))) if you want them.

    • And by the way, I don’t think you need to ‘fight’ against your survival instinct. I think your survival instinct is healthy and it is wise for you to listen to your instincts and your gut feelings, especially when you feel unsafe. Your instincts are part of the way God created you. Your abuser has tried to shut down your instincts. Your instincts are your friends. Your abuser is not your friend.

      • Mel

        Thanks so much for your reply Barb. I guess you’re right. I haven’t thought about it that way. I’m so used to my feelings being minimised or dismissed. I am still working on my escape plan. God bless.

    • AKSDA

      For 30+ years I prayed at various times for me to be able to love my spouse and yield to him in a loving way despite the verbal and emotional trauma I had been living with. As I was pleading with God and crying during my private morning devotions, the Holy Spirit spoke to me “It’s not safe for you to trust him or to love him as you are praying for”.
      This was part of the impetus to finally say “enough” and start the divorce proceedings. I am over 2 years single now….in my late 60s. It’s never too late to start a healthier life free of anxiety, depression, coercion, abuse and manipulation.
      Jer 29:11

      • Mel

        Thank you AKSDA, it’s great that you got out. I’m struggling to break free, I know I’ll get out at some point. I’m just trying to cope while I’m still stuck here. It gets confusing you know, to try feel sane while I’m stuck here I pretend that things are ok and they aren’t and it messes with my head. I’m leading a double life. I play the part of his wife, meanwhile I’m plotting my escape. God bless.

      • I’m leading a double life. I play the part of his wife, meanwhile I’m plotting my escape.

        It will encourage you to know that that approach is perfectly in line with what Don Hennessy recommends to female victims in his book Steps to Freedom [*Affiliate link].

        *Amazon affiliate link — ACFJ gets a small percentage if you purchase via this link.
      • Innoscent

        I second Barbara. Dear Mel, the one living the double life is your abuser, not you.

        Secrecy is perfectly OK for victims of abuse in order to keep safe. Living with an abuser is like being constantly on a battlefield, the abuser waging a covert battle against you.

        So….concealing your plans from the enemy is using heavenly military strategy.

        When your “heart country”, your life, is being occupied by the enemy you have to become a war resistant [resister?] with God as your Commandant.

        I encourage you to read the example of Abigail in 1 Samuel 25. She said not a word to Nabal, her wicked husband, and made plans and went her way to meet David, which resulted in her saving her household and keeping the future king from shedding innocent blood.

        It took me months of planning after the Lord showed me He was clearing the way for my escape from my emotionally abusive H. I kept it for myself, dug out my underground gallery day by day, it was hard, I felt weak, lonely many times, but I can assure you that God always sent someone or a promise, or confirmation, to keep me going until I was out. I’m in my first months post-divorce (after a few years of separation), reclaiming my life, my freedom, everything. It is all so worth it!

        Ye shall not fear them: for the Lord your God, He shall fight for you.
        Deuteronomy 3:22 (KJV)

      • Innoscent, thank you so much for replying to Mel and encouraging her!

        I love it when the ACFJ community help each other. We are all in this together. And the coals in the fire burn brighter when they are surrounded by (and warmed by) other coals.

        So….thank you. 🙂

  4. bluebird121

    It’s still hard for me to talk about “strangulation.” I’d much rather say “choking.” This article helped clarify my thinking on the manner [matter?]. It seems as though it benefits the abuser to downplay the severity of their actions. For the target, the meaning of strangulation is clear. But when we use other words to describe our experience we unintentionally allow for hazy interpretations by those in whom we confide. We allow ourselves to uphold the lie that it wasn’t that bad. It was. It is. It’s terrifying to admit to yourself – I was strangled. Because to admit that means to recognize that that abuser is walking around, living their life, a threat to you and to others. However, using this precise and accurate language is beneficial. It criminalizes their behavior. It displays their depraved hearts. It adds urgency to safety planning.

  5. Finding Answers

    Song Of Joy commented:

    Just my personal belief (solely based on gut feeling and not scientific statistics) is that suffocation is similar in intent to strangulation. Suffocation from a pillow, a hand, and I would include holding someone’s head under water (attempted drowning). Denying someone oxygen is a very sinister and terrifying kind of assault. I too would be very interested to know if there are any statistics on these other DV methods.

    Though harder to track or prove, I would be interested to know if the statistics on suffocation / strangulation could be traced back (or not) to childhood.

    One abusive sibling pulled a heavy blanket over my face when I was an 18-month old baby, sleeping in my crib. The same sibling tried to drown me when I was around 5 years old.

    I don’t know if he attempted to suffocate / strangle anyone else, though he definitely is an abuser.

    Perhaps the change in his physical stature altered his chosen methods of abuse.

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