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Gender + Sexuality

The Hidden, Deadly Epidemic in Partner Violence

Strangulation does lasting damage and is a warning sign that a partner will kill. It’s still often undetected.

Mary Fowles 8 Feb

Mary Fowles is a Vancouver-based journalist with over 15 years of experience in print media and documentary filmmaking.

It wasn’t the first time Rick put his arm around Lisa’s neck and tightened his grip so she couldn’t breathe. (Both names are pseudonyms.)

That night they were arguing, and Rick became enraged. Throughout their relationship, his violence had repeatedly ended with him strangling her.

There were times Lisa would pass out and wake up on the floor, not knowing how she got there, with him standing over her. He’d called for paramedics in the past, but Lisa always made up a story of how she had fallen, and then refused medical care.

Lisa didn’t think of the man she loved as abusive. Rick would act like everything was fine, so Lisa would, too. “I’m OK,” she’d say to herself the next day. “Things will get better.”

Several years into the relationship, however, Lisa’s injuries had become chronic. “My doctor insisted there was something wrong with my neck,” she says. When he ordered a scan, the results shocked her. They revealed serious damage.

It was Rick who called 911 that night. Lisa couldn’t stand up, was nauseous and dizzy, and couldn’t see clearly. When police officers and paramedics arrived, Lisa panicked because this time she didn’t have a cover story.

“I didn’t want Rick to get arrested or go to jail,” she says. “The officer wanted to know if this was the first time. I didn’t answer and said I didn’t want to press charges.”

There was enough evidence to arrest Rick and he was taken into custody. Lisa had bruises on her leg and arms, but no visible injuries on her neck. She refused to go to the hospital, as she had in the past. When everyone left, she was still on the floor.

This time, though, things wouldn’t go back to normal. “I realized now I wasn’t safe. I knew I needed to get out,” she says.

Awareness of strangulation as a serious and potentially deadly crime that happens mostly to women in intimate partner violence has been growing globally in recent years. Studies show that women who’ve been strangled by an intimate partner and survived — termed “non-fatal strangulation” — are at a 600-per-cent increased risk for attempted murder and a 750-per-cent increased risk for domestic homicide.

In 2019, Canada amended its Criminal Code to include a new offence, strangulation — Section 267(c) — as a serious assault charge, on par with assaults with a weapon and assaults causing bodily harm. It carries a sentence of up to 10 years.

Prior to this amendment, strangulation could not be charged as an offence in and of itself. It could typically only bring charges of simple assault, carrying a far lighter sentence.

Another section of the Criminal Code, Section 246, did address strangulation, but only when used to render someone “incapable of resistance” — in other words, to hold someone down and prevent them from fighting back in order to commit another offence such as rape or robbery. The Crown was losing prosecution of strangulation in cases of partner assault because of the strangeness of how this law was framed.

Manual strangulation, which can be carried out by hand or through a chokehold, often leaves no visible signs of injury and typically occurs in secret within the context of intimate partner violence.

In a study of over 300 survivors of strangulation, only 16 per cent had visible injuries significant enough to photograph.

But passing a law is one thing. Enforcing the new law and carrying it through to a conviction requires awareness, training and a co-ordinated response between everyone from police, prosecutors and judges to 911 responders, doctors and ER staff.

Without that training, victims may not be asked the right questions or receive adequate care. Police may fail to obtain needed medical evidence or provide a full report to prosecutors. The crime may slip through the cracks in the system, despite the updated law.

According to the BC Prosecution Service, there have been 78 cases involving intimate partner violence in B.C. courts with convictions for s.267(c) since Jan. 1, 2020. But there are few available public records to examine these convictions.*

The crime is not uncommon. Studies show that among those who experience extreme partner violence, up to 50 per cent are strangled.

B.C.’s police policies for domestic violence were written in 2010, and while they do recognize strangulation as high-risk factor, the policies don’t outline any specific police protocol on how to investigate or gather evidence specific to strangulation, a complex, often invisible crime.

In November, B.C. updated its mandatory police training for cases of intimate partner violence, which is informed by these policies. The added training modules on “evidence-based, risk-focused intimate partner violence investigations” consists of four hours of coursework that must be completed by all current officers before December 2022.

But despite requests to B.C.’s Ministry of Public Safety and Solicitor General, the coursework was not made available to The Tyee for review. It’s unclear at this time how the training will serve to improve strangulation investigations and prosecutions going forward.

Understanding, and misunderstanding, partner violence

Understanding the deadly significance of strangulation as a crime started in 1995 with research in the San Diego City Attorney’s Office.

Known as the San Diego Study, it showed for the first time that strangulation of female victims of domestic violence is a key predictor of future domestic homicide, and that it’s often minimized or overlooked due to a lack of visible injuries.

Studies also show the crime is a key red flag for a person “more likely to kill police officers, to kill children and to later kill their partners.” In short, a person who poses a risk to society at large.

Strangulation can cause severe and potentially lifelong internal injuries as it starves the brain of oxygen and blood flow. A victim can lose consciousness in just five to 10 seconds and can die within four to five minutes.

Even victims who walk away from the assault appearing unharmed continue to be at risk from stroke or blood clots over the next two days, and up to two years later.

Victims can suffer brain injury, leading to memory loss and confusion, and they may have seizures and vision changes. If a victim blacks out during the assault, they can struggle to remember exactly what took place and may act drunk, high or scattered when police arrive, leaving them at risk of being dismissed as not credible.

After an attack, it’s common for victims like Lisa to be more concerned with protecting their partners than with seeking help for themselves. They may cover up or downplay their injuries and refuse medical care. Unless emergency responders are trained and supported by protocols that help them identify possible strangulation cases, the crime can go undetected.

Understanding of strangulation and how it presents in victims has been growing slowly since the San Diego study. In 2011, the Training Institute on Strangulation Prevention was founded by Casey Gwinn and Gael Strack, both of whom were instrumental participants in the San Diego Study.

The institute’s training materials and advocacy work have been influential, leading to new laws, more charges and, most importantly, an understanding of the deadliness of strangulation and what it signals about an offender.

The recent case of Gabby Petito, a young American blogger who was killed by her boyfriend Brian Laundrie on a cross-country van trip last fall, brought these complex dynamics of intimate partner abuse, police response and strangulation into public discussion. Bodycam footage released after Petito went missing showed an eerily naive response from law enforcement to an incident that happened between the couple.

On tape, Petito cries hysterically, describing her situation in a hoarse voice. She later tells an officer that Laundrie had grabbed her around the face and jaw. These details could have been flagged as key signs to trigger further investigative questioning; instead, they were ignored.

Officers concluded that Laundrie was the victim, not Petito. An officer told Petito he wouldn’t charge her but had to separate the couple for the night. No one asked Petito if she’d been strangled. One month later she was pronounced missing, and a week after that, her body was discovered. She had been strangled to death.

Angela Marie MacDougall, executive director of Vancouver-based Battered Women Support Services, says the police video was “so instructive in terms of giving us a front seat into what happens behind closed doors when police officers show up to a domestic and are making an initial assessment as to what is going on.”

“[The officer] was imparting his own personal values and experiences onto the scenario, minimizing the circumstances, denying any harm — even in the face of evidence — and blaming the victim. And that happens all the time.”

MacDougall, who’s supported victims and survivors for nearly 20 years, notes that violence against women is often minimized and typically resolved with an instruction for the couple to stay away from one another.

“It’s treated like a neighbourly dispute or disagreement between partners,” says MacDougall. “The underlying realities of abuse, violence and control are not recognized and are ignored. We are dealing with a system that is just overtly unwilling to recognize power imbalances between perpetrator and victim.”

‘I had all this evidence, but no one is asking me for it’

The morning after Rick was taken into custody, Lisa was shocked when he contacted her. The charges had been dropped, he told her, and he was coming home to pick up his belongings.

Rick soon arrived at the house where Lisa was alone, but he didn’t have keys. He started banging on the doors and windows to be let inside. Lisa hid until he left and then called the police.

An officer told her that since she had decided not to press charges, the case was closed.

“The officer said, ‘It is your fault,’” Lisa says. “Because I hadn’t made a statement. I will never forget those words. I was crying and very confused. I did not feel safe or protected. I think my boyfriend charmed these people and they were not looking out for me.”

Lisa explained that she’d been feeling dizzy, sick and in shock, and the officer at the scene had told her that her statement wasn’t needed.

Lisa moved into a shelter. She wrote her statement, sent it to the officer, and the case was reopened. Three days later she went to a clinic and documented her injuries.

With the case reopened, police charged Rick under Section 267 (c) — the new strangulation charge — and sent their recommendation to Crown counsel.

More than a month went by, but police didn’t follow up with Lisa to collect evidence, such as her medical reports or background history, she said.

“I had a lot of medical documents, because this wasn’t the first time this had happened to me,” Lisa says. “I had also seen a doctor after the attack who had documented all the details of the incident, and I had photos of the bruising.”

MacDougall notes that effective strangulation investigations need to be thorough. “It requires that police officers actually do that work and conduct a proper investigation, which, increasingly, they do not.”

The Crown moved ahead with the charges. But when Rick pleaded guilty to the lesser offence of simple assault, the “strangulation” charge was dropped.

“The Crown told me that in the long run it’s better to just get a conviction, because a lot of times there’s just not enough evidence to go to trial,” Lisa says, adding that going to trial without adequate evidence carries the risk of missing a conviction entirely.

“He got an amazing deal of a simple assault charge, and probation for one year,” she adds. “There has been hardly any impact on his life compared to what has happened to mine.”

The latest in BC

In B.C., police policy for domestic violence is developed by the Ministry of Public Safety and Solicitor General. The Violence Against Women in Relationships policy was written in 2010 — nine years before the new strangulation law came into effect — and mentions no specific protocols for strangulation.

The policy’s protocol for “high-risk cases,” also written in 2010, includes a brief mention of strangling alongside choking and biting as risk factors associated with “increased severity (escalation) of future violence.”

The guidelines, which are available to the public, instruct officers to assess for risk on a “case by case basis according to their professional judgment, training and experience.”

But without proper training or protocol for first responders in place, assessment of a primarily invisible assault can lead to minimizing or overlooking the crime or its severity, say experts.

Proper police protocol, as advocated by the strangulation training institute, includes asking pointed questions to determine the severity: “Have you been strangled?” “Did you pass out?” and “How long did the strangulation last?” These questions and others can assess if the assault was life-threatening and override an impulse to minimize it.

Proper police protocol can include assessing for subtle physical signs such as a hoarse voice, or petechiae (tiny red spots from ruptured blood vessels that may appear on the eyeball and on eyelids), as well as gathering any physical evidence at the scene, like photos or soiled clothing, which would indicate the assault was so extreme that the victim lost control of their bowels.

Police training courses specific to intimate partner violence are administered by the B.C. Ministry of Public Safety and Solicitor General and are mandatory for all B.C. police officers. These courses were updated in November 2021, but the coursework isn’t available to the public or media for review.

Amanda McCormick, an associate professor at the school of criminology and criminal justice at the University of the Fraser Valley, is currently conducting a study on police recognition of and response to strangulation files in B.C. to determine where training or other forms of education are most needed, and to understand where there are still gaps in awareness.

“The research is showing that police understand strangulation is a high-risk factor for severe or lethal violence, because they are trained in that,” says McCormick. “But we don’t know to what extent in practice they are recognizing strangulation and know how to gather the evidence. The findings of our research may lead to recommendations for enhanced practice.”

“In terms of the protocol and the tools in use,” she adds, “there is no checklist for questions to ask.”

She says that individual officers will sometimes self-select to gain additional training so they can learn more, but it’s not mandated. McCormick notes that the strangulation training institute is the only one of its kind in the world. Virtual courses are available online but cost US$500.

“There is currently no B.C. or even Canadian-based training available to officers,” she says. “We are just not there yet.”

PhD candidate Stephanie Ashton, a retired police officer, is working with McCormick on the research.

“Investigating strangulation is an advanced skill that some police officers in B.C. have and are applying in their work,” Ashton says. “But if a specific strangulation protocol is not written into the policy itself, it will not compel all police to be aware and to have that specific training.

“Right now, there is no direction or support in the policy for any level of response to strangulation.”

In B.C., police can only recommend charges, and it is up to the Crown to approve the charges or, based on a lack of evidence, recommend a lesser or different charge, or resolve the file through alternative measures.

There are currently no statistics on what percentage of police-recommended strangulation charges are dropped, or resolved by Crown through a peace bond, plea bargain or lesser included offence, as was the result with Lisa’s abuser’s charge.

This is one part of a larger problem — the data on how many intimate partner violence charges as a whole are resolved through a peace bond or lesser offence is not tracked in B.C. or across Canada generally.

Provinces and territories are responsible for administering justice within their respective regions, and police training and protocol can vary between the provinces, and even between jurisdictions.

Canada has no national action plan that would standardize or co-ordinate a response to crimes of intimate partner or gender-based violence across the country. By comparison, the U.S. has had its national Violence Against Women Act in place since 1994.

To illustrate how these policies can vary from province to province, Alberta offers one example.

In 2020, Alberta updated its police guidelines on domestic violence, including an entire section on strangulation. The section says an “apparent injury” is not needed in order to charge for the offence.

Alberta also specifically instructs officers to ask a victim if they passed out during a struggle, if they lost control of their bowels or bladder, if they are experiencing ringing in their ears or are having difficulty hearing, and if they are having difficulty breathing.

Such factors could indicate that strangulation was severe, therefore an even more severe charge of aggravated assault or attempted murder can be recommended. Finally, the guidelines recommend that first responders call for an ambulance to assess and attend to the victim.

These protocols conform to what the Training Institute on Strangulation Prevention recommends when investigating if strangulation has occurred and its level of severity.

The strangulation training institute in San Diego advocates for this training to be offered as a team approach, with police officers, medical first responders, judges and lawyers participating in the workshops at the same time.

This training was offered in Waterloo, Ontario in 2019, and since then more than 200 strangulation charges have been laid by the Waterloo Regional Police Service. The region’s staff sergeant with the intimate partner violence unit attributes this, in part, to increased detection, investigation and understanding of the crime.

No stats, however, have been released as to how many of those charges ultimately led to convictions or what sentencing was carried.

The need for proper medical documentation

Traditionally, most of what’s known about documenting strangulation injury has come from forensic medicine, for use in autopsy reports, with little guidance on how to document injuries in survivors.

Documenting the evidence of strangulation — complex internal injuries and symptoms, and their likely cause — relies on clinical forensic medicine.

Tracy Pickett, a clinical professor in the department of emergency medicine at University of British Columbia with a clinical practice in emergency medicine and sexual assault, says the Training Institute on Strangulation Prevention transformed her approach and protocol when caring for victims and properly documenting an assault.

“In the past,” Pickett said, “if a patient had presented to the ER with history of or signs of strangulation injury such as faint red marks around the neck, I would have asked, ‘Do you have any trouble swallowing?’ and if they said ‘No,’ I would not have given the strangulation another thought.”

Pickett notes that proper assessment of strangulation is crucial after an attack to provide adequate care to a victim.

Depending on what resources are available, medical assessment could require X-rays, bronchoscopy, vascular studies, CT and CTA scans with vascular studies, MRIs, or a period of medical observation in order to not miss an invisible, often complex, potentially lethal injury.

“There are limitations,” says Ashton. “Remote communities have fewer medical resources available to people who present with strangulation injuries, and so obtaining the documentation to prove the crime can be even more difficult.”

Pickett notes that worrisome symptoms following discharge from the hospital can include slurred speech, fainting or asymmetrical pupils. This information is provided to patients in an aftercare brochure that she has brought to her department.

After receiving the institute’s training, Pickett added a strangulation evaluation form for use in her sexual assault unit. With the proper followup, this form can be submitted to the Crown in a police report as evidence.

When it comes to charging perpetrators of partner violence, the Crown is guided by a Charge Assessment Policy, which sets out an evidentiary test to determine if there is a reasonable prospect of conviction.

When a co-ordinated response and proper followup between police and medical responders is in place, there is a greater likelihood of having adequate documentation to provide the Crown with the evidence it needs to go to build its case and go to trial.

If the case does go to trial, “judges assess the evidence as tendered in the trial and determine whether it proves the elements of the offence beyond a reasonable doubt,” says Bruce Cohen, Superior Courts communications officer.

The first step in terms of proper protocol and documentation can be as simple as asking if the patient has been strangled, Pickett says.

When she started to ask that question in her sexual assault services department, she says up to 20 per cent of patients said yes, a figure that correlates to findings in other sexual assault centres across Canada.

This simple question could have been helpful to Lisa. “Throughout all my years of medical appointments, and presenting with chronic injuries, no one ever once asked me if I was being abused or if I’d ever been strangled,” she says.

Lisa is still unable to work due to chronic pain, neck injury and PTSD symptoms including insomnia, panic attacks, flashbacks and nightmares.

As time goes on, she remembers more of the details of the attack, putting the pieces together into a clearer picture.

“I had to start listening to what everyone was telling me, and not go back to him. I needed to just keep telling the truth. In our relationship, he and I were both covering up the violence,” Lisa says.

“I realize now that the best thing I can do for myself and for him is to tell the truth.”

* Story corrected on Feb. 8 at 1:34 p.m. This story originally said there have been no convictions for S.267(c) in B.C. However, the BC Prosecution Service says there have been 78 convictions since Jan. 1, 2020.  [Tyee]

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