Patients experiencing nonfatal strangulation during intimate partner violence (IPV) are suffering the consequences of unrecognized injuries and delayed life-threatening medical sequela. Forensic nurses offer expertise in the physical assessment and documentation to a variety of assault victims including those impacted by IPV. This project addressed whether an educational program on nonfatal strangulation increased the knowledge and assessment skills of forensic nurse examiners. The purpose of this doctoral project was to develop a continuing education program on the topic of nonfatal strangulation for forensic nurse examiners. The project design was created using Knowles's adult learning theory principles. The content outline was guided by the International Association of Forensic Nurses Nonfatal Strangulation Toolkit as well as input from content experts on nonfatal strangulation. The evaluation of the project was through pre- and posttest scores. The nonfatal strangulation continuing education training resulted in a statistically significant increase in participants' posttest scores (z-value= -3.064; p value =.002) indicating that the training material and teaching modality positively affected the participants test scores. This continuing education program on nonfatal strangulation increased knowledge of forensic nurse examiners and its application in the field might contribute to positive social change by increasing the identification of IPV and providing appropriate intervention.

Background: Non-fatal strangulation (NFS) is a life-threatening event in cases of sexual assault. The incidence of NFS during sexual assault is increasing on a global scale. NFS is a gendered crime as most victims are women and most assailants are men and is more common in intimate partner violence. Strangulation victims only have visible neck injuries around 50% of the time, but visible injuries are not a reliable indicator of the severity of the assault. NFS can cause neurological damage from lack of blood flow to the brain and result in physical and psychological trauma. NFS indicates a high degree of lethality in cases of sexual assault and victims of NFS are more likely to become homicide victims in the future. Methods: Information was gathered through a retrospective chart review of sexual assault medical forensic examination forms in a Mountain West state from 2019-2022. Descriptive statistical and Chi-square analyses were conducted. Interrater reliability (Cohen's Kappa) was calculated. Results: This retrospective, exploratory study of 2,077 sexual assault cases found the following variables statistically significant in NFS cases (~27.01% of total cases): age; gender; prior history of sexual assault; established suspect relationship; pain reports post assault; victim hit by assailant; victim reports of breathing changes; increased number of penetrative acts; and anogenital and non-anogenital injuries. Conclusion: NFS in SA are overall more violent assaults. Increased awareness and understanding of NFS during sexual assault will lead to improved medical management, nursing care, and services for victims experiencing NFS.

One incidence of intimate partner non-fatal strangulation (NFS) significantly increases the risk of homicide by asphyxiation (i.e., deprivation of oxygen resulting in death). The implications of NFS are well examined but the prevalence and dyadic influences of asphyxiation are less understood. This study examined various relationship types to determine if those defined by longevity and intimacy (e.g., dating and spousal) demonstrated the highest risk for NFS/asphyxiation, and evaluated the prevalence of other types of force at the time of the assault (e.g., firearms, personal weapons). Data for this project were obtained from the Tennessee Bureau of Investigation’s online incident-based reporting system. There were 34,448 reported cases of intimate partner violence (IPV) in 2019 included in the analysis. Independent variables included the survivor-offender relationship, (dating, marital, acquaintance) the force involved at the time of the assault, including the use of a firearm, NFS, asphyxiation, dangerous weapons (knife/cutting instrument, blunt object), or personal weapons, (hands, fist, feet, arms, teeth) and the location of the assault. The dependent variable was classified by the offense type (aggravated assault, simple assault, homicide, and forcible rape). Data were first cleaned using KuTools for Excel, 23.00 and then analyzed in SPSS Version 25. Regarding homicide, the most lethal type of force involved was not asphyxiation (6.5%; n = 3), but instead the use of a firearm (56.5%; n = 26), followed by dangerous weapons, (23.9%; n =11). The majority of NFS cases were classified as aggravated assaults (95.3%; n = 528) and mainly occurred at the survivor/victim’s residence (85.1%; n = 441). Regarding dyadic influences, the majority of incidents of NFS/asphyxiation occurred in dating (boyfriend/girlfriends; 63.9%; n = 354) and spousal (19.5%; n = 108;) relationships with homicides mainly occurring against spouses (50.0%; n = 21). A multinomial logistic regression model examining relationship type on the effect of force involved was significant, χ2(12, N =34,448) = 261.533, p < .001, Nagelkerke’s R2= .011. Only those in boyfriend/girlfriend (OR = .019; CI = .017-.021) and ex-boyfriend/girlfriend (OR = .024; CI = .019-.031) relationships significantly increased the likelihood of experiencing NFS or asphyxiation compared to the use of personal weapons. Those in acquaintance (OR = 3.447; CI = 2.618-4.539) and ex-boyfriend/girlfriend (OR = 2.266; CI = 1.927-2.664) relationships demonstrated the highest likelihood of a firearm being used at the time of assault. Findings indicated that dating and spousal relationships demonstrated the highest risk and prevalence of NFS and asphyxiation, but most cases of homicide involved a firearm. Proper screening by clinicians and medical personnel should assess for the current relationship type, past instances of NFS, and the presence of a firearm within the home. Further options for screening will be presented.

La suffocation est une forme d’asphyxie dans laquelle l’oxygène ne peut atteindre le sang. Il existe divers types de suffocation dont la suffocation par confinement/ environnementale, les étouffements externe et interne, et les asphyxies traumatique/ positionnelle. La littérature scientifique sur la suffocation est relativement pauvre, étant principalement constituée de revues de cas et de quelques séries de cas limités à un contexte particulier de suffocation. Dans le contexte actuel d’une médecine basée sur les preuves, les ouvrages de médecine légale n’ont guère d’études pour appuyer leurs enseignements, tirés essentiellement de l’expérience personnelle de générations de médecins légistes. Le présent projet vise à palier ce manque de données sur la suffocation, un type de décès pourtant important en pratique médico-légale. Il s’agit d’une étude rétrospective de six ans portant sur tous les cas de suffocation non-chimique ayant été autopsiés au Laboratoire de sciences judiciaires et de médecine légale. À notre connaissance, cette étude est la première à établir le portrait systématique des morts par suffocation non-chimique en milieu médico-légal. Elle permet, entre autres, de confirmer les modes de décès usuels par catégorie de suffocation, le type de victime et les contextes courants. Généralement, les résultats concordent avec la littérature, appuyant ainsi le savoir commun des pathologistes sur la suffocation non-chimique. Toutefois, certaines dissimilitudes ont été notées quant aux modes de décès lors de l’étouffement externe. Par ailleurs, les questions reliées à la classification des asphyxies et aux définitions souvent contradictoires sont discutées. En un effort de normalisation, ce projet souligne les divergences retrouvées dans les classifications usuelles et tente d’en dégager les définitions courantes afin de proposer un modèle de classification unifié. / Suffocation is a general term that encompasses several forms of asphyxia generated by a deprivation of oxygen. It includes different subtypes such as environmental suffocation/ entrapment, choking, smothering and traumatic/ positional asphyxia. In the forensic literature, suffocation has been the object of several papers, but mainly case reports or cases series. Studies of subsets of suffocation deaths, limited to a specific scenery or category, have also been reported, such as suffocation in motor vehicle collisions. Nonetheless, there are still several areas of forensic pathology mainly based on tradition, with textbook explaining and describing common knowledge that is not supported by modern research data: suffocation makes no exception. The present project is intended to contribute to evidence-based data on non-chemical suffocation deaths. It comprises a 6-year retrospective study of all non-chemical suffocation cases in the forensic victim population of Quebec. As far as we know, this is the first paper to ever portray a systematic study of non-chemical suffocation deaths in forensic setting. In general, the results are concordant with the textbook literature, therefore supporting common knowledge related to manner of death in non-chemical suffocation. However, discrepancies have been underscored in smothering. Furthermore, the classification of asphyxia and the definitions of subtypes, such as suffocation, are far from being uniform, varying widely from one textbook to another and from one paper to the next. Unfortunately, similar research designs can lead to totally different results depending on the definitions used. Closely comparable cases are classified differently by equally competent forensic pathologists. Therefore, the present project highlights the discrepancies between textbook classifications and tries to draw mainstream definitions, in order to propose a more unified classification of asphyxial deaths.

La suffocation est une forme d’asphyxie dans laquelle l’oxygène ne peut atteindre le sang. Il existe divers types de suffocation dont la suffocation par confinement/ environnementale, les étouffements externe et interne, et les asphyxies traumatique/ positionnelle. La littérature scientifique sur la suffocation est relativement pauvre, étant principalement constituée de revues de cas et de quelques séries de cas limités à un contexte particulier de suffocation. Dans le contexte actuel d’une médecine basée sur les preuves, les ouvrages de médecine légale n’ont guère d’études pour appuyer leurs enseignements, tirés essentiellement de l’expérience personnelle de générations de médecins légistes. Le présent projet vise à palier ce manque de données sur la suffocation, un type de décès pourtant important en pratique médico-légale. Il s’agit d’une étude rétrospective de six ans portant sur tous les cas de suffocation non-chimique ayant été autopsiés au Laboratoire de sciences judiciaires et de médecine légale. À notre connaissance, cette étude est la première à établir le portrait systématique des morts par suffocation non-chimique en milieu médico-légal. Elle permet, entre autres, de confirmer les modes de décès usuels par catégorie de suffocation, le type de victime et les contextes courants. Généralement, les résultats concordent avec la littérature, appuyant ainsi le savoir commun des pathologistes sur la suffocation non-chimique. Toutefois, certaines dissimilitudes ont été notées quant aux modes de décès lors de l’étouffement externe. Par ailleurs, les questions reliées à la classification des asphyxies et aux définitions souvent contradictoires sont discutées. En un effort de normalisation, ce projet souligne les divergences retrouvées dans les classifications usuelles et tente d’en dégager les définitions courantes afin de proposer un modèle de classification unifié. / Suffocation is a general term that encompasses several forms of asphyxia generated by a deprivation of oxygen. It includes different subtypes such as environmental suffocation/ entrapment, choking, smothering and traumatic/ positional asphyxia. In the forensic literature, suffocation has been the object of several papers, but mainly case reports or cases series. Studies of subsets of suffocation deaths, limited to a specific scenery or category, have also been reported, such as suffocation in motor vehicle collisions. Nonetheless, there are still several areas of forensic pathology mainly based on tradition, with textbook explaining and describing common knowledge that is not supported by modern research data: suffocation makes no exception. The present project is intended to contribute to evidence-based data on non-chemical suffocation deaths. It comprises a 6-year retrospective study of all non-chemical suffocation cases in the forensic victim population of Quebec. As far as we know, this is the first paper to ever portray a systematic study of non-chemical suffocation deaths in forensic setting. In general, the results are concordant with the textbook literature, therefore supporting common knowledge related to manner of death in non-chemical suffocation. However, discrepancies have been underscored in smothering. Furthermore, the classification of asphyxia and the definitions of subtypes, such as suffocation, are far from being uniform, varying widely from one textbook to another and from one paper to the next. Unfortunately, similar research designs can lead to totally different results depending on the definitions used. Closely comparable cases are classified differently by equally competent forensic pathologists. Therefore, the present project highlights the discrepancies between textbook classifications and tries to draw mainstream definitions, in order to propose a more unified classification of asphyxial deaths.

Text in English / As an external cause of death, strangulation represents an extreme and particularly pernicious form of violence. Following the evidence gap in the extant literature, the current research examined the incidence, distributions, individual and situational predictors, and structural determinants of homicidal strangulation in the City of Johannesburg for the period 2001-2010. The thesis is structured around four discrete but interrelated studies, which collectively offer an initial contribution to the body of scholarship on homicide generally, and on the characteristics and patterns of strangulation homicide specifically. The research drew on data from the National Injury Mortality Surveillance System and the South African National Census. Study I is a descriptive study that quantifies the extent of homicidal strangulation in the City of Johannesburg and describes its distribution by characteristics of person, time, place and alcohol consumption. The remaining studies are analytical in focus, and are aimed at explaining homicidal strangulation in the City of Johannesburg in terms of its determinants. These studies are differentiated by their focus on individual-level and neighbourhood-level risks. Study II assesses overall homicide strangulation risk in relation to all the other leading causes of homicide. Study III undertakes further disaggregation to investigate homicidal strangulation risk by gender specifically. Study IV considers the socio-structural correlates and geographic distributions of fatal strangulation. The study engages select micro-level and macro-level theories that focus on the intersection between vulnerability and routine activities, gender and neighbourhood derivatives of violence to explain the social ecology of lethal strangulation. The research findings demonstrate that homicidal strangulation in the City of Johannesburg is a unique phenomenon that is distinct from overall homicide. As the fourth leading cause of homicide in the City of Johannesburg, fatal strangulation exhibits a marked female preponderance in victimisation and distinctive socio-demographic, spatio-temporal, sex-specific and neighbourhood-level variation in risk. The study is aligned with the increasing trend towards disaggregating overall homicide into more defined and conceptually meaningful categories of homicide. The study may represent one of the first empirical investigations that also attempts to offer theoretically-derived explanations of homicidal strangulation in South Africa. Fatal strangulation is a multi-faceted phenomenon that requires multi-dimensional and multi-level interventions directed at several points of its social ecology. / Psychology / D. Phil. (Psychology)

Text in English / As an external cause of death, strangulation represents an extreme and particularly pernicious form of violence. Following the evidence gap in the extant literature, the current research examined the incidence, distributions, individual and situational predictors, and structural determinants of homicidal strangulation in the City of Johannesburg for the period 2001-2010. The thesis is structured around four discrete but interrelated studies, which collectively offer an initial contribution to the body of scholarship on homicide generally, and on the characteristics and patterns of strangulation homicide specifically. The research drew on data from the National Injury Mortality Surveillance System and the South African National Census. Study I is a descriptive study that quantifies the extent of homicidal strangulation in the City of Johannesburg and describes its distribution by characteristics of person, time, place and alcohol consumption. The remaining studies are analytical in focus, and are aimed at explaining homicidal strangulation in the City of Johannesburg in terms of its determinants. These studies are differentiated by their focus on individual-level and neighbourhood-level risks. Study II assesses overall homicide strangulation risk in relation to all the other leading causes of homicide. Study III undertakes further disaggregation to investigate homicidal strangulation risk by gender specifically. Study IV considers the socio-structural correlates and geographic distributions of fatal strangulation. The study engages select micro-level and macro-level theories that focus on the intersection between vulnerability and routine activities, gender and neighbourhood derivatives of violence to explain the social ecology of lethal strangulation. The research findings demonstrate that homicidal strangulation in the City of Johannesburg is a unique phenomenon that is distinct from overall homicide. As the fourth leading cause of homicide in the City of Johannesburg, fatal strangulation exhibits a marked female preponderance in victimisation and distinctive socio-demographic, spatio-temporal, sex-specific and neighbourhood-level variation in risk. The study is aligned with the increasing trend towards disaggregating overall homicide into more defined and conceptually meaningful categories of homicide. The study may represent one of the first empirical investigations that also attempts to offer theoretically-derived explanations of homicidal strangulation in South Africa. Fatal strangulation is a multi-faceted phenomenon that requires multi-dimensional and multi-level interventions directed at several points of its social ecology. / Psychology / D. Phil. (Psychology)