When someone is strangled, the danger doesn’t end when the grip is released.
Strangulation is one of the most serious — and most frequently overlooked — forms of violence in intimate partner relationships. It causes internal injuries that may not be immediately visible. There may be no bruising, no swelling, no outward signs at all. Yet beneath the surface, the damage can be profound: brain injury, stroke, or even death may occur hours or days later.
“The deadliest injury doesn’t get treated because no one can see it,” says Janet Morales, Younity’s Crisis Sexual Assault Response Specialist. “Even law enforcement often misses it. So do doctors. And most of all—victim-survivors themselves.”
But the danger isn’t just medical.
Strangulation is also one of the strongest predictors of future lethal violence. Victim-survivors who have been strangled by a partner are 750% more likely to be killed by that same partner (Journal of Emergency Medicine, 2008).* It’s a major red flag — one that’s too often dismissed in the moment, despite its strong correlation with homicide in abusive relationships.
Why This Matters Now
The push to raise awareness around strangulation and smothering wasn’t driven by headlines — it came from the front lines.
“We noticed that many victim-survivors were not reporting strangulation or smothering as a major concern after a domestic or sexual assault incident,” Morales explains. “Even when it came up during advocacy conversations, few sought medical follow-up. We realized we needed to increase our own understanding to help them recognize the risks — and increase the likelihood they’d seek care.”
This lack of awareness is dangerous. Many survivors may not immediately report being strangled — or may not even realize how serious the incident was. As a result, critical medical care is delayed or avoided altogether.
“By learning to recognize the signs ourselves,” Morales says, “we can share life-saving information. These injuries may be invisible, but they’re deadly. Talking about it could literally save someone’s life.”
A Growing Pattern in New Jersey
These concerns aren’t isolated. Recent statewide data shows that reports of domestic violence — including cases involving strangulation — are on the rise in New Jersey. In 2023, the state saw a 15% increase in reported domestic violence incidents, with advocacy groups and public safety officials sounding the alarm on the link between strangulation and fatal outcomes.
This growing trend has prompted new legislative attention and changes to how these cases are classified and prosecuted. It has also reinforced the need for advocates, law enforcement, and healthcare providers to treat strangulation as a medical emergency — not just a legal issue.
Introducing the BREATHE Protocol
In 2024, New Jersey implemented the BREATHE Protocol — short for Breathing/Blood Flow Restriction Event: Advocacy, Treatment, Help, and Empowerment. This statewide initiative redefines how we respond to strangulation and smothering, treating them not just as criminal acts, but as urgent medical events.
The protocol addresses a dangerous pattern of minimization:
- No visible injuries
- No immediate symptoms
- No forensic exam
- No consistent follow-up care
- No one treating it seriously
BREATHE is about interrupting that pattern. It trains law enforcement, advocates, and healthcare providers to ask deeper questions: Did the victim lose consciousness? Has their voice changed? Did they change their clothes before help arrived (a possible sign of bladder control loss during the incident)? Are they aware that damage to the brain or arteries may still be developing?
“We have to heighten that sense of awareness,” Morales says. “If a victim turns down a forensic exam, we remind them they still have five days to seek one. Because when you’ve been strangled or smothered, your body is still responding long after the moment has passed.”
What Strangulation Really Does
It takes just 4 to 11 pounds of pressure — about the force of a handshake — to restrict blood flow to the brain. And the consequences can be devastating:
- Brain damage
- Stroke (even years later)
- Hearing loss
- Dislodged bones in the neck or throat
- Blood clots
- Memory loss or confusion
- Loss of consciousness
- Death
Many of these injuries are internal or delayed. Women in their 30s or 40s who suffer strokes may, in fact, have been strangled years earlier — without ever making the connection.
“It’s not uncommon for someone to say, ‘I didn’t even realize I blacked out,’” Morales says. “But that’s how serious it is. You can die hours, or days, or even years later, and people don’t know.”
A Charge That Rarely Reflects the Crime
Despite its lethality, strangulation is often misclassified or undercharged as simple assault — especially when there are no visible injuries. But New Jersey law is clear: As of 2021, strangulation in a domestic violence context is a second-degree aggravated assault — a felony that carries 5 to 10 years in prison and a presumption of incarceration.
In more extreme cases, where there is evidence of intent to kill, a history of escalating abuse, or serious injury, strangulation may be prosecuted as attempted murder — a first-degree offense.
“People don’t realize what it means to survive strangulation,” Morales says. “That someone put their hands around your neck with enough force to kill you. That’s not a ‘fight’ — that’s attempted murder.”
A Pattern of Control — and a Predictor of Lethality
Strangulation is rarely the first incident in an abusive relationship. It often happens toward the end of a relationship, when the abuser feels a deep loss of control. By that point, anger and desperation are high — and nothing else is “working” to maintain power. That’s what makes it especially dangerous.
“When it gets to that point,” Morales explains, “it could be too late.”
- Victims who have been strangled are 750% more likely to be killed by their abuser
- Nearly 1 in 3 officers killed in the line of duty were murdered by someone with a known history of domestic violence and strangulation
- And yet, strangulation remains one of the least documented and least prosecuted forms of violence
“Strangulation is so normalized in pop culture,” Morales adds. “People get choked in movies or TV and then they’re fine. But in real life, real people die. Or they carry damage they don’t even know about.”
What You Can Do
At Younity, advocates like Morales and Varonda Kendrick, Coordinator of the Response Teams of Mercer County, use the BREATHE Protocol to help survivors access urgent medical care, seek forensic exams, and create safety plans.
If someone you know has been strangled or smothered:
- Encourage them to seek immediate medical care. Forensic exams are available within five days. While the exam itself — conducted by a certified Forensic Nurse Examiner — is free of charge, there may be additional hospital-related costs (such as imaging or lab work), depending on insurance or eligibility for programs like Charity Care or VCCO.
- Stay with them for at least 24 hours. Symptoms may be delayed and can worsen rapidly.
- Look for red flags: hoarseness, memory gaps, dizziness, changes in mood or speech
- Connect them to Younity for safety planning and advocacy
“We’re not trying to scare people,” Morales says. “But we can’t sugarcoat it either. People need to know what strangulation really means: That it is never just a scare tactic. It is lethal. And it is urgent.”
Source:
* Glass, N., Laughon, K., Campbell, J., Block, C. R., Hanson, G., Sharps, P. W., & Taliaferro, E. H. (2008). Non-fatal strangulation is an important risk factor for homicide of women. The Journal of Emergency Medicine, 35(3), 329–335. https://doi.org/10.1016/j.jemermed.2007.02.065
For advocates supporting victim-survivors of strangulation or suffocation, this toolkit offers essential guidance. Developed by the Training Institute on Strangulation Prevention, the Advocacy Toolkit for Survivors of Strangulation/Suffocation includes practical tools, safety planning strategies, and survivor-centered language to help navigate these high-risk situations with care and expertise.
Access the full resource here:
