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. 2021 Jun 14;8(2):95–103. doi: 10.1089/vio.2020.0012

Examining Relationship and Abuse Tactics Associated with Nonfatal Strangulation Experiences Before and After a Protective Order

TK Logan 1,✉
PMCID: PMC8219188  PMID: 34179213

Abstract

Nonfatal strangulation is associated with significant physical harm and lethal violence. The overall objective of this study was to examine relationship and abuse tactics for women with (n = 369) and without (n = 276) nonfatal strangulation experiences the year before, and the year after, a civil protective order (PO) against an abusive (ex)partner was obtained. Furthermore, this study sought to examine which abuse tactics, including nonfatal strangulation, were associated with mental health status at follow-up. In the year before the PO, 57% of women experienced nonfatal strangulation and 12.4% experienced nonfatal strangulation in the year after the PO by their abusive (ex)partner. Those with nonfatal strangulation experiences in the year before the PO were 3.5 times more likely to experience nonfatal strangulation after the PO. Additionally, death threats in the year before the PO as well as having spent any time in the relationship with the abuser after the PO were uniquely associated with post-PO nonfatal strangulation. Furthermore, abuser control tactics and severe violence after the PO were significantly associated with mental health status at follow-up after controlling for baseline mental health status. Study results also suggest that those with nonfatal strangulation experiences may have an especially difficult time initiating and maintaining separation from abusive partners. Results suggest that there are specific risk factors to consider in tailoring PO protections, safety supports, and resources for those with prior nonfatal strangulation experiences.

Keywords: strangulation, partner abuse, protective orders

Introduction

As many as 1 in 10 women report experiencing nonfatal strangulation by an intimate partner in her lifetime (Black et al. 2011). Strangulation is defined differently depending on specific state laws, but, in general, it is a form of assault, and, in this article, is examined as a specific tactic of partner abuse (Dunn and Smock 2017; Pritchard et al. 2017). Nonfatal strangulation can result in a wide range of injuries depending on the amount of pressure applied to the throat and the length of time of the strangulation (Dunn and Smock 2017; Training Institute on Strangulation Prevention 2018). Furthermore, injuries from nonfatal strangulation are mostly internal, rather than external, and many victims do not seek medical treatment for nonfatal strangulation, despite the potential physical damage and health consequences (Joshi et al. 2012; Patch et al. 2018; Strack et al. 2001; Wilber et al. 2001). Nonfatal strangulation has also been identified as a risk factor for lethal partner violence (Spencer and Stith 2018). One study found that women with a history of strangulation from their abusive partner were over six times more likely to have been subjected to fatal or near-fatal violence from that partner (Glass et al. 2008). This study examines nonfatal strangulation experiences, along with relationship factors, other abuse tactics, and mental health status, among women who obtained a civil protective order (PO) for partner abuse.

Civil PO, also known as “restraining orders,” are court orders that are granted to victims of partner abuse who seek protection from the courts. The orders prohibit contact, or at least violent contact, with victims by their abusive partners (Logan 2020). Women seeking civil POs experience a range of abuse tactics with some who experience control and psychological abuse but no physical abuse, whereas others experience severe physical violence before the PO (Logan and Walker 2009, 2010; Logan et al. 2006). Studies report that between 30% and 77% of civil POs issued for partner violence are not violated (Logan and Walker 2009, 2010; Logan et al. 2006; McFarlane et al. 2004). Many victims who experience PO violations still report reduced incidence and frequency of abuse and violence (Logan 2020; Logan and Walker 2009). Even so, there are some victims that continue to experience severe abuse and violence after obtaining a PO. In particular, there have been limited studies examining nonfatal strangulation experiences after the issuance of a PO and the factors that may be associated with nonfatal strangulation after a PO.

In general, nonfatal strangulation has been associated with other severe abuse and violence tactics. Specifically, studies have found that nonfatal strangulation co-occurs with other forms of abuse (Mittal et al. 2018; Shields et al. 2010) and severe violence tactics (Joshi et al. 2012; Messing et al. 2014, 2018; Mittal et al. 2018; Thomas et al. 2013), including sexual violence (Church Barker et al. 2019; Messing et al. 2014, 2018; Nemeth et al. 2012; Zilkens et al. 2016). Nonfatal strangulation is also associated with death threats (Bendlin and Sheridan 2019; Messing et al. 2014; Shields et al. 2010; Stansfield and Williams 2018; Wilber et al. 2001) and threats or use of weapons (Messing et al. 2018).

Nonfatal strangulation experiences have also been associated with significant fear (Joshi et al. 2012; Sorenson et al. 2014; Thomas et al. 2013). Prior research has found that nonfatal strangulation experiences were associated with depression and anxiety (Mittal et al. 2018; Wilber et al. 2001). Previous research has also found that women with nonfatal strangulation experiences have high fear levels and more negative health and mental health outcomes (Messing et al. 2014; Nemoth et al. 2012; Smith et al. 2001). This study also examines whether post-PO nonfatal strangulation is associated with mental health status at follow-up after controlling for relationship and other abuse tactics as well as mental health status at baseline.

Nonfatal strangulation may also be associated with increased controlling behavior by abusers and greater victim fear, which may impact the ability for victims to successfully separate or become free of the abuser (Joshi et al. 2012; Nemeth et al. 2012; Thomas et al. 2013; Vella et al. 2017). Separating women are at risk of continuing violence and stalking from an abusive partner for a variety of reasons, including partners' desire to reconcile, partners' desire for revenge, and partners' desire to maintain control (Logan and Walker 2004; Logan et al. 2004, 2008, 2009). Separation and stalking have both been associated with lethal violence as well (Logan and Walker 2017; Spencer and Stith 2018). This study also examines separation attempts and stalking with nonfatal strangulation experiences.

This study is the first to identify factors associated with nonfatal strangulation after a PO. The overall goal of this study is to better understand relationship factors (e.g., separation attempts and spending time back in the relationship) and abuse tactics associated with nonfatal strangulation after a PO is obtained to inform both courts as well as advocates working with partner abuse victims for safety planning. Furthermore, this study seeks to understand relationship and abuse tactics, including nonfatal strangulation, and the association of those factors with mental health status at follow-up. Within this context, the current study has four main objectives, including to: (1) compare demographic, relationship status, abuse, and mental health status (depression, posttraumatic stress disorder [PTSD], and substance use disorder [SUD]) among women with nonfatal strangulation experiences (n = 369) in the year before the PO and those who had never experienced nonfatal strangulation (n = 276) by the abusive (ex)partner; (2) explore prevalence of nonfatal strangulation as well as bivariate differences in other abuse tactics and mental health status among those who did and who did not experience nonfatal strangulation in the 12 months after a PO was obtained; (3) identify factors associated with nonfatal strangulation in the 12 months after the PO; and, (4) describe the association of relationship factors and abuse tactics, including nonfatal strangulation, on mental health status at follow-up controlling for baseline mental health status.

Methods

Participants

Study participants were recruited out of court when they obtained a PO against a male intimate partner and then followed 12 months later (n = 756). To be eligible for the study, participants were: (1) female, (2) 18 years and older, or 17 and emancipated, and, (3) had obtained a PO against a male partner within 6 months of entering the study. The average length of time between issuance of the PO and entry into the study was 40 days. Approximately 1 year after women participated in the first interview, follow-up interviews were conducted (mean = 11.7 months, standard deviation = 1.31, range = 9–18). The follow-up rate for the study was 94%, resulting in a sample size of 709. Six of the women had missing data for the nonfatal strangulation question. Overall, 61% (n = 427) reported nonfatal strangulation experiences from their abusive (ex)partner. Of those who had ever experienced nonfatal strangulation by the abusive partner, 13.6% (n = 58) had not experienced nonfatal strangulation in the year before the PO and were not included in the final sample for this article. Of the total sample used for this article (n = 645), 276 women had never experienced nonfatal strangulation from their abusive (ex)partner, whereas 369 women reported nonfatal strangulation experiences from the abusive (ex)partner in the year before obtaining a PO. Overall, women in the study were 31 years old, 81.9% were white, 54.7% were unemployed, and 28.2% had less than a high school education. Almost half of the women were from rural areas (48.5%).

Measures

Physical and sexual victimization tactics were measured with items adapted from the Revised Conflict Tactics Scale (CTS2) (Straus et al. 1996) and items developed from pilot work with the target population (Logan and Walker 2009; Logan et al. 2003). At the baseline interview, for each item, women were asked whether they had experienced the abuse tactic in the year before the PO was issued. At the follow-up interview, for each item, women were asked whether their (ex)partner had used the tactic since the PO was issued.

Nonfatal strangulation was measured with, “Did your partner ever choke, strangle, or put his hands on your throat?” And if so, participants were asked how many times this happened in the past year.

Abuse tactics experienced in the year before and the year after a PO included: control, threats to kill (death threats), threats or use of a gun or knife, severe physical violence, sexual violence, and stalking. Injury from the partner violence was also measured. Control was measured with eight items that asked whether their (ex)partner, in the year before the PO was issued, monitored their time, denied them access to money, stopped them from seeing or talking to friends or family, interfered in their relationship with others, tried to keep them from doing things to help themselves, restricted their use of the telephone, stopped them from leaving or going somewhere, or took their money. The maximum number of days any of these tactics were experienced was used as a proxy of frequency of coercive control given the overall majority of participants used in the analysis for this article experienced at least one of these controlling tactics in the year before obtaining a PO.

Participants were asked whether their partners had threatened to kill them. Threats or use of a gun or knife was assessed with two separate questions. Any threat or use of a weapon was used in the analysis. Severe physical violence was assessed by asking whether their partner had punched or hit them with an object that could have hurt them, slammed them against a wall, kicked them, burned them, bit them, or had beaten them up. Because so many participants had experienced severe violence in the past year, the number of different severe violence tactics was used in the analysis for this article (ranging from 0 to 6). Sexual violence was measured by asking participants whether their partner had threatened or physically forced them into any sex acts. Any instance of sexual violence was used in the analysis for this article. Stalking was measured by asking women if their (ex)partner had “Repeatedly followed you, phoned you, and/or showed up at your house/work/other place? In other words, did your partner ever stalk or obsessively pursue you when you did not want him to and it frightened you?”

Participants were asked if they experienced any injuries from the abuse in the past year such as a sprain, bruise, or cuts, broken bones, passing out from being hit on the head, vaginal tearing, pain or bleeding, and pain that still hurt the next day because of a fight with their partner.

Relationship Characteristics included questions about the type of relationship status, duration of the relationship, number of separations, and whether they had minor children in common with their (ex)partner. Women were also asked, at follow-up, whether they had been involved in an intimate relationship with the abusive partner during the follow-up period.

Mental health status included questions about symptoms of PTSD, depression, and substance use disorder (SUD). For the logistic regression, a dichotomous variable was created with 1 (having any of these mental health problems) versus 0 (having none of these mental health problems).

PTSD measures were adapted from the Diagnostic Interview Schedule (DIS) (Robins et al. 1981), which has shown to have good reliability and validity (Foa et al. 1993). Participants were first asked if they had ever experienced any listed events (e.g., natural disaster, serious accident, stalked, shut or kept in small places, mugged or threatened with weapons, beaten up, raped or sexually assaulted, threatened with a weapon). If any of the events had been checked, participants were asked a list of symptoms in the past 30 days associated with their self-perceived worst event. To meet criteria for PTSD for this article, individuals had to have (1) experienced a qualifying traumatic event, and, in the past 30 days (2) reported one or more of the reexperiencing symptoms, (3) reported three or more of the avoidance symptoms, and (4) reported two or more of the hyperarousal symptoms (American Psychiatric Association 2000). The trauma items did not specifically list nonfatal strangulation experiences but did ask about abuse and violence from their (ex)partner.

Depression questions were adapted from the Mini-International Neuropsychiatric Interview (M.I.N.I.), which has shown to have good reliability and validity (Sheehan et al. 1997). The original concepts and ordering of the depression questions in the M.I.N.I. were retained. Because the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) states that a period of at least 2 weeks of depressed mood or loss of pleasure or interest is the first criterion for a major depressive episode (American Psychiatric Association 2000), the first two questions of the M.I.N.I. were separated (i.e., feel depressed, sad, low, or down AND feel less interested in things or less able to enjoy things you used to enjoy) and were used to determine if the subsequent questions relating to additional depressive symptoms were asked. Additionally, response options for questions were adapted from the original Likert-scale ratings into a dichotomous yes/no variable.

Substance use disorder

Measures for SUD were based on the criteria in the DSM-IV-TR for substance abuse and dependence (American Psychiatric Association 2000). Questions about alcohol use and dependence were from the M.I.N.I (Sheehan et al. 1997). The time frame for the questions was the past 12 months. Individuals were classified as meeting DSM-IV-TR criteria for alcohol abuse or dependence based on their self-reported responses to the questions.

Procedure

Recruitment took place from four court jurisdictions (three rural and one urban) in one southeastern state with baseline interviews collected between February 2001 and March 2003 and follow-up interviews collected between October 2001 and December 2004. A female staff member approached women who obtained a PO against a male intimate partner from a judge after a court hearing. Participants completed a 3–4-h face-to-face baseline interview and an approximately 2-h follow-up interview. Both interviews were conducted in private rooms in public facilities in the community of the women's choice (e.g., libraries, hospitals) and began after informed consent was given. Each participant was provided with an educational protocol about safety and was given a referral resource pamphlet containing pertinent health, mental health, and safety planning resources tailored for the community in which she lived. Participants were compensated for their time. The study was approved through the University's Institutional Review Board (IRB).

Data analysis

Chi-square tests and one-way analysis of variances (ANOVAs) were used to examine significant bivariate differences on demographic information, relationship status, abuse experiences, and mental health status for two nonfatal strangulation groups: those who had (n = 369) experienced nonfatal strangulation in the year before the PO and those who never (n = 276) experienced nonfatal strangulation by their abusive (ex)partner. Additionally, the bivariate association of nonfatal strangulation before and after the PO was examined. Chi-square tests were also used to examine relationship, abuse, and mental health status for those with and without nonfatal strangulation experiences after the PO was obtained. A binomial logistic regression was used to examine associations with nonfatal strangulation after a PO with demographic factors (age, education level, employment status, and living in a rural or urban area), relationship factors (number of separation attempts, time spent in the relationship after the PO), abuse tactics (days of being controlled, threats to kill, threats or use of a weapon, severe violence, forced sexual activity, and stalking), injury, and nonfatal strangulation experiences in the year before obtaining the PO. A binomial logistic regression was also used to examine the association of nonfatal strangulation with mental health status at follow-up, controlling for demographic and relationship factors, abuse tactics and injury at follow-up, and mental health status at baseline.

Results

Demographic, relationship, abuse, and mental health status by nonfatal strangulation group

There were no demographic differences by nonfatal strangulation group. Those with nonfatal strangulation experiences had more separation attempts, on average, than those without nonfatal strangulation experiences (Table 1). There were no other significant relationship differences by group.

Table 1.

Relationship, Abuse, and Mental Health Status by Nonfatal Strangulation Group

  No nonfatal strangulation experiences (n = 276) Nonfatal strangulation experiences 12-months before PO (n = 369) DF X2or F
Demographics at baseline
 Average age (SD) 32.1 (9.7) 30.7 (9.0) 1, 643 3.513
 Full or part-time employment 48.6% 42.8% 1 2.094
 Rural 44.2% 51.8% 1 3.612
 Technical or college 43.5% 35.9%    
Relationship
 Married to their (ex)partner 51.4% 51.8% 1 0.006
 Average years in relationship with their (ex)partner (SD) 6.7 (7.0) 6.6 (6.4) 1, 641 0.110
 Minor children with their (ex)partner 48.6% 50.4% 1 0.218
 Average number of separations (SD) 3.6 (4.2) 4.5 (5.1) 1, 643 4.891*
 Spent any time in the relationship after the PO 35.9% 35.8% 1 0.001
Abuse year before the PO
 Days of abuser controlling tactics (SD) 145.3 (157.6) 208.0 (158.0) 1, 643 24.867***
 Threats to kill 55.2% 80.7% 1 46.284***
 Threats or use of gun/knife 30.8% 57.2% 1 44.266***
 Severe violence 52.5% 88.6% 1 104.732***
 Average severe violence tactics 1.9 3.0 1, 470 74.108***
 Forced sexual activity 14.9% 30.4% 1 20.958***
 Stalked 46.4% 52.6% 1 2.426
 Injured due to abuse 51.4% 89.2% 1 113.986***
Had injuries after a fight with PO partner
 Sprains, bruises, cuts 39.9% 85.1% 1 142.946***
 Felt physical pain the next day 40.0% 82.4% 1 123.293***
 Pass out from being hit in the head 2.2% 16.0% 1 33.256***
 Had vaginal tearing 4.0% 13.8% 1 17.581***
 Had a broken bone 5.1% 10.6% 1 6.325*
Mental health status at baseline
 Any mental health problem 64.1% 76.2% 1 11.084**
 Current depression symptoms 50.0% 60.1% 1 5.794*
 PTSD symptoms 35.7% 45.0% 1 5.495*
 SUD symptoms 28.6% 37.0% 1 4.991*
Any nonfatal strangulation after the PO 4.7% 18.2% 1 26.279***
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*

p < 0.05; **p < 0.01; ***p < 0.001.

DF, degrees of freedom; PO, protective order; PTSD, post-traumatic stress disorder; SD, standard deviation; SUD, substance use disorder.

Those with nonfatal strangulation experiences reported significantly more days of being controlled by their partners and more of the women in the nonfatal strangulation group experienced death threats, threats or use of a weapon, severe violence, and forced sexual activity in the year before the PO was obtained compared with those without nonfatal strangulation experiences. Among those who experienced any severe violence, those in the nonfatal strangulation group experienced more severe violence tactics than those without nonfatal strangulation experiences. More women in the nonfatal strangulation group reported they had been injured in the past year compared with those who did not report nonfatal strangulation. Specifically, more women in the nonfatal strangulation group reported sprains, bruises, and cuts; felt physical pain, passed out from being hit in the head, had vaginal tearing, and/or had a broken bone after a fight compared with those who did not experience nonfatal strangulation in the year before the PO (Table 1).

More of those with nonfatal strangulation experiences reported symptoms of depression, PTSD, and SUD at baseline than those without nonfatal strangulation experiences.

The majority of women who experienced nonfatal strangulation before the PO did not experience it after the PO (81.8%). However, of those who experienced nonfatal strangulation before the PO, 18.2% experienced strangulation after the PO compared with 4.7% who were strangled after the PO by their (ex)partner but had not experienced it in the year before the PO.

Relationship, abuse, and mental health status by the nonfatal strangulation group after the PO

Overall, 12.4% of the sample experienced nonfatal strangulation after the PO. More of those with nonfatal strangulation experiences after the PO spent time in the relationship after the PO was issued compared with those without nonfatal strangulation experiences (Table 2). The majority of those who spent time back in the relationship with the abuser lived with the abuser (82%, not shown in a table). Also, more of those with nonfatal strangulation experiences after the PO also experienced more abuser control, death threats, threats or use of weapon, severe violence, forced sexual activity, stalking, and injury from their abusive (ex)partner after the PO than those without nonfatal strangulation experiences. Furthermore, more women with nonfatal strangulation experiences reported depression, PTSD, or substance abuse disorder at follow-up compared with those without nonfatal strangulation experiences after the PO.

Table 2.

Relationship, Abuse, and Mental Health Status by Nonfatal Strangulation Group After the Protective Order

  No nonfatal strangulation experiences after the PO (n = 565) Nonfatal strangulation experiences after a PO (n = 80) DF X2or F
Relationship
 Spent any time in the relationship after the PO 31.3% 67.5% 1 39.888**
Abuse tactics after the PO
 Any abuser controlling tactics 30.4% 93.8% 1 118.858**
 Threats to kill 16.8% 72.5% 1 120.097**
 Threats or use of gun/knife 6.4% 45.0% 1 105.444**
 Severe violence 13.1% 91.3% 1 243.242**
 Forced sexual activity 2.1% 23.8% 1 71.343**
 Stalked 17.8% 56.3% 1 59.140**
 Injured due to abuse 5.9% 72.5% 1 256.024**
Mental health status at follow-up
 Any mental health problem 47.8% 71.3% 1 15.434**
 Current depression symptoms 31.9% 52.5% 1 13.143**
 PTSD symptoms 22.5% 42.3% 1 14.293**
 SUD symptoms 19.5% 36.7% 1 12.094*
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*

p < 0.01; **p < 0.001.

Logistic regression analysis examining factors associated with nonfatal strangulation after the PO

Results of the logistic regression examining factors associated with nonfatal strangulation experiences after the PO are shown in Table 3. Having spent time in the relationship after the PO as well as nonfatal strangulation and death threats in the year before the PO were significantly and uniquely associated with nonfatal strangulation after a PO.

Table 3.

Logistic Regression Results of Factors Associated with Nonfatal Strangulation After the Protective Order

  B Wald OR Lower CI Upper CI
Age −0.008 0.269 0.992 0.961 1.023
Education (0 = less than high school, 1 = high school or GED, 2 = technical school or college) −0.298 2.774 0.742 0.523 1.054
Employment (0 = unemployed, 1 = employed) 0.038 0.016 1.039 0.575 1.877
Area (1 = urban, 2 = rural) −0.224 0.571 0.799 0.447 1.428
Separation attempts before PO 0.003 0.016 1.003 0.952 1.058
Any time in the relationship after the PO 1.701 35.155 5.482*** 3.124 9.620
Days of abuser controlling tactics year before PO −0.001 1.540 0.999 0.997 1.001
Any threats to kill year before PO 1.023 5.549 2.780* 1.187 6.510
Any threat or use of weapons year before PO −0.008 0.001 0.992 0.533 1.845
Severe violence tactics year before PO 0.149 1.888 1.160 0.939 1.435
Any forced sexual activity year before PO 0.274 0.813 1.315 0.725 2.385
Any stalking year before PO 0.294 0.973 0.973 0.748 2.406
Any injury year before PO 0.060 0.016 0.016 0.419 2.688
Any nonfatal strangulation year before PO 1.165 8.492 8.492** 1.465 7.022
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*

p < 0.05; **p < 0.01; ***p < 0.001.

CI, confidence interval; GED, General Education Diploma; OR, odds ratio.

Logistic regression analysis examining factors associated with mental health status at follow-up

Table 4 shows the results of the logistic regression examining nonfatal strangulation and other factors associated with mental health status after the PO. Abuser controlling behavior and severe violence after the PO were uniquely associated with nonfatal strangulation after the PO controlling for demographic and baseline mental health status.

Table 4.

Logistic Regression Results of Factors Associated with Mental Health Status at Follow-up

  B Wald OR Lower CI Upper CI
Average age 0.014 2.061 1.014 0.995 1.034
Education (0 = less than high school, 1 = high school or GED, 2 = technical school or college) −0.329 7.898 0.720** 0.573 0.905
Employment (0 = unemployed, 1 = employed) −0.017 0.008 0.983 0.674 1.434
Area (1 = urban, 2 = rural) 0.136 0.519 1.146 0.791 1.660
Separation attempts before PO −0.015 0.610 0.985 0.949 1.023
Any time in the relationship after the PO −0.142 0.403 0.867 0.559 1.345
Any abuser controlling tactics after the PO 0.636 6.624 1.889* 1.164 3.067
Any threats to kill after the PO −0.002 0.000 0.998 0.592 1.681
Any threat or use of weapons after the PO −0.605 2.126 0.546 0.242 1.232
Any severe violence after the PO 0.863 4.581 2.371* 1.075 5.228
Any forced sexual activity after the PO 0.551 1.007 1.734 0.592 5.085
Any stalking after the PO −0.102 0.207 0.903 0.581 1.403
Any injury after the PO −0.182 0.195 0.834 0.372 1.870
Any nonfatal strangulation after the PO 0.240 0.370 1.271 0.587 2.754
Any depression, PTSD, or SUD symptoms at baseline 1.967 78.793 7.147*** 4.629 11.033
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*

p < 0.05; **p < 0.01; ***p < 0.001.

Discussion

Research suggests that nonfatal strangulation is experienced by many partner violence victims, and that many victims experience nonfatal strangulation repeatedly (Messing et al. 2014; Pritchard et al. 2017). Understanding nonfatal strangulation experiences both before and after a PO is obtained can help inform safety planning and legal protections. This study is one of the first to examine nonfatal strangulation experiences before and after a civil PO and associated relationship factors, other abuse tactics, and mental health status. There are four main findings that will be discussed, including: (1) nonfatal strangulation experiences in the year before the PO were relatively common, and nonfatal strangulation experiences co-occur with abuser control tactics, threats, and severe violence; (2) about one in eight women experienced nonfatal strangulation after the PO and both nonfatal strangulation and death threats in the year before the PO were associated with nonfatal strangulation experiences after the PO; (3) although nonfatal strangulation was associated with depression, PTSD, and SUD at the bivariate level, nonfatal strangulation experiences do not appear to be uniquely associated with mental health status at follow-up when controlling for other abuse experiences and baseline mental health status; and, (4) those with nonfatal strangulation experiences may have more difficulty initiating or maintaining separating from abusive partners as indicated by more separation attempts and more who reconciled with the PO partner after the PO; and, consistent with prior research, the current study found that nonfatal strangulation was a relatively common experience among partner abuse victims who obtained a PO, with about 61% indicating their abusive (ex)partner had ever strangled them (Malek et al. 2000; Messing et al. 2018; Pritchard et al. 2017; Wilbur et al. 2001). Of those who had ever experienced nonfatal strangulation by their abusive (ex)partner, the vast majority (84%) had experienced it in the year before obtaining a PO. Furthermore, in the year before the PO was obtained, more of partner abuse victims who experience nonfatal strangulation also experienced more days of controlling behavior, death threats, threats and use of weapons, severe physical violence, sexual violence, and reported more injury because of the abuse. This finding is consistent with prior research (Messing et al. 2014; Wilbur et al. 2001; Zilkens et al. 2016). In fact, several studies suggest it is rare for partner abuse victims to only experience strangulation with fatal or nonfatal consequences (Everytown for Gun Safety 2019; Shields et al. 2010; Thomas et al. 2013). The current study findings support partner abuse risk assessments that focus on severe incidents of physical violence. For example, law enforcement tends to focus on a small number of factors that they consider to be important when evaluating risk, such as direct threats or the use of a weapon, nonfatal strangulation, physical assault resulting in injury, and escalating severe violence (Robinson et al. 2016).

However, one problem of a narrow focus on physical violence incidents is that controlling behaviors and stalking are downplayed or ignored creating the illusion that these factors without severe threats and physical violence mean lower risk (Messing et al. 2017; Robinson et al. 2016; Stark 2007). The current study found that those who experience nonfatal strangulation also experienced more days of abuser control both before and after the PO, and more victims with nonfatal strangulation after the PO also experienced control and stalking after the PO compared with those without nonfatal strangulation experiences. This finding, which is consistent with other research suggesting coercive control, including controlling behavior, sexual coercion/violence, victim isolation, and victim fear, is the “golden thread” that underlies more severe violence (Myhill and Hohl 2016). Those authors also concluded that risk assessments structured around coercive control may help police officers move beyond an incident-based approach. Some studies have suggested that nonfatal strangulation may be a particularly powerful abuse control tactic (Pritchard et al. 2017; Stansfield and Williams 2018; Thomas et al. 2013). Future research is needed to better understand the trajectory, scope, and nature of abuser control, sexual abuse, and threats with nonfatal strangulation to inform risk assessments (Logan 2017). A better understanding of these issues may be crucial to intervening in cases before an escalation to nonfatal strangulation and to prevent revictimization.

Overall, about one in eight women (12.4%) in the current study experienced nonfatal strangulation in the year after obtaining the PO. The majority of those who experienced nonfatal strangulation before the PO, did not experience it after a PO (81.8%). However, those with nonfatal strangulation experiences in the year before the PO were 3.5 times more likely to have experienced nonfatal strangulation after the PO compared with those with no previous experiences of nonfatal strangulation from their abusive (ex)partner. In addition to prior nonfatal strangulation experiences, being in the relationship and death threats after the PO were significantly and uniquely associated with subsequent nonfatal strangulation experiences after the PO. Thus, the seriousness of recent nonfatal strangulation and the risk for repeat nonfatal strangulation after a PO should be considered by advocates in safety planning. This may particularly be the case for those with prior nonfatal strangulation experiences and who reconcile with their abusers although safety planning strategies may be challenging in this situation (Logan and Walker 2018a, 2018b).

Death threats may also be an important risk factor to consider especially in combination with prior nonfatal strangulation experiences. Similarly, a prior study found that death threats toward an (ex)partner before an arrest was associated with later nonfatal strangulation (Stansfield and Williams 2018). Another study found that the frequency of explicit threats was associated with concurrent abuse, violence, distress, and fear (Logan 2017). Several authors have concluded that death threats and nonfatal strangulation are likely used to dominate and intimidate their partners (Logan 2017; Stansfield and Williams 2018; Thomas et al. 2013). In addition, those who have experienced nonfatal strangulation often believe that the threats of harm by their abusive (ex)partner are credible given the abuser literally holds her life in his hands (Stansfield and Williams 2018; Thomas et al. 2013). These factors all suggest that partner violence victims seeking interventions like POs may need additional safety supports and resources, as their risk for severe violence and injury is heightened.

At the bivariate level, the current study found that more of those with nonfatal strangulation experiences reported symptoms of depression, PTSD, and substance abuse disorder at both baseline and at follow-up. These results are consistent with prior research, which also found that more women with nonfatal strangulation are depressed or anxious (Mittal et al. 2018; Wilber et al. 2001). Other research has found that women with nonfatal strangulation experiences have more negative health and mental health outcomes; and these negative outcomes may be more common among those with multiple nonfatal strangulation episodes (Messing et al. 2014; Nemoth et al. 2012; Smith et al. 2001). However, in the current study nonfatal strangulation did not have a unique association with mental health status after controlling for other abuse tactics, which is consistent with prior research (Mittal et al. 2018). Even so, the combination of severe violence, nonfatal strangulation, controlling tactics, and death threats with negative mental health status may also make initiating and maintaining separation difficult. The current study results found that those with nonfatal strangulation experiences had separated more times than those without nonfatal strangulation experiences, and twice as many of those with nonfatal strangulation experiences spent time back in the relationship with the abuser after the PO than those without nonfatal strangulation experiences after the PO. Tangible, emotional, and safety support for initiating and maintaining separation may be especially crucial for those with nonfatal strangulation experiences.

Furthermore, the current study was done in a state that allowed for two kinds of POs, including a no-contact order and a no violent contact order (Logan et al. 2009). There are many reasons women may want or need to continue contact with their abuser, including coparenting, which is often ordered by the court even within the PO (Logan 2020). Although having a PO is one step toward a victim seeking to be free from abuse, reconciliation is a normal part of the separation process for many couples with or without abuse histories (Logan 2020; Logan and Langhinrichsen-Rohling 2020; Logan et al. 2004). Furthermore, having a PO is only one part of protection for women. Enforcement of PO violations is critical, and if there is no enforcement of PO violations, partner abuse victims may be at higher safety risk and/or reconcile for their safety or the safety of their children or other loved ones (Logan 2020). Courts should be aware of the complications that occur within abusive relationships and craft PO protections that fit each case rather than approach cases as one-size-fits all. In particular, cases in which the abuser is highly controlling, stalking the victim, have severely violent histories such as nonfatal strangulation, and those that make death threats should be given heightened attention with regard to crafting protections.

One possible limitation of this study, as with others on strangulation, was the measure of nonfatal strangulation. Nonfatal strangulation experiences can vary by nature and severity; for example, whether victims pass out, the specific abuse contexts of the strangulation (e.g., part of a sex act, a physical “sign” of seriousness), and the direct physical consequences of the strangulation (Armstrong and Strack 2016). More research is needed to better capture the details and contexts of these experiences as well as the best questions to use in screening for nonfatal strangulation (Messing et al. 2017). This sample was mostly white and may not be representative of racial/ethnicity differences in partner abuse, nonfatal strangulation experiences, and PO outcomes. Also, the sample for this study was recruited out of court as women received POs for intimate partner violence. This sample included women who have experienced a sufficiently high threshold of violence for a judge to grant a PO. Also, for women to take the initiative to obtain a PO is a significant step since it commits them to a course of action, thus suggesting an awareness of serious safety concerns (Logan et al. 2005). Also, although abuse tactics were assessed before and after the PO was issued, mental health measures at baseline did overlap, for some women, for up to 40 days on average after the PO was issued. Thus, more longitudinal data on abuse, mental health symptoms, and the issuance of POs are needed to better understand the complex relationship among these factors. Furthermore, more research is needed to better understand a wide scope of risk factors for nonfatal strangulation and prediction of nonfatal strangulation after court interventions.

In summary, this study found that nonfatal strangulation is common in the year before partner abuse victims seek POs, and that nonfatal strangulation experiences co-occur with abuser control, death threats, physical violence, and sexual violence. This study, in combination with others before it suggests that, if nothing else, nonfatal strangulation should be included on assessments of risk for future harm among partner violence victims as it is frequently an indicator of more severe and lethal violence (Mcquown et al. 2016; Messing et al. 2017). The results of the current study also suggest that death threats should be considered as a high-risk indicator for ongoing violence. Additionally, study results also suggest that those with nonfatal strangulation experiences may have more difficulty in separating from abusive (ex)partners and may require increased safety planning and resources. The characteristics of nonfatal strangulation along with its likely physical and emotional sequelae should be included in trainings for court personnel, victim advocates, law enforcement, health, and mental health professionals (Pritchard et al. 2017). This study also suggests that judges may want to tailor PO conditions and sentences for violations of POs to abusers who have perpetrated any severe violence and specifically nonfatal strangulation instead of treating cases as isolated incidents that are unrelated to an offender's pattern of violence (Frantzen et al. 2011).

Author Disclosure Statement

No competing financial interests exist.

Funding Information

The data collection was supported by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) Grant Number AA12735-01 and the University of Kentucky General Clinical Research Organization funded by the National Institute of Health Grant #M01RR02602.

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