Strangulation is an Enforcement Mechanism of Coercive Control

“Strangulation is an enforcement mechanism of coercive control.” All violence is not equal—it matters what the function of the violence is. Once an act of strangulation is used, it may not need to be used again; the survivor may comply in future out of fear.
-Kelsey McKay, Former Prosecutor

Strangulation Response Across Systems

After hearing from subject matter experts, including survivors, and engaging in extensive discussions during taskforce meetings, we all developed a much deeper understanding of how strangulation occurs and how easily it can be missed. Strangulation can happen in many ways and is often overlooked when professionals are not trained to ask detailed questions or recognize the signs.  

We also heard repeatedly how important language is—survivors may describe their experiences in ways that do not immediately sound like strangulation (e.g., choking), so asking clear, specific questions is critical. As discussions continued, it became increasingly evident that effectively supporting survivors, identifying injuries, and holding offenders accountable requires a nuanced understanding of strangulation and its impacts. Combined with the need for a time-sensitive response to these assaults, it was almost shocking for the group to see how easily cases can be missed, sometimes with deadly consequences. As with the conversations around stalking, everyone was energized by what they were learning and focused heavily on solutions that could improve system responses and help survivors receive the care, safety, and support they deserve.  

There is a Need for Standardized Trainings, Assessments and Protocols

One of the clearest themes throughout the discussions was the need for ongoing, standardized strangulation training across systems including law enforcement, healthcare, EMS, advocates, 911 dispatchers, prosecutors, probation, child welfare, family law attorneys, and courts. Folks highlighted different training needs based on their own roles and experiences and topics that rose to the top were the different forms of strangulation, visible and invisible symptoms, traumatic brain injury, trauma responses, documentation practices, survivor-centered approaches, and safety planning. 

There was a consensus that current training is often inconsistent and dependent on local efforts. While Texas made important progress in 2019 by requiring law enforcement training on strangulation (SB 971, 86th Legislature), everyone recognized that ongoing and specialized training is needed in law enforcement, and across all systems that could interact with a strangulation survivor. People also saw how important training efficacy, accountability measures and advanced certifications models could be. 

Members also noted the lack of standardized documentation tools called out their own professions at times for failing to ask detailed questions, recognize non-visible symptoms, or connect survivors to advocacy and follow-up care. Domestic violence lethality tools are sometimes skipped due to time pressures, and survivors may not disclose strangulation until after the initial medical encounter. Our subject matter experts in the criminal justice system as well as healthcare talked about the importance of using standardized  tools, forensic toolkits for physicians, and perhaps even mandated use of Texas’ strangulation supplement (a detailed assessment tool used by law enforcement and first responders) or other standardized assessments in different sectors—and members definitely saw the value in these suggestions.  

Survivor-Centered, Multidisciplinary Responses Improve Outcomes

Every person in the room has noted in one way or another the value of this taskforce—a multidisciplinary group seeking to make change. They know the same kind of cross-sector approach is needed on the ground to respond to strangulations. The discussion turned to the multidisciplinary teams some communities already have, and which some members are a part of: Domestic violence high risk teams (DVHRT). DVHRTs coordinate responses to survivors who are assessed to be at a particularly high risk of lethality to improve survivor safety and offender accountability. The team typically consists of law enforcement, advocates and the local district or county attorney’s office, but can also involve probation, healthcare, child protective services and others. Some folks who have participated in or researched DVHRTs shared that these teams have improved identification, survivor engagement, and prosecutions. At the same time, they acknowledged that implementation varies widely across communities, especially in rural or under resourced areas where staffing shortages, limited funding, and reduced volunteer capacity create additional barriers.  

Forensic Nurses are Critical, but Workforce Capacity is Limited

Many members were already aware of the important role forensic nurses play in supporting sexual assault survivors and recognized their potential impact for IPV survivors, however, hearing directly from emergency medicine doctors and a forensic nurse gave members a deeper understanding of the critical role forensic nursing can play in strangulation assault cases. Members gained a deeper understanding of how trauma-informed assessments and documentation from forensic nurses strengthen investigations, prosecutions, and survivor safety, even when injuries are not visible. Members saw the importance of ensuring survivors can access forensic exams, advocacy, and medical care, free of charge, and without requiring law enforcement reporting, while also recognizing significant workforce shortages among forensic nurses and advocates. Discussion focused on potential solutions, including mobile forensic nursing teams, telehealth models, expanded training and certification pathways, and stronger support for program leadership and supervision. 

Additional Emergent Themes: Data Gaps, Public Understanding, and System Reform

Across multiple taskforce discussions, members noted that strangulation data is inconsistently coded and difficult to track across healthcare, law enforcement, and prosecution systems, limiting the ability to measure prevalence, outcomes, and system effectiveness. They talked about the need for standardized reporting (including explicitly naming strangulation), improved interagency coordination, long-term survivor outcome research, and accountability measures such as audits, fatality reviews, and oversight of coordinated response efforts, while also recognizing that improved identification may initially increase reported cases without indicating a true rise in prevalence.

At the same time, similar to our conversations about stalking, members highlighted the need for public education and broader system culture change, noting that survivors are often not believed, injuries are underrecognized, and coercive control is poorly understood; they called for survivor-centered awareness campaigns and training that reframes survivor behaviors as survival strategies that may seem counterintuitive but are the survivor’s best efforts to stay alive.

Finally, discussions underscored persistent sustainability challenges, with many efforts dependent on local champions, short-term funding and informal partnerships, and members calling for dedicated funding streams, reimbursement models, statewide policy support, and braided funding approaches, including consideration of adapting sexual assault forensic exam funding frameworks for strangulation response without diverting resources from existing sexual assault services. 

Ideas for Change

Policy considerations centered around the themes mentioned above: consistent and required training (including specializations or proficiencies in strangulation), standardized assessments and protocols, cross system collaboration and teams, strengthening data collection and coordination, and improving accountability measures for abusive parties as well as safety for survivors. 

Where More Learning is Needed

We had long discussions about areas in which more information would be helpful, including the intersection of strangulation and pregnancy, coercive control, children’s exposure to violence, rural access barriers, and prevention-focused strategies such as teen dating violence education, lethality identification, and battering intervention and prevention programs (BIPPs). Members were also interested in learning more about DVHRTs and their effectiveness and funding options to support future legislative and community efforts. 

Final Thoughts

Walking into our final taskforce meeting discussion focused on strangulation we were all holding the voices of the brave survivors who had participated in a panel to share their experiences. Moderated by our very own task force member Jamie Wright, their accounts left us with equal amounts of hope and frustration. If strangulation means a survivor is 750% more likely to be killed then how could one system disregard a survivor who shared her story and enable the abusive partner while another was met with a holistic response that supported their life and safety? Where else would we allow this chance when the risk of homicide is so high? How do we ensure every survivor of strangulation gets the health and advocacy support they need AND the system holds the offender accountable? These questions were at the heart of what the task force explored in detail in April and May and as you can see from the highlights above, the taskforce is as dedicated as ever to making meaningful change.    

Stay Connected

Follow along with the taskforce’s progress through our monthly updates, and feel free to reach out to TCFV’s policy team at policy@tcfv.org with any questions or thoughts—we’d love to hear from you!

Jen Mudge, TCFV’s Legislative Public Policy Manager and the voice behind this blog, can be found clocking in long hours at the Capitol during legislative session (basically her seasonal residence), advocating for policies that support survivors’ safety, rights, and voices. She is also honored to co-lead TCFV’s survivor involvement work. Her advocacy began over 25 years ago as a volunteer and has been shaped by the experiences of survivors, family, and friends—fueling her ongoing commitment to systems change in Texas. Outside of work she has entered her birdwatching era and finds joy and wonder in the natural world, from a lichen hugging a rock to a craggy, majestic live oak.