title: Non-fatal strangulation in sexual assault: A study of clinical and assault characteristics highlighting the role of intimate partner violence.
abstract: OBJECTIVE
  To describe the prevalence, risk factors, signs and symptoms of non-fatal strangulation (NFS) in women referred to a Sexual Assault Resource Centre (SARC) following recent sexual assault.
  
  
  METHODS
  A cross-sectional study using data routinely collected at time of forensic examination of women (age ≥ 13 years) referred to the Western Australian SARC between Jan-2009 and Mar-2015 alleging a recent sexual assault. Data on demographics, assault characteristics and forensic findings were available.
  
  
  RESULTS
  A total of 1064 women were included in the study; 79 (7.4%) alleged NFS during the sexual assault. The prevalence of NFS varied significantly by age-group and assailant type. Of women aged 30-39 years 15.1% gave a history of NFS compared to less than 8.2% in all other age groups. Of women assaulted by an intimate partner, 22.5% gave a history of NFS compared to less than 6% of women assaulted by other assailant types. Of all sexual assaults with NFS, intimate partners were the assailant in 58.2% of cases, whereas in sexual assault cases without NFS, intimate partners were the assailant in 15.9% of cases. Odds of NFS were 8.4 times higher in women sexually assaulted by an intimate partner compared to women assaulted by an acquaintance/friend and 4.9 times higher compared to women assaulted by a stranger. When considering both age and assailant type the highest proportion of NFS (33.9%) was in women aged 30-39 years sexually assaulted by an intimate partner. Other factors associated with NFS during sexual assault included deprivation of liberty, verbal threats, being assaulted in the woman's home and use of additional blunt force. External physical signs of NFS were absent in 49.4% of all NFS sexual assault cases.
  
  
  CONCLUSIONS
  This study identifies and quantifies NFS risk factors in female sexual assault and highlights the strong association with intimate partner sexual assault. Greater awareness of NFS in sexual assault should lead to improvement in medical screening, forensic management and safety risk assessment by sexual assault and domestic violence services, emergency departments and police.
authors.affiliation: Centre for Population Health Research, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia. Electronic address: r.zilkens@curtin.edu.au.
authors.forename: Renate R
authors.initials: RR
authors.lastname: Zilkens
authors.affiliation: Centre for Population Health Research, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia; Sexual Assault Resource Centre, King Edward Memorial Hospital, Subiaco, Western Australia, Australia. Electronic address: Maureen.Phillips@health.wa.gov.au.
authors.forename: Maureen A
authors.initials: MA
authors.lastname: Phillips
authors.affiliation: Sexual Assault Resource Centre, King Edward Memorial Hospital, Subiaco, Western Australia, Australia. Electronic address: Maire.Kelly@health.wa.gov.au.
authors.forename: Maire C
authors.initials: MC
authors.lastname: Kelly
authors.affiliation: Centre for Population Health Research, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia. Electronic address: Aqif.Mukhtar@curtin.edu.au.
authors.forename: S Aqif
authors.initials: SA
authors.lastname: Mukhtar
authors.affiliation: Centre for Population Health Research, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia. Electronic address: James.Semmens@curtin.edu.au.
authors.forename: James B
authors.initials: JB
authors.lastname: Semmens
authors.affiliation: Sexual Assault Resource Centre, King Edward Memorial Hospital, Subiaco, Western Australia, Australia. Electronic address: Debbie.Smith@health.wa.gov.au.
authors.forename: Debbie A
authors.initials: DA
authors.lastname: Smith
mesh_terms: D000328:Adult; D001237:Asphyxia / Q000209:etiology*; D003430:Cross-Sectional Studies; D003680:Deglutition Disorders / Q000209:etiology; D005260:Female; D006801:Humans; D000066511:Intimate Partner Violence / Q000706:statistics & numerical data*; D019838:Neck Injuries / Q000209:etiology*; D019547:Neck Pain / Q000209:etiology; D015995:Prevalence; D012307:Risk Factors; D012742:Sex Offenses / Q000706:statistics & numerical data*; D055815:Young Adult
keywords: Domestic violence; Forensic medicine; Intimate partner violence; Non-fatal strangulation; Sexual assault