Because nearly half of all strangulation victims have no visible injuries, the King County medical examiner and a senior deputy prosecutor are training police, medics and emergency-room personnel to recognize and document the symptoms.

Share story

Stevie Barber’s roommates awoke to her screams as her boyfriend strangled her into unconsciousness, then set fire to her bedroom.

Barber’s boyfriend and her roommates made it out of the burning Central District duplex. Firefighters pulled Barber, 21, from the blaze with burns to her entire body. She was declared dead on arrival at Harborview Medical Center just five days into 2000.

Her death more than 17 years ago would become a watershed event in the careers of King County’s chief medical examiner and a senior deputy prosecutor, who have both spent countless hours educating lawmakers, first responders, ER physicians, nurses and jurors about the physical and psychological impacts of strangulation on victims of domestic violence.

“You can easily conclude strangulation is more a technique of intimidation than it is an intent to kill. This demonstrates, ‘Your life is in my hands,’ ” said Dr. Richard Harruff, who became the county’s chief medical examiner the same year Barber was killed.

Help for domestic-violence survivors

If you are in immediate danger, call 911. If you have been abused by an intimate partner, you can call the 24-hour National Domestic Violence Hotline at 800-799-7233 or 800-787-3224 (TTY). A variety of agencies in the area offer assistance, including confidential shelters, counseling, child therapy and legal help. For a list of resources, visit the Washington State Coalition Against Domestic Violence's website.

Because nearly half of all strangulation victims have no visible injuries, the goal of the training sessions is to help police, medics and emergency-room personnel recognize and document symptoms and behavior consistent with strangulation. In some cases, injuries manifest hours or days later, said Terri Stewart, the Sexual Assault Nurse Examiner (SANE) program coordinator at Harborview Medical Center and the state’s SANE training coordinator.

“A lot of times victims have memory loss … A lot of times they can have agitation and confusion and restlessness as a result of lack of oxygen to the brain,” she said. “I think a lot of first responders misinterpret that as (the victim) being over-dramatic or ramped-up due to this domestic-violence event.”

(Unlike in many dictionary definitions, strangulation is not necessarily a fatal act in legal or medical terms.)

Explaining to juries that a woman without a mark on her was in fact a hair’s breadth from death is part of the challenge in holding perpetrators accountable, said Senior Deputy Prosecutor David Martin, who with Harruff recognized the pervasiveness of strangulation in domestic-violence relationships after working on Barber’s homicide case.

“It takes good advocacy in the courtroom and good investigations and good expert testimony to explain the lack of injury, when lack of injury is pretty common in strangulation,” Martin said.

The Barber case, which was the first murder Martin helped prosecute, became the impetus for public-health research by Harruff, who with Martin rewrote a state law making strangulation a felony offense.

It used to be that prosecutors had to be able to prove a victim lost consciousness or control of bodily function for a strangulation to be charged as a felony. That changed in 2007, when the state Legislature adopted the update to state law written by Harruff and Martin that recognized strangulation as one of the most lethal forms of domestic violence.

Lawmakers concluded the “particular cruelty of this offense and its potential effects upon a victim both physically and psychologically, merit its categorization as a ranked felony offense.”

A decade later, second-degree assault by strangulation is the most frequently filed domestic-violence felony charge in King County Superior Court. Martin, who heads the prosecutor’s domestic-violence unit, said his unit is on pace to file 200 strangulation assault cases by the end of the year.

First-time offenders face a standard sentence range of three to nine months in jail, though some are able to plead down to fourth-degree assault, a gross misdemeanor punishable by up to 364 days in jail that also results in the loss of firearms rights. But many of the men Martin prosecutes are serial domestic-violence offenders who face lengthy prison sentences.

All but five states have felony strangulation laws like Washington’s, and California is going a step further. Starting Jan. 1, police officers there will be required to inform strangulation victims that they may have suffered internal injuries, and encourage them to seek medical attention.

Under Senate Bill 40, officers will also incorporate information about strangulation into domestic-violence incident reports, just as they do after domestic violence involving a weapon.

The ‘last warning shot’

While strangulation is most often seen in domestic-violence assaults, 10 percent of the 472 rape victims who had sexual-assault exams at five King County hospitals last year also reported being strangled — and nearly a quarter of them lost consciousness, said Harborview’s Stewart. Another 30 percent of rape victims couldn’t say if they had been strangled, because they couldn’t remember all of the details of their assaults, she said.

Strangulation is not a common cause of death for female homicide victims, although it’s widely viewed as a red flag that an abuser’s violent behavior is escalating — and it’s often a precursor to homicide by other means.

“Strangulation is the last warning shot,” said Gael Strack, a former San Diego County deputy prosecutor and the CEO and founder of the Training Institute on Strangulation Prevention. “If somebody punches you, the likelihood of that being a life-threatening injury is minimal. If somebody goes for your neck, it’s like if somebody goes for a gun — something bad is going to happen.”

The homicide rate for women has decreased along with other violent crimes over the past 30 years, and deaths from strangulation in King County have been roughly halved. Between 1980 and 1989, an average of nearly 29 women were killed by homicidal violence per year, and 25 percent of them died by strangulation, according to Harruff.

After the passage of the federal Violence Against Women Act in 1994 — which recognized the severity of crimes associated with domestic violence, sexual assault and stalking, and provided funding for prosecution — the female homicide rate and strangulation deaths both declined dramatically, Harruff said. From 2010 to 2016, the average number of female homicide victims in the county had dropped to roughly 14 per year, with 12 percent resulting from strangulation, he said.

“If you want to control your woman, you strangle her. If you want to kill her, you shoot her,” said Harruff, noting women are far more likely to be shot, stabbed or beaten to death by an intimate partner than killed by strangulation.

Harruff believes the state law that elevated strangulation to felony assault also has had a direct impact on lowering homicides, since abusers are often prosecuted before they can kill.

He and Martin are working on a study they will present to the American Academy of Forensic Sciences in February. By analyzing 848 King County homicide cases involving females killed from 1978 through 2016, they are attempting to measure whether a history of strangulation is a significant contributor to an eventual homicide. They believe it is.

What happens

In domestic-violence cases, manual strangulation — the use of hands, forearms or both to compress someone’s jugular veins, carotid arteries, airway or all three — is more common than ligature strangulation, in which an object like a phone cord, belt or bed sheet is used.

A victim who is strangled can lose consciousness in a few seconds, stop breathing in less than two minutes and die in three to five minutes. While an average male handshake has been measured at between 80 and 100 pounds of pressure per square inch, it takes only four to seven pounds of pressure to compress the jugular veins, which carry deoxygenated blood from the head to the heart, and twice that amount of pressure to compress the carotid arteries, which carry oxygenated blood from the heart to the head, according to Harruff and Strack. Compressing someone’s airway requires about 30 pounds of pressure.

Cerebral hypoxia — a reduced oxygen supply to the brain — is the essential injury involved in strangulation.

“The first part of the brain sensitive to lack of oxygen is the hippocampus, which is responsible for recording and filing information. The first thing that will go is your memory,” Strack said.

Half of strangulation victims won’t have any visible injuries. Those that do could have bruises, scratches, fingernail impressions and petechiae, which are pinpoint hemorrhages that occur on the skin and eyes when blood is trapped too long in the jugular veins, causing tiny blood vessels to break. Even victims who don’t lose consciousness may suffer brain damage, since it doesn’t take long for oxygen-starved brain cells to die.

“You’re not able to throw somebody into an MRI or do a CAT scan to see the damage,” Martin said.

But forensic exams by trained SANE nurses are incredibly valuable, because symptoms like a raspy voice, difficulty swallowing, or memory loss can be documented along with a victim’s history of assaults, he said, pointing to a program launched in 2012 by the Maricopa County Attorney’s Office in Arizona to document evidence of strangulation. There, he said, strangulation victims do receive forensic exams.

“I hope we’ll one day make that happen here,” said Martin.

Remembering a victim

When Harruff was recognized in 2006 by the King County Coalition Against Domestic Violence — now called the Coalition Ending Gender Based Violence — for his work on strangulation, he dedicated the award to the memory of Barber, the woman who died in the fire after she had been strangled by her boyfriend, Isaiah Ashley.

Barber, a Montana native, moved to Seattle seven months before her death and was trying to make her way in the world, said Martin, the deputy prosecutor. He recalled phone conversations with Barber’s mother and the raw anguish of her loved ones who addressed the judge during Ashley’s sentencing hearing.

Ashley pleaded guilty to second-degree murder and spent 13 years in prison before his release in February 2014. As of last year, Ashley, now 37, appeared to be living in Spokane, court records show.

“It was just an enormous tragedy, and it’s hard on a certain level to think he’s out now,” Martin said.