Characteristics of alleged sexual assaults involving non-fatal strangulation

This month we talk with FAMSACA’s Education Officer, Tracey Markham. The paper discussed is:

Thomas R, Willmot K, Seimon R, Derrick N, Dinh MM, Templeton DJ. Characteristics of alleged sexual assaults involving non-fatal strangulation at a Sydney metropolitan emergency department: a prospective descriptive study. J Forensic Leg Med. 2025 Oct;115:102967

Host: Assoc Prof Kathy Kramer
Guest: Tracey Markham

www.famsacaustralia.org.au
info@famsacaustralia.org.au

Transcript

SPEAKER_00 0:02

Welcome to Medico-Legal Matters, a podcast where we explore the medico-legal aspects of clinical forensic practice, specifically criminal cases arising from violence, abuse, and neglect.

SPEAKER_02 0:16

Welcome to the last podcast for the year, the Famsacker Podcast. I'm Kathy Kramer, I'm your host. I'm the immediate past president, and today I am delighted to have with me again Tracy Markham from our committee. Tracy's the education officer. So if you went to the fabulous conference in November, you can thank Tracy and her team for that. She's a nurse practitioner, she's an experienced sexual assault nurse examiner. She wears many hats, amongst other things. For example, she's a medicinal cannabis prescriber. So, Tracy, thank you so much for joining us today. Thank you for having me, Kathy. What paper have you picked out for us today?

SPEAKER_01 0:52

Today I wanted to talk about a paper that I think I'm really passionate about and lots of people passionate about this area of topic at the moment. It looks at a non-fatal strangulation in sexual assault presentations. The paper is called Characteristics of Alleged Sexual Assaults Involving Nonfatal Strangulation at a Sydney Metropolitan Emergency Department.

SPEAKER_02 1:16

Terrific. And we'll obviously put the citation in the show notes so you can go and have a look at it for yourself. So, what research question were they trying to answer?

SPEAKER_01 1:25

It was a prospective study out of Royal Prince Alfred's Hospital in Sydney, Australia. They looked at patients presenting to a Metropolitan Emergency Department after sexual assault, specifically focusing on those who reported non-fatal strangulation. I think what they were trying to figure out was really a few practical questions. How often does strangulation happen in sexual assault? What do these patients look like clinically? What red flags are they presenting with? And are we actually investigating and managing them properly in emergency departments?

SPEAKER_02 2:04

So this is a really rare beast in our field, isn't it? A prospective study and as you say, a big service. Hopefully, their patient group's going to be in a very applicable to the rest of us. How do they go about examining these questions?

SPEAKER_01 2:18

These weren't just forensic clinic clients, they were hospital-based ED clients. So every patient coming in for a sexual assault assessment was actively screened if they disclose strangulation. Clinicians then filled out a structured strangulation checklist, and that data was then combined with their forensic medical record and their ED electronic notes. So they were identifying patients in real time, not retrospectively. Yeah.

SPEAKER_02 2:48

Wow. So they're coming into the emergency department, they're disclosed on fatal strangulation, and we're getting documentation by the ED physician. And then if the sexual assault service gets involved, we've also got that documentation. So really, it's had like a really rich vein of information, the forensically informed stuff from us, but also the sort of real-world everyday clinical care that these patients get if they present to an emergency department. How many people are we talking about?

SPEAKER_01 3:13

Pretty decent size. They looked at 802 sexual assault presentations and found 113 cases of strangulation. So, you know, about 14%. Almost all of those were women, about 93%. And around a quarter of the cases involved intimate partner violence. So either current or ex-partners.

SPEAKER_02 3:38

So over 100 people in the study, which is, again, by forensic standards, that's a pretty solid study. And I suppose neither of us were surprised it were so few men because, of course, some of the male anatomy is going to be quite different, and are the findings the same. So the six million dollar question, what did they find?

SPEAKER_01 3:54

So I guess this is where it gets interesting. They used a set of red flags, things that they could suggest serious injury. The most common were difficulty breathing, voice changes of or hoarseness, and visible neck bruising. And they said about two-thirds of patients had at least one red flag. Just over half of those patients were referred on for ED medical review. And only about a third had imaging.

SPEAKER_02 4:24

Okay, that's interesting. So let's see if I've got those numbers right. So about two-thirds had a red flag. Yes. Isn't that right? And of those two-thirds, did you say about a third went on to have imaging?

SPEAKER_01 4:36

Yeah, about a third had imaging. Okay. So all up how many people had imaging? I think there was 31 had a CT, none had a MRI, two had an X-ray, one had an ultrasound, and then there was two that suggested other. I'm not sure what that other is. Maybe it might have been ENT or some other form of imaging.

SPEAKER_02 5:06

Okay, of the 31 who had a CT, then what was the injury rate?

SPEAKER_01 5:12

30 were normal, and there was one abnormal. So their single abnormal imaging result was a midline thyroid cartilage fracture of the larynx.

SPEAKER_02 5:23

Did they report on how many of the 114 odd patients had visible documentable external injuries?

SPEAKER_01 5:33

21 had genital findings, five had anal eyes or eyelids. It said five, face four, chest nine, scalp three, ears three, mouth twelve, and neck thirty-five.

SPEAKER_02 5:56

When it comes to finding injuries, did they give any definition of what would constitute an injury?

SPEAKER_01 6:03

The most common visible injuries reported in the neck were bruising, abrasion, and erythema. Do you want to talk about the substance use? They found alcohol affected consciousness in about 37% of the cases and 19% in drugs. But again, they didn't analyse whether intoxication made injuries worse or changed the outcomes. It was noted, but it wasn't really explored deeply.

SPEAKER_02 6:26

I think it's always important to be aware of the limitations of a study so that we're clear in our own heads we don't oversell it to ourselves, and of course we don't oversell it to a court. So can you walk us through the limitations of this particular study?

SPEAKER_01 6:40

We talked about red flags earlier, but I guess there's a limitation around that because they didn't statistically analyse whether red flags made an abnormal scan more likely. They just described the patterns. So I think that's a bit of a gap in the evidence. It was a single-sented study, so results might not apply everywhere. There was no long-term follow-up, and I think this is one of the things that interests me in the near future. So we don't really know what happens to people after they've been strangled numerous times, whether there's delayed strokes or carotid injuries, sometimes they could be missed, and some high-risk patients either declined ED review or left early, so they get a clear picture on everybody there. Overall, what they did work out is that it's really common. And for me, I guess the take-home message is most of these patients won't have obvious external injury. A normal examination doesn't mean they're safe, and our systems are pretty weak on follow-up and safety netting.

SPEAKER_02 7:52

I agree with all of those points. And perhaps an additional one that about the low CT yield, given the risks that having a CT. But yeah, I take your points. It's common, it's common in family domestic violence situations. It's quite common, as you say, not uh have any visible marks. And I think a really interesting Australian, relatively large, prospective study that I think we should all be taking to our services and having a chat about how we're going to best utilize it in our expert certificates. So, Tracy, once again, thank you for talking us through that. Much appreciated. Thank you. We have yet to decide what format the podcast series will take next year, 2026. So if you've got any thoughts, just reach out to FamSacca and let us know. Meanwhile, hope everyone has a safe and happy holiday time.

SPEAKER_00 8:44

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