How would I know if a patient had experienced non-fatal strangulation?

Up to 50% of non-fatal strangulation cases have no external signs of injury. A patient may not disclose it without being asked. Presenting symptoms can include headache, neck pain, voice changes, swallowing difficulty, or cognitive effects — all of which may appear after a delay. The CERSH toolkit provides guidance on how to ask.

What should a GP ask if they suspect a patient may have experienced strangulation?

CERSH's resource provides practical clinical language. Relevant questions include whether anyone has placed their hands around the patient's neck, whether breathing was restricted during sex, and whether the patient has experienced non-consensual sex. Signs and symptoms should be considered together with the mechanism of injury.

The injury that leaves no marks: GPs get a new guide for strangulation

She comes in for a headache. Or neck pain that won’t resolve. Or difficulty concentrating that started a few months ago. She doesn’t offer the reason. You don’t ask. The consultation proceeds. She leaves with a prescription or a referral. The underlying event — and what it signals about what is happening at home — remains unaddressed.

This is not a rare scenario. It is exactly what the new resource from the Centre for Excellence in Rural Sexual Health (CERSH) at the University of Melbourne is designed to change.

Non-fatal strangulation (NFS) is the act of restricting oxygen to the brain by applying pressure to the neck. It is closely associated with intimate partner violence. It can cause immediate harm — injury to the carotid arteries, tracheal trauma, brain hypoxia — and delayed harm that is harder to trace: cognitive effects, post-traumatic stress, seizures. Up to 50% of cases show no visible external signs of injury at all.

That statistic is the clinical problem. A broken wrist announces itself. Non-fatal strangulation frequently does not.

Why this matters, and why it’s been hidden

Associate Professor Siobhan Bourke, sexual health physician and CERSH clinical lead, is direct about why NFS has become normalised in a way that makes clinical detection harder. Widespread exposure to depictions of choking in pornography has shifted how some people interpret the experience — both those who administer it and those who receive it. Consent during strangulation cannot be fully ongoing: breathing restriction impairs the ability to withdraw agreement. But patients may not identify what happened as violence, and may not connect their subsequent symptoms to the event.

The result is a harm that sits in plain clinical view and is routinely missed.

The CERSH toolkit — which includes a position statement, a clinical resource covering red flags and assessment, and referral to free RACGP-accredited online training — is built for the generalist clinical setting. Dr Wei-May Su, GP and chair of the RACGP Specific Interests Abuse and Violence in Families group, notes that NFS often surfaces in conversations about sexual health or mental health, not through explicit disclosure.

Both-and: the clinical limits and the clinical opportunity

The honest picture of NFS assessment in general practice is constrained. There is no validated screening tool with high sensitivity. There is no single sign that is diagnostic. Assessment requires synthesising reported mechanism with symptoms and signs — which means making a clinical judgement in a time-pressured consultation, about a topic most GPs received minimal training in, with a patient who may be navigating significant risk.

And: the clinical opportunity is real, and it does not depend on perfect disclosure or perfect detection.

Dr Su makes a useful clinical distinction: even when a patient does not want to engage with the domestic violence framing, a GP can address the physical harm. Repeated NFS has analogues to repeated concussion. A patient who has experienced it benefits from monitoring for cognitive effects, carotid assessment if indicated, and an ongoing clinical relationship that makes future disclosure more possible.

The resource acknowledges that external signs are frequently absent and specifically guides GPs not to rely on visible injury as a criterion for taking the presentation seriously. The 2022 Australian Journal of General Practice article on NFS management established the evidence base this new resource builds on; the 2026 CERSH update reflects an updated clinical framework and a new module on non-consensual sex and coercion currently in development.

2 cents

If you are a patient reading this: symptoms after any experience of pressure on your neck — even when it was described or agreed to as consensual — are worth taking seriously. Persistent headaches, neck pain, difficulty concentrating, voice changes, swallowing difficulty, or a sense of fogginess after an episode are not trivial. They are signals from a body reporting what happened to it.

If you are wondering whether to bring this up with your GP and you’re not sure how they’ll respond: the RACGP resource, published this week, tells GPs exactly why they should ask. “How are things at home” is a legitimate clinical question. So is “has anyone ever placed their hands around your neck?”

If you are a GP: the CERSH online training is free and RACGP-accredited. It is one of the more direct ways to add a clinical skill that addresses harm that is serious, prevalent, and rarely surfaced without a framework to surface it.

Verdict: yes — an important, practical clinical resource addressing a harm that is common, serious, and frequently missed.

The injury that leaves no marks: GPs get a new guide for strangulation

Why this matters, and why it’s been hidden

Both-and: the clinical limits and the clinical opportunity

2 cents

Sources cited

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