Warning: This story references physical and domestic abuse.

A clinic in Surrey, B.C., that has long served victims of strangulation has dedicated a clinic for those services.

"We needed a specialty clinic where this could be looked at and people could feel supported," said nurse practitioner Hannah Varto at Embrace Clinic, which since 2015 has provided services for strangulation victims.

"This gives me shivers even just saying it … people who've been strangled, primarily women, from their domestic partner, are at seven times the risk of being killed by their partner in the future."

Previously a mobile clinic, Embrace secured a permanent location across Surrey Memorial Hospital in 2021 — where, last fall, it opened the Strangulation Clinic, which they say is in recognition of the serious health and safety consequences of the violent act. 

The province told CBC News it's unaware of other such clinics in B.C.

Typically overlooked, strangulation has become the focus of more study recently due to consequences like health issues and domestic homicides, experts say. 

It's the leading indicator of escalating violence in the future, according to Winston Sayson, a Crown prosecutor for 30 years who is now retired.

"When you reach that stage, you are in a very dangerous red zone," he said, adding strangulation is now equivalent to assault with a weapon or assault causing bodily harm.

In 2019, the criminal code addressing assault with a weapon or causing bodily harm was amended to include an additional offence that factors in choking, suffocation or strangulation. If convicted, an offender could face imprisonment of up to 10 years.

Another criminal code addressing sexual assault also had a subsection added, factoring in a similar offence related to strangulation. 

An analysis by Fraser Health found that from 2017 to 2022, strangulation occurred in 55 per cent of cases among 405 intimate partner violence patients at Surrey Memorial Hospital.

According to the health authority, forensic nurses at the hospital — who work closely with the Strangulation Clinic — have observed more reports of the violence since documenting those incidents in 2014, including strangulation leading to loss of consciousness, and loss of bowel or bladder control.

"It was eye-opening to consider how many incidents of strangulation — and the physical, emotional social and safety impacts that we may have missed by not specifically asking and addressing strangulation as its own stand-alone health and safety risk," Fraser Health said in an email statement. 

Services at the clinic include a full head and neck exam to assess injuries and blood vessel damage, sleep management strategies, counselling, conversations about mental health and treatment options following an attack.

Varto says many are surprised to learn they might have a brain injury from strangulation or strikes to the head.

"What we're seeing here is when we follow up with these patients, they've got every symptom of a concussion" — including persistent headaches, and difficulty concentrating, sleeping and remembering things, Varto said.

Last year, of the 480 patients who visited the clinic following recent violence, 60 per cent disclosed strangulation, head injury or both during their assault, according to Fraser Health. 

If strangulation and concussions become repetitive, injuries are similar to those seen in retired professional hockey or football players with a history of hits to the head, says Paul van Donkelaar, health and sciences professor at the University of British Columbia Okanagan and principal investigator of SOAR (Supporting Survivors of Abuse and Brain Injury through Research).

"They're living with these chronic effects, chronic symptoms for months to years and the implication being that it likely will lead to longer-term neurodegenerative disorders like dementia and Alzheimer's disease," he said, adding more research is needed on brain injuries from intimate partner violence.

Strangulation victims are often underserved, partially because the violence is not always reported and injuries can be invisible, says SOAR co-founder Karen Mason.

The health ministry says victims may be treated in emergency departments and not admitted to an inpatient bed.

Strangulation may also coincide with other attacks that leave injuries such as bruising. When victims don't disclose the strangulation while seeking care, the other injuries may become the focus, explains Fraser Health, adding the lack of blood flow and oxygen to the brain during strangulation can also cause memory loss in victims.

Health-care workers aren't often aware of brain injury from strangulation during intimate partner violence, says Mason.

"If those professionals don't understand the nuance and complexity of an abusive relationship, if they're not trained in trauma-informed practice, they will not be able to serve the survivor in the way that she needs."

Vancouver-based Battered Women's Support Services (BWSS) says it is helping educate medical students about the prevalence of strangulation and assessing traumatic brain injuries.

Accessing services also comes with barriers, says Angela Marie MacDougall, executive director of BWSS, as controlling partners often prevent victims from seeking care.

"It doesn't mean that she's free to simply go and get medical attention," she said, adding it's important to work with local organizations, crisis lines and transition homes to help people safely access medical support.

"We want to make sure that she's safely navigating what could potentially be a very lethal situation."

Anyone age 13 and older who has experienced recent strangulation can book an appointment with the clinic by phone or email, or get a referral from medical clinicians, community service providers or police.