Hi, everyone. I would like to welcome you all and thank you for attending today's webinar, DNA and Sexual Assault Cases Part Two, Implications for Current and Future Practice. This webinar is being brought to you through IFN's Technical Assistance Project. We are grateful to be able to host Dr. Julie Valentine and Rebecca Kay for today's webinar. My name is Gail Horner, and I am a forensic nursing specialist with IFN. Before we get started, let me just share some housekeeping information. Today's webinar is possible due to funding provided through the Office on Violence Against Women, and the presenters of today's webinar disclose no conflicts of interest. As a benefit of membership, IFN members are eligible to receive 1.5 contact hours for this continuing education activity. The IFN is an approved provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. For IFN members to obtain CE for this activity, they are asked to attend the webinar in full and complete the post-activity webinar evaluation to obtain a certificate documenting the contact hours for this activity. For non-IFN members, with the completion of the post-activity webinar evaluation, you will receive a certificate of attendance. This webinar is being recorded today and will be available on the SafeTA website for viewing at a later date. IFN will send an announcement to all registered attendees once the webinar is available for viewing. And then finally, I would like to introduce today's presenters. We have with us Dr. Julie Valentine, who is an associate professor at Brigham Young University College of Nursing, and a certified adult adolescent sexual assault nurse with Wasatch Forensic Nurses. Her clinical specialty and research focus areas are sexual and gender-based violence. She conducts research to inform interdisciplinary practice and policy and improve criminal justice response in sexual assault cases. Dr. Valentine and her research team currently have multiple research studies utilizing their large, growing database of 13,000 sexual assault cases. They are keenly aware that each sexual assault case represents an individual who suffered sexual assault trauma and strive to represent the survivor's voices. Dr. Valentine is also a primary author of three awarded federal grants since 2015, totaling $3.45 million. She is the primary investigator on several studies related to sexual and gender-based violence. Additionally, Dr. Valentine has served in leadership roles with the International Association of Forensic Nurses, from Utah Chapter President to Director-at-Large on the International Board of Directors 2020 to 2022. And also presenting with Julie, we have Rebecca Kay. Rebecca is a forensic biologist and senior manager over the biology section of the Utah Bureau of Forensic Services. She has worked as a forensic scientist for the past 18 years in both private and public forensic laboratories and has provided expert testimony in Utah, Arizona, and Nevada. Since joining the Bureau of Forensic Science in January of 2008, Rebecca has held positions of senior forensic scientist, DNA technical leader, and manager of the homicide, high throughput, and DNA technical teams. And she has played an integral role in bringing new technologies and testing capabilities to the Utah Bureau of Forensic Science, including more sensitive testing methods such as YSTR analysis and DNA sequencing. She is an appointed member of the OSAC Human Forensic Biology Subcommittee and the Utah Cold Case Review Board, teaches forensic science courses for Southern Utah University, and holds a Master of Science degree from the University of Florida. And if it's okay with you guys, I will turn the webinar over to you all to get started. Thank you, Gail. Welcome to the webinar. I will be referencing part one that we had done earlier that you can watch, and I hope you do, but this is part two, Implications for Current and Future Practice. We're going to be talking about some research findings, current national best practices, and how we apply those things to practice. So the views presented are mine, but I want to acknowledge Utah Bureau of Forensic Services, which is the Utah State Crime Lab. The data that I will be presenting to you today is in collaboration, a research study with Utah Bureau of Forensic Services. And Rebecca Kay is one of their amazing forensic scientists, and the lead there in the DNA and biology department. I also want to acknowledge Utah Forensic Nursing Teams. You will see in the research that we are presenting that there is information from the sexual assault medical forensic exam records. And then of course, our patients, who is the driving reason why we do this research to improve practice and policy. I want to also acknowledge funding from the Utah Commission on Criminal Juvenile Justice, and the National Institute of Justice. So here are the learning outcomes. We hope that by the end of this webinar, that attendees will have an increased knowledge of evidence collection, best practice recommendations in sexual assault cases to optimize DNA analysis findings, increased knowledge of current research findings to inform same practice and guide clinical judgment in evidence collection and sexual assault cases, and then improve DNA analysis and interpretation methods that may impact current and future same practice and policy in evidence collection. So out of those, feel free to drop in what you are really here for. I think whenever we look at any education that we are striving to learn more about, we have to think, all right, so what are my goals? What am I hoping to get out of this? Feel free to drop that into the chat. So I first want to go over the big picture. There's a statement that it's not all about the box, right? That as sexual assault forensic examiners, our focus holistically is the patient. And as we know, many of us care for victims of violence. We also care for perpetrators of violence. They're all our patients or those impacted by violence or trauma. So our focus really is on the patient. So in the constructed theory of forensic nursing care, this is really emphasized, that forensic nursing care informs, impacts, and improves patient health outcomes, while it also informs, impacts, and improves forensic evidence outcomes and criminal justice outcomes. Today, our webinar is primarily focused on forensic evidence outcomes, but we always have to go back to that we are healthcare providers, nurses first, and the patient health outcomes, both short-term and long-term, are our focus. So I want to review some definitions from the Part 1 webinar. I'm going to turn this slide over to Rebecca to give us a refresh on these definitions. Short tandem repeat DNA, or what we refer to as STRs, is the type of testing traditionally done in all cases in the crime laboratory. It is specifically looking at markers on autosomal DNA and therefore nuclear DNA, so within the chromosomes, where we know people differ. And what is different between people is the number of times a certain short sequence of DNA is repeated in tandem, so right next to each other. And so all we're looking at with traditional DNA testing are these areas where people differ in the number of repeats, and this provides what we know as their DNA profile. Each person has two copies of every chromosome and therefore two copies of every location that we're looking at. And so typically a DNA profile is going to represent a series of numbers, two at each location, specifically addressing how many times they have this short sequence repeated at each location. And so at one location, I might be a 7-11, another individual might be an 8-12, and another individual might be a 9-9. And so it is in totality of these locations that we're looking at. Typically right now we're looking at about 21 locations within the chromosomes where we would provide the number of repeats that individual has at each location. Y-STR DNA is also STR DNA, so again looking at locations where people vary in the number of times they have a certain sequence repeated at a specific location. The difference here is all of these locations are on the Y chromosome, so it's not spread out through all the chromosome pairs within the nucleus and is only present on the Y chromosome and therefore is really targeting male DNA within a sample. If there's female DNA in the sample as well, it simply ignores the female DNA in that respect, since they do not carry a Y chromosome, and in that way allows us to really hone in on what may be a very small amount of male DNA from a male contributor to a sample, somewhat ignoring all of the female DNA that may be present. Trace or touch DNA is referred to using both of those terms interchangeably, is DNA or cells that may be left behind on a particular item that's not associated with a bodily fluid. So it's not necessarily a saliva stain or a seminal fluid stain, it is simply DNA and cells that are deposited based on contact, touch-type contact. When we talk about CODIS eligibility, there are several factors that have to be considered. There are scenario-type factors, meaning the sample has to be collected as part of a crime or crime scene, it has to be associated with the putative perpetrator in order to meet CODIS eligibility requirements, and so therefore if it is known that this particular DNA profile or DNA left behind is from a consensual partner, that will not be entered into the CODIS database. If it is from the victim, that will not be entered into the CODIS database. And so we really have to be careful as we're looking at evidence and looking at the profiles that we get from evidence to determine do they meet this CODIS eligibility and the requirements set forth by the FBI and at the national level of the types of samples that are even eligible to be put into the database or searched in the database. The other part of that, other than scenario or sample-driven, is actually the data. So a profile has to be and meet certain minimal requirements in order to be eligible to be put into CODIS as well. So for example, if I get a DNA profile but it's from a very small amount of DNA and therefore it's what we term partial, it has to meet a certain number of locations and it also has to meet a certain frequency or statistical weight in order to be put into the database. And the reason for that is if we enter something into the database and we get a hit or a match, we want it to be to the one true person. We don't want to get a whole bunch of matches to different people because it's such a small amount of the profile that maybe it overlaps with several individuals. And so as analysts, as we have evidence that we're working in a case and we get these DNA profiles ultimately downstream, we then have to go back and say do any of these profiles or samples meet those CODIS eligibility requirements before we can actually enter them into the database. Thank you, Rebecca. Hopefully you absorbed all of that. I recommend you really listen to part one webinar where we go into detail on that. I also would hope all of you would know within your jurisdiction if your crime lab does YSTR DNA testing. I think that's one of the great things about presenting with Rebecca is just to highlight the importance of having a strong collaborative relationship between those who collect the evidence, the forensic examiners, and those who analyze the evidence. There needs to be a lot of discussion and working together to really get the best outcomes. So find out if you don't know about YSTR DNA. We have done other, I've done with Heather Mills, who's another forensic scientist with Utah Bureau of Forensic Services, looking at Touch DNA and Trace DNA. And we have other webinars and videos that we've done on that. Also look at your jurisdiction. What are your guidelines? Are you collecting where areas have been touched or traced? What are your guidelines there? And work with your forensic scientists in establishing your jurisdiction's guidelines there. So with that, I'm going to jump into a little bit of background on DNA evidence collection in sexual assault cases. To really learn more about history of DNA in general and use in forensic sciences, please review the Part 1. I'm specifically going to cover a bit of history on sexual assault kits. And hopefully many of you know this, but we really owe Marty Goddard a huge thanks. She was a victim advocate in Chicago in the early 1970s, who was really concerned as a victim advocate. And when she would see victims who presented as patients at the hospital for care and evidence collection, that police shared that a lot of the evidence was incomplete or incorrectly collected or packaged. And so it wasn't really helpful in a case. And remember, we're back when we were looking at microscopes for sperm in some of these, but she really had an idea to standardize evidence collection. And she went to the Chicago police lab with this idea and was really laughed at. But they then realized that she had a great idea. And I think it was Louie Vitullo who developed the first sexual assault kit that was used in Chicago. Some of the guidelines with that initial kit, such as collecting for 72 hours, in some of those decision-making, there wasn't as much evidence as we're hoping to get now on driving some of this. And we know that these sexual assault kits have changed a lot. I remember when I was first doing cases, we were making slides. That's not recommended anymore. Plucking hair is not recommended anymore. These original SACs, we've had a number of changes. So the changes and updates that align with the science, the current state of science as we know it, one is the length of time of evidence deposition. So the time between the sexual assault and the examination, when we collect the evidence. We're going to talk about best practice guidelines. National best practice guidelines are that it's five days or more per jurisdiction guidelines, rather than three days. Current best practices is five days. I know there are some areas in the country that are not doing five days. I know that there are some that are doing substantially more than five days. I would recommend that you really work with your forensic scientists, but really look at the current state of science. We will be talking more about that. And then the swab collection guidelines. Those have also really changed. We used to have multiple slides collecting from a small area like the vagina and the cervix. The guidelines were you would have two sets of two swabs for vaginal and then a set for cervical. So that was six swabs in this one vaginal vault area. The guidelines now that science supports is that we concentrate the collection of evidentiary samples by using no more than two swabs per area of collection. And we will be talking more about that a bit. And then with the increased discrimination of DNA, we have to always be thinking about cross-contamination concerns. If you, or when you, if you haven't yet watched DNA part one, Rebecca really goes over in the laboratory how all the steps that they take to make sure that there is no cross-contamination. Everything from the flow of actually geographically, how a laboratory is set up to the PE that they wear when working with evidence. We need to start those concerns as soon as we take swabs out of a package and expose them to error until we have them sealed up into the box. So we're going to go over some of those cross-contamination concerns as well. So when we look at, all right, where do we find the best practice guidelines? I'm hoping that all of you are very aware of these guidelines. We also just recently out is a national protocol for IPV exams. The national protocol for sexual assault, medical forensic examination, adults and adolescents is actually being relooked at and rewritten right now to be more up-to-date with science and also linguistically with some of the pronouns use and different things. So that is being updated currently. And then we have the pediatric national protocol. And then the most recent one that was published by NIJ is the national best practices for sexual assault kits that was published in 2017. And that is a multidisciplinary approach. There is one chapter specifically for forensic examiners, but it also looks at law enforcement. It looks at guidelines for submitting kits. It goes through all the multidisciplinary approach guidelines. So I hope you're aware of those. The best practices, which is our most recent document, here are just some screenshots from DNA evidence collection guidelines. So recommendation eight, I mentioned this earlier, examiners should concentrate the collection of evidentiary samples by using no more than two swabs per collection area. So rather than left vulva, right vulva, left breast, right breast, really think that you want to concentrate the DNA on those swabs. We also have recommended timeframes, and you'll see that it has recommendations regarding body area. Again, these are recommendations. This is a growing area of science, but our current state is, here are the recommendations. And then we have, this is the first document where we actually have listed about touch DNA. So you can see here, there's from skin, whether it be a bite or oral contact, which is, we know that saliva is a rich source of DNA, but we also, this acknowledges that we can get information, useful information from skin contact. So I want to talk a little bit more about avoid cross-contamination. In our Utah sexual assault kit, within the actual kit now, this was pre-COVID, now all of us got really used to wearing masks. Now a lot of the hospitals are rolling back and we aren't wearing masks, but in our sexual assault kits for our state, we have masks and gloves. Masks should be worn as soon as you start to collect the evidence and open up those swabs. There may even be some concern if you're really close to a patient by their neck or something, and you're looking for a trace amount of DNA, should you be wearing a mask at that point? But once those swabs are out of the container, and especially when they're moistened, you want to make sure that you avoid speaking over or near these open swabs. You want to limit the number of individuals in the room. You can consider requesting men in the room to wear a mask. Rebecca talked about YSTR, which does not need as many cells to develop a profile. So we want to make sure that we're not just erroneously contaminating any swabs with any men in the room. Drying boxes. Drying boxes, the old drying boxes, and some of you may still have those, had a fan. And it used to be that we would collect the swabs and put them in these drying boxes, and we would flip on the fan to enhance the drying. I remember when I was in the safer working group, when we discussed this, the look of horror on all of the forensic scientists' faces, when we talked about these drying boxes, because what can happen is then all that little DNA can get blown from one swab when you turn that fan on. Fans should not be used in drying boxes. Drying boxes alone without a fan can be useful because they can protect that DNA. So we just have to be very clear that we are really cautious of avoiding any kind of cross-contamination from the time we begin evidence collection. So we're talking about the kits, and I'm going to be sharing with you, we're going to talk about three case studies. We're going to kick off with these case studies because then it leads into some new research. I'm going to summarize some of the research that's in the literature and some of the research that we have been doing. But I want to be really clear that this research, we don't yet have enough to say we need to absolutely change practice and policy. We need to continue, and you'll see on multiple slides, I'll say more research needed. I would suggest that everyone look at the best practice guidelines and follow those best practice guidelines. But I hope today's webinar gets you excited to learn more about the research because we need to be aware of the research and even excited to possibly work with your crime lab and saying, hey, what are some things that we could look at together? But this is not meant to encourage anyone to change practice or policy based on a couple research findings that we have right now. Please rely on national best practices. So with that, I am going to read, and these are, we have thousands of cases in our database, but I am ultra cautious about protecting the identity of anyone in our database. And so these are not written out. I'm going to just say these, and I'm not going to give the exact age. It will be a range of age, but we're going to talk about what swabs or evidence would you collect, and then I will tell you what the findings were from the DNA analysis. So many times as forensic examiners, we don't know what happened in that case from a forensic science perspective. What were the DNA analysis findings? If you are not getting that feedback and working collaboratively with your forensic lab, please do so. It will improve your practice, both of your practices. So case one, there is, this is a 25 to 29 year old patient with female genitalia. The assailant relationship was ex-boyfriend. The time between the sexual assault and examination was 126.5 hours. So a little over five days. Assailant ejaculated, but not on the patient per patient history. There was no condom or lubrication use. The patient showered at least once between the assault and the exam. The patient reported no consensual sex in the past five days. The patient started her period after the sexual assault before the examination and used tampons and pads. The exam found no anal genital or non anal genital injury. The patient reported this contact, vaginal and oral penetration by assailant's penis. Assailant's mouth on the patient's mouth, breast and neck. I want you to think about, and you can drop this in the chat, what swabs or evidence would you collect? So these were the swabs that were collected. The forensic examiner collected vaginal swabs. Collected a set of swabs. In our jurisdiction, we call them pubis to anus swabs, so the external genitalia swabs. Collected breast swabs, because a patient reported oral contact on breast. And collected neck swabs, because a patient reported oral contact on neck. Other items collected were also a sanitary pad that the patient was wearing, using at the time, and underwear. The items analyzed were the vaginal, the perianal, and the neck swabs. The initial testing that was done at the crime lab was checking for male DNA, or quant male DNA, and it found that no male DNA was detected on the vaginal and perianal swabs. Remember the patient had started her period between that time. But quant male was detected on the neck swab, and it was enough quant male DNA that it went to STR DNA testing, and the DNA results were that the neck swab developed a partial STR DNA profile that met the CODIS eligibility guidelines to go into the state CODIS database, and it was a test that was done at the crime lab, and it was called ESTES. So it was the neck swab. So I want to talk about a couple of things in this case. The patient had showered. We have several cases in our database where we have gotten useful information from neck swabs after showering. For those of you who, women listening on this, I have had some patients tell me that they took a shower and really washed that area. They wanted to really wash that area. She also had her period, but I want you to think about neck tissue, and you can look at mine for an example because I have a wrinkly neck, but necks have creases, right? So when you think about holding on to some of that DNA, we do find some really helpful information from the neck swab. The benefit of, regardless that the patient showered, that the forensic examiner went ahead and collected neck swabs was critically important in this case. All right. Now we're going to go to the second case study. This patient reported lack of consciousness or awareness. Now, just in our Utah cases, we have over 9,000 cases. We actually have 48% of the 9,000 of our patients report loss of consciousness or awareness at some point during the examination. How we ask this question is in our state form, we say at any point, did you lose consciousness or awareness? And sometimes the patient will say, yes, I don't remember how I really got into that room. Everything's fuzzy. So sometimes that is the extent of the change or loss of consciousness or awareness. Or you have some patients will say, I remember taking a drink and then I don't remember anything until I woke up and I didn't have my clothes on. So you can have hours missing, but we have 48%. So when I do trainings with law enforcement, I talk about that. That's not unexpected. We see a high amount of that. So in this case, this is an 18 to 25 year old patient with female genitalia who reported receiving a beer from an acquaintance at a party. Believed she had loss of consciousness for two to three hours. She awoke in a different location with ripped underwear and her clothing askew. The time between the sexual assault and examination was 18 hours. The patient did not shower. Reported drinking water between the assault and the examination. They brushed their teeth and gargled. No anagenital injury was found. There were three non-anagenital injuries. The patient attributed happened during the assault. They were all on one arm. They were bruises. The patient reported no consensual sexual partner in the last five days. And the contact, the what touched what, the patient stated unknown to every question. They didn't know what had happened to them. What would you collect? We're going to talk a little bit more about the guidelines and the national best practices when a patient has loss of consciousness. In this case, the forensic examiner, the nurse collected vaginal, pubis to anus, rectal, breast, neck, hands, and oral, perioral. These are the recommended swabs to collect in the best practice guidelines. The items that were analyzed were vaginal, perianal, and breast. The DNA results, remember this was 18 hours between the time this happened and the examination. The DNA results were no quant male was detected. So no further testing was done at that time. I will share with you some of our findings that when patients report unknown, we have less development of a useful DNA information because we have no patient history to help guide where we're collecting, correct? Also, the patient's not quite sure what happened to them. So this is not terribly unusual, but still, we would collect all of those swabs that are listed in the national best practices for collection. So now we're going to do case number three. Case number three is an 18 to 25-year-old patient with female genitalia. The assailant was an acquaintance. The time between the assault and exam was 6.5 hours. This patient had urinated after assault and removed and flushed a tampon. No shower, only drink water. No non-anogenital injuries. But there was a small laceration and bruise at the anus. We used tulidine dye. This patient had a laceration picked up tulidine dye at the anal opening. This patient reported a consensual partner of vaginal penile sex five to six days earlier. The patient reported that contact included penile penetration in anus, no condom used, but the assailant used lubrication. This patient reported that the assailant, there was no oral contact anywhere on her body, including mouth-to-mouth. We ask about, obviously, to guide our collection about where an assailant's mouth touched a patient. We found that only 49% of this large database that we have, the patient reports mouth-to-mouth contact. I would also share this with law enforcement, that the idea that maybe that many of these cases are making out that just goes too far. I think having only 49% report mouth-to-mouth contact is something that we need to think about as possibly. Does that mean it's some degree with law enforcement? Do they need to look at that as that might be an indication that the assailant may have had contact with the patient? We also found that the assailant did not have any nonconsensual act, something for them to consider. The swabs collected were anal, rectal, perianal, breast, abdomen, and buttocks. The clothing was submitted. The items analyzed were rectal, perianal, and breast. We also developed quant male DNA. The rectal swab and breast swabs were both moved forward to STR DNA testing. The rectal swab developed an STR DNA profile that was entered into CODIS, both endos and estes. This exam was, again, a little over six hours between the assault and the examination. The patient reported anal penetration, and that is where they found the useful DNA information. Let's follow up with those case studies with what we find in the literature. There's not a lot of research out there about how many sexual assault kits develop useful DNA profiles of foreign contributors. I have the research that's out there, but there's a pretty big range. It's actually 25% to 57% were entered into CODIS. CODIS is an outcome variable. We know that CODIS is incredibly helpful because it can help connect case-to-case matches. It also can help to identify a perpetrator, perhaps. But CODIS is not the only outcome measurement. Rebecca talked about why STR DNA, that there is other information that can come out that can be useful in a case. And, Rebecca, I don't know if there's anything you want to add more on that. Yeah, I just thought I'd touch on, for those who may not know, Julie referenced to both estes and endos. And so there are actually three levels within CODIS. There's eldest, which is the local level. There's estes, which is the state level. And then there's endos, which is the national level. And the two parts that I talked about CODIS eligibility, the scenario and sample-driven part of eligibility will be the same. But the data side of CODIS eligibility can differ between local, state, and national levels. And so one of the cases that she went through had a profile that was put into estes, or the state part of CODIS, because it met the requirements to be added to the state level, but did not actually meet the requirements to be pushed up to the national level. The national level is going to be more restrictive as far as you need more data to be able to have a useful search at the national level, because the database is so much bigger. And so when I talked about the statistic part of that eligibility or the kind of probability of finding that one true match, you require more information out of the profile to be useful at that level. It is dependent on the size of the database. Most state databases are going to be smaller than the national one, and so therefore you may not require as much totality of the profile to be entered at that level. And so there are some differences there. As Julie pointed out as well, we have YSTRs, which is not going to be searched really in CODIS, and so having a CODIS-eligible profile is not the only useful outcome. But I'll also add that you can have a partial profile that does not meet CODIS eligibility requirements as far as the amount of information that's within that profile to be useful, but it still might be comparable. So let's say out of the 21 loci that we're targeting, I got a profile that only has maybe six loci of information. Although it may not meet the requirement to go into the national level of ESDIS or even the state level, there's still a six loci profile that if a standard is submitted from a potential suspect, I could still potentially do that comparison and provide in a report in our conclusions that this person is excluded as being the donor of that six loci sample profile or potentially that they are consistent with that six loci profile. So CODIS is an easy kind of cutoff and an easy one for us to point to and say, let's look at the number of samples that make it into CODIS as being this scale as to whether or not we're getting useful data. But it's not necessarily the only way to look at data or the only way to have useful data out of a DNA analysis from the swabs that you're collecting. Thank you, that was perfect. And one other thing I want to add here when we talk about useful data, about 30% of our patients report consensual sex within five days. Work with your jurisdiction. In our jurisdiction, what we have decided to do is sometimes you will see a patient who reports a sexual assault at a party and their consensual partner is there with them as a support person. We try to get that consensual partner standard collected if they are there as a support person during the exam because that can be very useful if they do only have six loci profile or if it's greater than that for them to be able to say, all right, we have a standard of the consent partner and to be able to run that standard to see how useful is this, the other information. So as much as you can, try to get the consent partner at the time of the exam. All right, so the information I'm going to be sharing with you is information from a study. Our study now is larger, but this is our latest finalized data analysis. We're running the other study with the larger numbers, but this is in Utah from 2010 to 2019. And we had some basic research questions. What percentage of sex developed CODIS-eligible STRDNA profiles? And then what victim or patient and assault features were associated with development of CODIS-eligible STRDNA profiles? This is incredibly helpful research question for us as practitioners to help guide where we collect. One of the powerful things about our database is we have information from the sexual assault medical forensic exam records through was the kits submitted to the crime lab through the DNA analysis findings. And so we can look at these variables and see how they interact, how they're associated to really move the needle more towards evidence-based practice from best practices. So with that, our methodology is we initially on our earlier charts, we have our research team that coded from hard copy charts across the state. We would travel around the state. We now have an electronic medical record. So it's, we have clearance to get from the electronic medical records. So we do not have to travel. We have calculate inter-rater reliability and you want your inter-rater reliability to be Cohen's Kappa over 0.80. And we are about 0.9 to 0.955 through all the years that we've tested it, which is really important, which means our data is valid and reliable. We have this high inter-rater reliability. So between 2010 and 2019, we have 6,627 sexual assault medical forensic exams with sexual assault kits. And we had 4,626 submitted sexual assault kits. In 2017, House Bill 200 mandated the submission and testing of all sexual assault kits. Before that time, we did not have all of them submitted. So that's why you see that lower number. And out of those, about 95% were from patients with female genitalia, 4,404. So the first thing that we looked at regarding how do these interact is we looked at gender. So we look at female genitalia and male genitalia. And I want you to look at the column where it says uploaded. You can see on female genitalia, we're at 34%. And male genitalia, we're at 19%. We did not include transgender intersex because we have such low patient numbers. Again, trying to make sure that we have no identifying information. So as soon as we found that information, we realized to adequately or accurately study what variables from the victim and the assault impact development of a CODIS-eligible profile, we really had to separate those collected from patients with female genitalia and those collected from patients with male genitalia. So the remainder of the information that I am going to share with you is on female genitalia. We are currently doing data analysis on the male genitalia because there's not much out there on that and we really need that published. So the next thing that we looked at is age. And you can see, I want you to follow where it says that eligible column, that first column right here, look at this eligible. You can see our range on eligible. This database, we start at age 14. You can see not eligible. We have a patient 94, but our oldest age range on eligible was a 79-year-old patient. And then we have a race breakdown. No huge surprise. We predominantly are white in Utah and that is not going to be a factor. And then we looked at consensual sex. And I will share with you that our findings on consensual sex did not match up with some of the other research out there that has shown that if they report consensual sex, they're more likely to have an eligible profile. We did not find that. But I want to dive a little bit more into the age issue. So we group these, it starts at age 14 and we group these in age buckets. And you can see that starting at age 14, we have a high CODIS eligibility. But then as the age, here we get to mid 30s and it stays pretty much the same. But then as those with female genitalia age, we see a drop-off and we really see that at around age 55, even more so a steeper decline. We believe that as a woman ages, there are changes to the anal genital tissue that impact holding on to that DNA of a foreign contributor. So we found that age, so genitalia is again, the so what that female genitalia, we have higher degrees of developing a CODIS eligible profile than male genitalia. Anatomically females have vaginas, which are gonna hang on to DNA, that internal structure more than male genitalia. And then we have age. We think on age that as women get older and their estrogen levels drop, the changes in the anal genital tissue and the decreased secretion, they likely are less likely to hold on to this foreign contributor. So when we look at, anytime you have research, you look at, so what does this mean? And now what? And again, we are not saying that any policy or practice changes should be made with this. These are things to consider as you make clinical judgment calls in caring for patients. So the now what is collect as early as possible, especially those with male genitalia or elderly patients, really important that we get into collect as soon as we can. And then the more research is needed again to have evidence-based driven research. We then wanted to look at the time of evidence deposition. So the time between the assault and when they had their examination. You can see here a huge range. We have one case that was collected at 757 hours, and you might be saying, what? I will tell you our guidelines are about, we're now at six days, but we were at five days for a while. 757 hours, cases that we have seen patients and we have seen patients beyond five or six days, it's because they still have injury. And that's why they're seen and the forensic examiner may opt to still collect evidence, but that is our range. But you can see here the median 16 hours and the mean is 26 hours. And I also put the percentiles. So in 50% of the cases, the patient comes in 16 hours or less, 75%, 34 hours or less. Again, working with law enforcement, talking about that patients oftentimes are processing, what do I do? And many patients wait, and that does not imply anything about that patient or what happened to them, but not all patients report earlier, but we do have 75% that report 35 hours or earlier. We also found that there was, no huge surprise, a time between the assault and the sexual assault medical forensic exam and bathing and showering. Meaning if they didn't come in for four days, they're much more likely that they would have bathed or showered between that time period than if they came in within six hours. So I wanna show you a graph looking at that association. So the orange line up here are patients that did not bathe. So you can see, especially early on, and this is days, so this is more six hours or less, the early on, if they do bathe, there is a difference in developing CODIS eligible profile. As time goes on, that difference becomes less when you look here at the bottom on the days. I believe I have a slide that talks about comparing internal and external swabs. No huge surprise that if you look at those that did not bathe and a CODIS eligible profile, you can see an internal swab and an external swab if they did not bathe. So those external genitalia swabs that we have about the same percent that develop a CODIS eligible profile. But if they bathed, you can see here that we're more likely to develop a CODIS eligible profile from internal swabs. And these specifically are vaginal swabs. So what does this mean? That the time between assault and a sexual assault medical forensic exam, I think our research supports what is currently in the national best practices to collect five days or more, depending on your jurisdiction. But at the five days, if you're not there, I would talk to your multidisciplinary partners. And also that bathing and showering, we still get very useful profiles after bathing or showering. Not too long ago, a couple of months ago, I was called by a patient actually who had gone to an emergency room and someone had erroneously turned them away for an exam because she reported bathing or showering. And I feel like we're in an area where we have done a lot of education on this, but that education needs to continue to happen. We still see patients and collect evidence regardless of bathing or showering. So collect regardless of that to continue to educate multidisciplinary partners and the gatekeepers of the sexual assault medical forensic exams and that we need more research again. So we also wanted to look at what about the relationship between the patient and the assailant? Does that matter? So what we found is it matters only when the patient says, I don't know. We always ask, what is the relationship between the potential or the perpetrator? And when a patient says unknown, that also means that they also say unknown to what happened to them. And that's where we really see a big drop-off in developing a CODIS eligible profile. I wanna talk for a minute about ex-boyfriend. Back in 2011, when I first started this database, our state forums had stranger, acquaintance, spouse, partner, or other, but I kept seeing written under other ex-boyfriend or ex-partner. And we have in some areas of our state, we actually have higher levels of sexual assaults committed by ex-partners than current spouse partners. Many areas of the state, they're actually about the same. So it's important to consider what you're seeing in yours. We also see multiple assailants. If there's multiple assailants, that there is a decrease in developing a CODIS eligible profile. When there are mixtures, and Rebecca talked about mixtures in her earlier PowerPoint, it can be more difficult to discern. Some of the changes that are happening in DNA interpretation are making it more helpful to detect mixtures, but we see a decrease when they report multiple assailants. And then what about the actions of the assailant? Does that matter? We found that if the patient reported strangulation and being grabbed or held, that there was an increased association of CODIS eligible profile. Not quite sure what to make out of this. We found that hitting, and actually statistically significant, that there was a decreased association of CODIS eligible profile. In my mind, I don't know if that makes much sense, but it does make sense that the more contact there is, grabbing and holding, strangling, the more contact there is between that perpetrator and the victim, we would see increased DNA being deposited, increased CODIS eligible profiles. Then we wanted to look about what about patient injuries? Does that matter? And we found that, yes. Now, non-anogenital injuries, you can see eligible profiles. If they had non-anogenital injuries, that 35% developed CODIS eligible profile compared to 31% if they did not. 72% of our patients in our data set have non-anogenital injuries. And we only count those injuries that the patient says at the time of the exam, I didn't have that before the assault. We find that most of our non-anogenital injuries are on extremities, and they are mainly bruises and abrasions. Frequently, the victims will report being grabbed or held on the extremities, and that's where we see the bulk of our injuries. Anogenital injuries we see in 50% of patients, and we also found that it's statistically significant that anogenital injuries, they are more likely to develop a CODIS eligible profile. We also look at number of assaultive acts, which links to anogenital injuries, and they are more likely if there's a higher number of assaultive acts. We also wanted to look at ejaculation and condom use. Did that matter? No big surprise, it does, but I want to point out that on ejaculation, we ask the patient if the perpetrator ejaculated. Over half, 53% of patients say, I don't know. When I do trainings with law enforcement, I talk about that being a sign of a non-consensual act, that in consensual sex, most people know if their partner ejaculated. In a non-consensual act, a victim or a patient is not focused on that, and so the majority, well, over half report unknown to that. But no huge surprise if they report yes to ejaculation, that we would see a higher percentage that would develop a CODIS eligible profile. Now, condom use, if they report yes to condom use, note that it's still 31% of patients that report condom use developed a CODIS eligible profile. No, 41%, so more likely develop a CODIS eligible profile if they report no condom use, but still that's a high number with condom use. Over here, I have the number of patients that reported condom use, and you can see it's only 7%. We don't have very many sexual assault cases where the perpetrator used a condom, and again, 29% reported unknown because they likely were not focused on that at the time of the sexual assault. So what about if the patient can't remember? I've alluded to this before, but does that matter? And absolutely, it matters. So you can see over on loss of consciousness, if a patient says yes to loss of consciousness, 30% develop a CODIS eligible profile. We do have a small amount that say unknown. Many of times, these are cases that we have done in the ICU where the 49%, where are these 49 cases, these are cases where the patient was unable to communicate with us. And same thing for drug facilitated, that if they believe it was drug facilitated, that we are less likely to get CODIS eligible profile because, again, we don't have the patient history to guide where we are collecting, and they are not sure what happened to them. So with that, I'm going to turn some time over to Rebecca to talk about what is on the horizon that you should be aware of. Yeah, so we have several things that we're looking at and that can actually potentially improve the results downstream. One of those is on the interpretation of the data itself. As Julie said, if we get mixtures, in order to put something in to CODIS, we can only use part of a mixture. So we need to try to be able to tweeze out an individual's profile from what is a mixture of profiles from multiple individuals. And that can get, again, really tricky. And often we can't pull out a single component that we could then enter in to CODIS. That goes back to the CODIS eligibility based on the data. It still might be something that can be compared to, however, so if a standard from a suspect is submitted, there's still that potential to compare to that profile, just we aren't able to tweeze it apart enough to enter a single component in to CODIS. One of the new things that's happening, and this is happening across forensic DNA analysis, both nationally and internationally, is going from what was called the binary interpretation of data, which really involved just the human, right, looking at data and trying to tweeze these things apart and make best use of the information that's there to what's called probabilistic genotyping. And probabilistic genotyping is an approach that uses a statistical analysis of the mixture profile itself. And so it looks at probabilities, it sets up what combination of individual profiles best explains the data in this mixture. And so it really involves biological modeling and statistical theory and probability distributions and computer algorithms, computer being the really big part of it here. It is a software package that is used to look at these mixtures and help us to tweeze apart the individual components. The computer's ability to run through a ton of statistical calculations and probabilities is so much more than what the humans sitting there looking at the data can do, that it's really helping us to tweeze apart some of these mixtures and look at some of these profiles and be able to pull out a component that can now be put into CODIS where we couldn't before. And so this is really changing not only the way we do statistics and the way we view these mixtures, but it is having that outcome of more profiles can be entered into CODIS, which is great in so many ways. We have more samples we can make great conclusions and comparisons to, but also more of these profiles are entered into CODIS where we can hopefully develop a lead as to who that DNA belongs to or potentially link it to other cases. Next. A few other things that they're looking at. So that's a downstream side of improvements. There's always the, can we collect more or can we get more from the DNA that's collected? And so some of the other enhanced enhancements that are coming out have to do with those DNA collection techniques, specifically for trace samples. And most of this is done in the laboratory. And for example, if clothing is submitted because there was contact and grabbing, there are different types of things that we're looking at, collecting the cells off of that item in order to have more to work with to develop better profiles. And so currently the techniques that most laboratories are using and have used for years are either cutting a piece of that material out or potentially swabbing a larger area of the material and hopefully collecting enough cells off of it onto the swabs that they can then be processed. So there are a few different types of swabs out on the market. Most places are just simply using the cotton swabs for this type of collection. And some companies have tried to create different types of swabs, different materials on the swabs, different shapes to those swabs. So there are definitely studies out there looking at the swab type matter and is there a type of swab that maybe helps to collect more of this evidence? Another way of going about it is a taping method where it has different types of tapes that you can use to lay across material and hopefully again, pulling up enough cells that you can then generate a profile downstream. Another instrument is called the MVAC. The MVAC is very similar to a liquid handling vacuum, so a wet vac, but it's used, it can be used across larger surfaces again to try to pull more cells out of that item so that it can be processed through the laboratory and develop a more complete profile. Some of the issues with MVAC that have to be considered when using it on different types of evidence is, I think I brought this up in our first presentation, the ratio of contributors and the number of contributors to any DNA sample really affects the outcome. And so the more people's DNA in a particular sample, the harder it is to make any conclusions downstream. And if there's too many people's DNA in one sample, we won't be able to say anything. It becomes too complicated. We aren't able to tweeze things apart. We aren't able to make conclusions and we definitely aren't able to get anything to put into CODIS. The other thing is the ratio of contributors. If one person leaves 30, 50 times as much DNA or as many cells as another person on any particular sample, we will only detect the person who left the most DNA and we won't detect the profile of the person who left the smaller amount of DNA. And so that ratio also becomes something that we have to be cognizant of. So there is absolutely a use for all of these different types of collection techniques. There's absolutely a use for the MVAC, but there's always that consideration of, are we just going to create more or collect more cells that create a huge mixture of individuals downstream? Or are we going to collect too many cells from one person and not enough from the person of interest? And so therefore we aren't able to actually detect the person of interest's DNA profile downstream. Some other things that are moving forward more in the laboratory side of things, so once it's collected and now we're trying to test it, there is research on trying to identify different biological fluids than maybe the typical ones that we're thinking of. As far as we have blood, we have semen, saliva, those are all things that we test for in the laboratory. But vaginal secretions, is there a way to identify that versus any other epithelial cell? And so there's the type of cell or where the cell came from. The vast majority of cells we're dealing with are just epithelial cells and so is there a way to pinpoint where those cells came from in a better way? And another thing that they're looking at is trying to age stains. This is something that comes up often, if it's a stain on clothing, when did that occur? If we're talking about ex-consensual partners or something like that, the when that was deposited can become a big question when things go to court. That was there from two years ago versus that was laid down last week can really be the point of interest in any particular case. And so there are, again, research going on looking at aging stains and trying to figure out when those stains were deposited. These are capabilities that most crime laboratories have. It's still very much in the research stage, but it's something to be aware of. This is definitely being researched. It's something that if they work out the kinks and it becomes something that is easy enough for the crime lab to adopt and it has a good research background and is proven to work, then you will start to see crime labs adopting some of these future technologies. It's an exciting time. And I just want to jump in there. Our kits, like the swabs, those cotton tip swabs, they have, they've stayed that way forever. As this research grows, will we move towards a different swab type? And I think that's something that I know people are researching. It's not there yet, but even within our sexual assault kits, that could be a possibility at some point. We also moisten swabs with saline or water. And there has been some research, especially on these trace DNA samples, of having improved yield when there's been a detergent, it's like a forensic detergent, that that has helped to increase yield. So we've, our boxes have looked the same for a long time, what's in the boxes. Just be aware that there is research out there. Over time, we may see some changes there. Oh, and I also wanted to say on this, I've consulted on a study on the identification of biological fluids, where they're looking to be able to determine menstrual blood from other blood. And as when we do swabs in a vagina and we might get blood, many times we can see the menstrual blood coming from the cervical os, but that could be helpful in cases, even on bedding and other things. So that's another research that's going on, identification of biological fluids. Rebecca, I'll let you kick off this slide. Okay. So we never know what's around the corner. DNA specifically is advancing all the time and we hate to see a case go cold. When they do, there's still that next thing, that future technology that can potentially go back to the evidence that was collected and stored properly to open the door and be able to figure out a way of getting at the cells and DNA of the person of interest, which maybe it can't be done right today, but next year, the next three years, the next five years, we don't know where that technology ultimately can go and what the capabilities and how sensitive that newest thing might be. And so we always say, and I know Julie and I are on the same page with this, if in doubt collect, because if you don't collect it, we can never test it. That you are the front line. You're the ones collecting the evidence. And if the evidence is collected at some point in the future, we might be able to find a way to test it and get that outcome to potentially match it to a person or get it into CODIS and find a lead on who that person is. But if it isn't collected in the first place, we can never go back in time and get that to be able to use the next bit of technology on and to be able to solve a case. Thank you. We really are the gatekeepers, right? As to what evidence is collected. And I just want to go back and say, earlier, I talked about concentrating the sample on those two slides. So we don't mean when in doubt collect and collect everywhere. This is using your clinical judgment, but don't discount. I shared that one case study where it was a little over five days and we got a CODIS eligible profile from the neck swap and the person had showered. So what if that nurse had thought, oh, they'd showered. It's been five days. I'm not going to collect. Use your clinical judgment looking at what is current research and am I adhering to best practice guidelines? And then communicate that with your multidisciplinary partners. On our electronic medical forensic exam forms, we have a box where we can type notes regarding the evidence that we've collected to the forensic scientists to help guide them because they're not there with the patient and we are. So we might say a note like patient, we mark that there was oral contact on breast and on neck, but we might want to add in there patient reported minimal contact on neck, significant oral contact on breasts, and that would then guide the forensic scientists, oh, the breast swabs might be more useful. So make sure that you are communicating as partners in this process. Julie, I'll just add before you go on too, that case was not a one-off. We've had multiple cases that we've looked at just, we were looking at cases from just last year where we had multiple cases where it was three, four, five days out to collection and it was that type of contact, oral contact on the neck, on the breast, and the individual saying they bathed one, two, three times since the assault occurred and we still got profiles and not just profiles but CODIS eligible profiles. That wasn't just the one-off case that maybe that one individual didn't bathe or shower well. It was eye-opening for us as well because as we're choosing samples and we're going through those kits to know that we no longer really look at did they bathe or shower in determining whether or not we take that sample forward. So I think it's the same at collection. Yes, note it. Yes, let, you know, make that part of your documentation that they're saying that they bathed or showered and it's this many days out but I wouldn't hinge my, I'm not going to collect because they said they showered and therefore I'm not, we're never going to get anything off of that. It's definitely something that has changed the way we even process through the laboratory to know that isn't just the one-off case. We've had several, many, multiple that have had that same kind of situation where we are in fact getting profiles downstream. Thank you and thank you for reinforcing that and that's why I picked that case for the case study to go back to say make sure that you're still collecting whether bathing or showering and regardless of how many days because that's why we're here doing all working together to be able to get useful information in these cases. I want to wrap up with, I started with talking about, we focused on DNA today but we are focused on our patients. At the end of an exam I have a card that I give all of my patients. It has a pictures of crocus blooming in the snow and I tell my patients that my favorite flower is a crocus because no matter how much snow we've had, no matter how long the winter is, that the crocus is strong and still blooms and that's my goal for my patients. That they are going to take this hard thing that has happened to them and find a way to still bloom and there's nothing else on this card except the word bloom. This is a link to a video that I did where I talk about this message and shared that as well. With that here are references and we can move to questions. So Julie I've tried to keep up on most of the questions that have been asked both in the chat and in the Q&A and I've tried to answer some of those already online but I did save a couple that I wanted to make sure that you were the one answering. One of them says, can the number of eligible samples also be correlated to fewer patients in the older age group? I think this goes back to when you were discussing the age and I'm not sure if that if you understand that question but yeah. So I think you're saying how accurate is that because we have smaller numbers and we absolutely and that is a limitation. We have to look at that but I think it is enough of a trend when we see that age drop and those we have quite a few on 55 etc that I feel that we can theorize about the changes in anogenital tissue of women that we do see a decrease as women age. I think it's Kirka et al but there's a reference at the end that they found the same thing that there was a decrease as women age. So we know that and we need a lot more research on pediatric cases but what's out there so far is we know we have less development of a CODIS eligible profile with younger children. Again, they can't tell us exactly what happened. We know there's a lot of delayed reporting etc and then we're seeing that also that lower amount with elderly patients. So I think it really would be it's probably a pretty good bell curve if we go across the lifespan. So hopefully I answered that. And then the other one Julie is, is it best practice to still use ALS if the patient has bathed or showered? So that and absolutely if your jurisdiction uses ALS whether they bathed or showered there still is a lot of research and you probably know that it's controversial about ALS and use in especially when cases will go to court but I would say if your jurisdiction if you are using ALS and you have examiners who are experts in that use and used to using it that can still be used after bathing or showering just based on what Rebecca and I both shared with you that we are seeing this DNA regardless of bathing or showering. Another one that's come up a couple times is regarding CODIS and I know we're about out of time so I'm going to try to make it quick. I have put the answer to both of the questions in the Q&A so if you're able to look there there seems to be some confusion that CODIS is only for convicted offenders and will somebody's DNA be put or will the evidence be put into CODIS if you know the person has never had a criminal history or something like that and also yeah if the perpetrator is unknown that is exactly what CODIS is for so yes you have offender samples in CODIS that's kind of one one side or part of CODIS is those offenders that are collected based on state law the other part of CODIS are the forensic samples the profiles that we generate off of the evidence go in there whether the person is known or not whether it's matched a standard or not the individual has a criminal history or not because those forensic samples are going to search each other to look for case-to-case hits to see if the same individual has been involved in multiple cases and those are also then going to search the offender profiles to see if it can help to identify an unknown perpetrator that maybe has been in the system for something else in the past and so that is exactly what CODIS is for and once those profiles are entered they stay in there and they're searching all the time and so maybe your perpetrator has no criminal history in the state you're in but maybe two years from now they travel to another state they get in trouble there they get collected ultimately put in as an offender all of a sudden you're going to get a hit to that case from three years ago that was entered in another state and so this is exactly what CODIS is meant for and why it's so important that we're putting those profiles into CODIS regardless if they're known or unknown or that you already have a standard you've already solved that one case why do I need to put anything in CODIS because there could be other cases that involve the same individual that are unsolved and so that's yeah that's exactly what CODIS is for and I hope I've been able to clarify in the Q&A if you're able to take a look at that and read my answer one of them's pretty extensive so I was hoping to clear some of that up thank you Rebecca yeah thank you Julie and Rebecca really very interesting webinar discussing a topic so pertinent to forensic nursing so thank you again today's webinar is being supported through IFN's technical assistance grant through this grant IFN has the safe TA website that houses various educational opportunities resources and national guiding documents you can contact IFN with any requests for technical assistance by directly calling the TA line at 1-877-879-7278 or you can submit a request form by clicking the request TA button on the website join us for July webinars you can visit safetya.org to see the events and to register for the July activities and again thanks Julie and Rebecca this was great thanks for being with us today and thank you all for joining us

webinar

DNA

sexual assault cases

current practice

future practice

Dr. Julie Valentine

Rebecca Kay

patient-centered approach

forensic nurses

evidence collection guidelines

case studies

CODIS