Responding to Intimate Partner Violence Related Strangulation Integrating Policy, Practice, and Rese

STACY LEE: Thanks for joining us for the “Responding to Intimate Partner Violence-Related Strangulation: Integrating Policy, Practice, and Research” webinar hosted by the National Institute of Justice. It is my pleasure to introduce Christine Crossland, a Senior Social Science Analyst at the National Institute of Justice.

CHRISTINE CROSSLAND: Thank you, Stacy. Welcome, everyone. I want to take a moment to sincerely thank each and every one of you for joining us today. Your time, attention, and participation are invaluable, and we would not be able to make this event a success without you. Whether you're here to learn something new, to share insight, or simply support, your contributions mean the world to us. As Stacy mentioned, I'm Tina Crossland. I oversee our Violence Against Women and Family Violence Research Program and will be moderating today's session. Before we hear from our esteemed presenters, I am honored to introduce Dr. Janine Zweig, NIJ's Executive Science Advisor, for some opening remarks. But before I turn things over to her, I'll do my best to spotlight some of her key career highlights.

First, Janine has nearly 30 years of research and evaluation experience. Before coming to NIJ, she conducted research, evaluation, policy analysis, and technical assistance on violent victimization, with a particular focus on sexual and intimate partner violence, as well as juvenile justice reform, substance use interventions, and programming for incarcerated and reentry populations. Throughout her career, Janine has worked to elevate the voices and needs of crime survivors and developed strategic partnerships to build knowledge and provide actual data-driven guidance. Even in her role at NIJ, she focuses on providing helpful information to policymakers and practitioners to solve problems, better assist providers, and expand the general body of knowledge. Janine, I turn to you for a few words to help kick things off.

DR. JANINE ZWEIG: Thank you very much for that introduction, Tina. Good morning or afternoon, wherever you find yourself. I am truly honored to share this space with you today and to participate in this webinar. To our presenters and audience, thank you for joining us. We're honored to have you with us, and we sincerely appreciate the time you're taking out of your busy schedules to participate and discuss an important issue. 

As all of you know, November is only a few days away. It is also Strangulation Awareness Month, an important opportunity to honor survivors. Across the federal government, we're working to prevent strangulation. These efforts include funding program evaluations of innovative practices.

Today's webinar showcases an example of a comprehensive approach involving policy, practice, and evaluation that emphasizes the cyclical nature of the process and its importance in impacting the field and improving responses to a serious problem. We think the information presented will be valuable to our stakeholders and we hope you’ll learn something new that you can apply in your own community. At NIJ, we believe that the most enriching discussions happen when everyone participates. Your thoughts, questions, and insights make this experience valuable for all of us. So please don't hesitate to share throughout today's webinar. We encourage you to ask questions using the Q&A feature and also encourage you to participate in the polls.

Your contributions will enhance your experience and create a dynamic environment for everyone involved. We're excited to engage with you, learn from one another, and foster a community of shared knowledge and inspiration. Thank you to our presenters for sharing their knowledge and joining us in this space as we learn more about an important topic and solutions that can lead to positive change. With that said, I'll turn things back to Tina.

CHRISTINE CROSSLAND: All right. Thank you, Janine. So, for our attendees, I'm going to provide a short bio for each presenter in short order.

Before doing that, though, I want to remind everyone to ask questions or submit comments to the Q&A box. I will monitor it throughout the presentation and queue up questions for our presenters to be asked at the end of their presentation. The presentation will be no longer than 45 minutes and we've allotted an additional 20 minutes for moderated question, answer, and discussion. I will also upload resource links to the chat box during the presentation, and I also want to assure everyone that the slides and webinar recording will be available in about two to three weeks. With that said, I'm going now to introduce our esteemed presenters in the order of appearance.

Today's first presenter is Mr. Ken Shetter, President and General Counsel of One Safe Place and the National Director of the Family Justice Center Alliance for HOPE International. Under his leadership, One Safe Place has established a highly successful training and educational program, developed one of the most innovative and successful crime-stopper programs, expanded the highly successful Imagine No Violence initiative, and created important programs for at-risk children and youth. I also want to point out that he was the former Mayor of Burleson and the brainchild of the ordinance that will be highlighted today. Following Ken will be Chief Billy Cordell of the Burleson Police Department, who has served in this capacity since 2014. He's also a major player in implementing this important ordinance, and we're so pleased he could join us today.

Finally, Dr. Tara O'Connor Shelley, a Professor in the School of Criminology and Criminal Justice and Public Administration, as well as the Director of the Institute of Violence Against Women and Human Trafficking at Tarleton State University, will discuss the evaluation of this innovative response to strangulation. Our three presenters will end each by discussing the ordinance’s impact on policy practice and research. But before I turn things over to Ken, we want to do one quick poll just so that we have an understanding of the audience.

And so with that, if you could please take the time, and in the next 10 to 15 seconds, if you could please tell us how you primarily identify, whether you're part of the public, a community leader, advocate, or activist, government official or policymaker, practitioner, researcher/academic, student, survivor, family and friends of survivors, or training and technical assistance provider, so we can get an idea, and our presenters can too, about who they're going to be talking with for the next 75 minutes. I'll give this a few more seconds for everybody to take the time to participate.

CHRISTINE CROSSLAND: Okay. The poll has been up for about 50 seconds. So, let's go ahead and close the poll and see what the results say. I realize categories are not mutually exclusive, but they offer us a glimpse of who is attending. We have quite a number of government officials, policymakers, and practitioners joining us today, followed by community leaders.

Quite a few people weren't able to participate in the poll. With that, I am going to turn things over to our first presenter. Whenever you're ready, Ken.

KEN SHETTER: Thank you very much. And thanks to you all at NIJ for hosting this webinar and highlighting the work that we did through this ordinance because I think all of us think it's very important and would like to see other communities, I would like to see states adopt this policy as a matter of law, so I'm excited to really begin this conversation and excited that we have the research now to really sort of prove up the value and effectiveness of the ordinance. 

So, just one note on my background that is sort of relevant to my remarks today. During the time that I was mayor, I was also President of One Safe Place, so being mayor wasn't really a paid job.

But at One Safe Place, among our other programming, we operate one of the largest and most comprehensive Family Justice Centers in the United States where we have worked extensively with their Training Institute on Strangulation Prevention over the years and where we have served thousands of victims of domestic violence. And so certainly, that work, and that experience very much informed everything that I will say to you today, and also informed my involvement in the development of this policy and the ultimate adoption of the ordinance. 

I know a lot of the folks that are participating today and thank you to everyone that is with us today for your interest. I know a lot of people already know this, but I want to just make sure we have proper context.

You may hear the words strangulation and choking used interchangeably. Choking is the term that is most commonly used, I think, by a lot of members of the public, even in the media. Certainly, when we are working with victims, we understand that choking is the term that is most likely to be understood or recognized, but the, certainly, technical term is strangulation. And when we are talking about strangulation, we are talking about the application of pressure to a victim's neck, and that might be grabbing someone's neck with your hands, it might be applying pressure with a forearm, it could be a ligature strangulation, which is the use of a rope or a cord, or some other device to apply that pressure. That pressure involves cutting or preventing air flow to the brain and also preventing blood flow.

Now strangulation, from a legal perspective, can also include the application of pressure to the chest area that would impede blood flow or oxygen. So just know that can be part of the definition of strangulation, or the term asphyxiation may be a term that's more broadly used. But I think, today, we will primarily use the term strangulation. 

In terms of justifying the policy and the need for the policy, I think this is what's really important to highlight here and that is just the commonality of strangulation as part of domestic violence, in particular, as part of other types of crimes as well. But let's focus on domestic violence and we'll also point out, not only is November Strangulation Awareness Month, the month of October, which we are in is Domestic Violence Awareness Month, so our timing is really good.

But somewhere between 68% and 80% of victims of domestic violence experience strangulation, so it is extremely common. Most victims who experience strangulation experience multiple incidents of strangulation, so it is so much more common than most people think. I often say to elected officials, to policymakers, wherever I am, in this community, you have a domestic violence problem, and you have a strangulation problem. I can say that without knowing particular statistics of any particular place because everywhere in this country, and everywhere in the world, frankly, has a domestic violence problem and everywhere specifically has a strangulation problem as well. And it's not just that strangulation is common, but the other thing is that strangulation is effectively the marker for risk of lethality.

That we know from multiple studies that strangulation is the most significant indicator of a risk of ultimate lethality and a violent relationship, particularly as it regards to intimate partner violence, and that a victim of domestic violence who has been strangled is 750% more likely to ultimately be killed than a victim of domestic violence who has not been strangled. I’ll note, those statistics certainly have relevance to the particular public policy that we're talking about today. But they have relevance to other aspects of domestic violence policy as well, and it's one of the reasons that in any aspect of domestic violence public policy that we are considering we have to think about the impact of strangulation. We know right now across the country that rates of domestic violence, homicide are up alarmingly and across the board.

Any serious effort to reduce lethality must involve taking a hard look at strangulation, strangulation policy, and how the community is responding to incidents of strangulation and must involve, as this ordinance ultimately does, any attempt to reduce domestic violence lethality in community must involve developing a multidisciplinary, multiagency approach to addressing strangulation. I also will note one more thing that's not represented on the slide, but just as strangulation is very common, it is also common for children to witness incidents of strangulation in the home. I would just flag that both for policymakers but also for advocates and practitioners that we have to think about a child who has been exposed to an act of strangulation, probably a little bit differently than kids that have been exposed to non-strangulation forms of abuse. 

The other thing that I think cannot be overstated is just that there is no safe way to strangle someone. In many contexts, whether that's mixed martial arts, strangulation during sex, which is a common problem, or the way that too many men perpetrate abuse. It is much more commonly men that are strangling women, but there is so no safe way to strangle. You can very easily accidentally kill someone by strangulation. As an example, it takes no more pressure than it takes to open a can of soda or to apply a typical handshake. That amount of pressure is enough in very short order to render a person unconscious through strangulation, and ultimately to kill a person as well. 

It is important to know, that particularly for practitioners, whether that's law enforcement or advocates, or those in the medical community, to know the many signs and symptoms of strangulation.

I think for too long for too many people, there is a common belief that you are always going to have a bruise around the neck in a case where someone is strangled. But the truth is, only about 50% of victims of domestic violence experience visible injuries. That fact has lots of implications. It makes it more important that a person who has been strangled has a medical assessment. And by the way, not to hide the ball, one of the most important things that the ordinance in the city of Burleson required is that any time there is an incident that police respond to that involves alleged or suspected strangulation, there must be an emergency medical response to the scene. And one of the reasons that that's important is that there so often are not visible injuries, and a victim may not subjectively know just the extent of their injuries.

So, I won't go through all of the signs and symptoms here. I think the most important point to make is that so many of the signs and symptoms are not what many people commonly believe or not visible at all. 

So again, just to make the point that I made the earlier, and we can't make it too many times, strangulation prevention—effective strangulation intervention is absolutely homicide prevention. You cannot have a plan to effectively reduce lethality and domestic violence unless you have a comprehensive plan to address strangulation and how strangulation is intervened in when it occurs. 

Again, I won't read through all of this, but I will just note—and this is not my opinion as an attorney or as an advocate, This is something I've learned in working with the Training Institute on Strangulation Prevention, and specifically in working with the medical professionals who are a part of the advisory group and faculty that is associated with the Training Institute.

I've asked this question many times and always gotten the same answer. Any time, any time a person is strangled, a medical exam by a medical professional is medically necessary. So, to think that we can put a law enforcement officer in a position of making a medical assessment on the scene is, A, we're not serving a victim well, and, B, we are not doing any favors to law enforcement when we are not doing everything we possibly can to ensure that victims who are strangled get an examination or assessment by a medical professional. And it's just a good time to point out that law enforcement everywhere, I think, or at least in most places is doing a really good job of advising victims on the scene of the seriousness of strangulation and then offering and recommending medical examination and that medical response is called to the scene.

But the reality is that almost always a victim is going to decline to have medical personnel come to the scene for many reasons. First of all, they subjectively just don't know how serious their injuries may be, and then, secondly, so often, the abuser is on the scene and so a victim has every reason to fear further retribution if after having called 911, calling law enforcement to the scene. They then instigate medical personnel coming to the scene as well. So, we know from experience that victims are going to decline the opportunity to have medical personnel come to the scene for many reasons. 

Here are some of the many examples of adverse health consequences. Obviously, anoxic or hypoxic brain injury, brain cell death, is significant and common.

I will also point out and just raise for your attention risk of stroke, either in the short term or in the long term. And that certainly can be a risk, and a victim would have no subjective awareness that that is a risk. Another thing that we have come into awareness of through clients that we have worked with at One Safe Place is that it is not uncommon for a victim who is pregnant to be strangled. That obviously can cause serious harm to the fetus that can create lifetime implications for the child after they are born. 

We're flying through this, but there's a lot of grounds to cover and I want to make sure I don't take still needed time of my co-presenters. But as we have been talking about, strangulation is so often minimized by victims and others as well.

But I think it's important here to talk specifically about the way that survivors themselves, victims themselves will minimize strangulation. And to the point that—and those of you who are advocates know this, or law enforcement—if you don't specifically ask a victim if they have been strangled, they often will not, just voluntarily offer that information. My opinion is that that's not usually because of some kind of the weakness or being embarrassed or afraid particularly that fact for one reason or another. I think it's often not offered up because it is become so normal as part of the abuse, they're experiencing that victims often just sort of intuitively think if they're telling you they've been abused, you understand that this is part of what they have experienced.

It's critically important that as part of these protocols, we are training up multiple disciplines to understand the nature of strangulation and to understand the signs and symptoms and to understand the right questions to ask. 

The big question is, “Why do this as an ordinance and not simply protocol procedure or SOP or something like that?” I have really three primary reasons. One is, frankly, sometimes protocols just aren't followed, right? And sometimes they're never followed and sometimes over time they're not followed for various reasons. That's number one. Number two, ordinances survive changes in leadership. So particularly now that I have not been mayor for four years, I am very thankful that we pursued this as an ordinance and not just as a policy because I have the confidence that the policy is going to live on beyond my role as an elected leader.

And frankly, just speaking as a former politician, woe to the politician that ever tries to undo this policy, right? So, I love the politics of it. It gives me greater confidence. Not only that the ordinance will survive but that elected officials would always have sort of the ability to ensure through their political advocacy that the policy continues to be not only in place but effectively implemented. Then finally, the most important reason I've already alluded to, with the most important reason to choose an ordinance over protocol, is it gives the officer on the scene the opportunity to say, “Oh, you know what? We have to call EMS or paramedics to the scene. I don't have a choice. It's the law.” So we're not putting this on the back of the victim and forcing them to make the choice even though we're not really giving them the choice when we leave it up to the victim to decide whether EMS is going to be called to the scene where you're actually doing in many cases is empowering the abuser to use power and control to discourage the victim from getting the help that they need.

Those are the three reasons I really love this policy as an ordinance. That's my part and we'll turn over to Chief Cordell.

BILLY CORDELL: Well, good morning or good afternoon everyone depending on where you are in the country watching. Number one, we appreciate you taking the time to come in and listen to this webinar. I want to start by acknowledging The Training Institute for Strangulation Prevention, as well as the International Associations of Chiefs of Police. Both of these entities have outstanding toolkits that they have presented, and we were able to use that along with some incredible data. Some of it presented by Ken just a little while ago that really helps you get down the path with stakeholders and things that I'm going to talk about shortly.

Also, I want to say I appreciate the incredible work and vision that Ken Shetter brought when he went to the training and then contacted me. We started talking about the ordinance. Then of course when Tarleton State came in to do the grant and the study and the research on this. Dr. Shelley, I got to work very closely with her and her team. It's been a great process for us. 

As Mayor Shetter said, the ordinance was the preferential route because it memorializes that commitment from the city to protect victims who are victims of strangulation and domestic violence. The first challenge that we ran into that we wanted to make sure that we started from there and this is a path that I would recommend for anyone, was to seek buy-in from our stakeholders. We did that and we're able to accomplish that by creating that multidisciplinary team that he made comment to. 

When you look at establishing the ordinance prior to that, we established as multidisciplinary team consisting of Burleson Police Department. In addition to myself, we had the supervisor over our criminal investigations, our crime analyst was heavily involved in this and our victim assistance coordinator. They all played significant roles in the processing of the information and packaging the reports for Tarleton State as well as the back end of it being able to pull out statistical data. In addition to that, the Burleson Fire Department, staff of MedStar was a great partner in this. And we had a contract ambulance at the time that was MedStar. Since then, Burleson Fire Department has started their own EMS, so everything is turned over and transitioned to them.

Another key partner was the medical director, or what you’d consider a forensic nurse, as a part of that team. District attorneys were by counties. We've got Tarrant and Johnson counties and Burleson. So, we brought all of the county attorneys from both of those entities together with us because that was going to be an important part of moving forward with the packets that we're going to be submitting. Of course, One Safe Place staff, Ken Shetter and Michelle Morgan, and so many others. One Safe Place, they've been doing this for so long. What a great resource for all of us. 

The relationships that we built through the process what I think was a huge part of the success of all of this. Each of these entities had protocol changes. They had to be there at the onset of this ordinance and to come together so that the primary goal was to help our victims, to help our victims and our survivors of domestic violence and those in particular involved in strangulation here. The other thing that we wanted to do with this team and working with our district attorneys was to file impede breathing as a third-degree felony in Texas which is a much higher charge than simply an assault. 

When you look at the language of the ordinance and how it's put in. We enacted that on February 19th, 2018. The majority of the language when you see the whereas clauses there, the majority of that came out of the International Association Chiefs of Police in their 121st annual conference, IACP, regarding increasing awareness of the lethality of intimate partner strangulation.

I'm going to highlight some of the main points that resonated with me. Strangulation is an indicator of the escalation of violence and associated with the increased risk of serious injury and/or death in cases of intimate partner violence. Strangulations been identified as one of the most lethal forms of domestic violence, as well as sexual assault. Oftentimes there are no external evidence or injury. We talked about that shortly. Fifty percent of the time you don't see any injury. And when you do, a very small percentage of those injuries are even able to be photographed. This was one that really hit home with me. Many first responders lack the specialized training to identify the signs and symptoms of strangulation. And they focus on the visible and obvious injuries.

That's how we were trained. Show me the bruise, the abrasion. Show me the broken bone or the blood and then we can classify that offense. This being one of the most lethal forms of domestic violence and we don't even see a mark on the person. That doesn't mean they don't need help and medical response. So, lack of training has led, as Ken said earlier, to a minimization of this type of violence. The bottom line for us in enacting this ordinance is that our goal is to raise awareness. It is to educate our victims of the lethality of strangulation and to also prosecute at a felony level. 

When you look at the ordinance implementation, again, the toolkits from Training Institute and IACP as well as the statistical data were used to develop our training protocols.

We made changes to our Family Violence Packets. We had to have the district attorneys involved in that so we could get the specific language they needed to be able to prosecute those cases. The protocols and policy on the ordinance and the policy were incorporated into our training when we created the training curriculum for this. From there, we developed that training and we started training all of our officers, both police officers as well as the fire department officers. We continue to train police officers, new officers, coming into the department, as well as telecommunicators. I think that's an important piece to this that I don't want to leave out. Our telecommunicators are the first responders that answer that call and screen that call for us. They actually have some protocols when the person—if they say strangulation—they have some protocols that they follow through. Also, we sent representatives to the Training Institute on Strangulation so that they could get firsthand training with regards to the training, see the numbers, and be able to ask the questions. 

When you look at the protocols from the police responsibilities when our officer responds, the act of strangulation is alleged or suspected within the city, the peace officer will summon emergency medical personnel to the scene. They will utilize a strangulation checklist for consistency. Those were taken from the Strangulation Prevention as well as IACP to create a consistent document that we ask the same questions over and over again.

We document the emergency medical personnel's presence and the role, what do they do on the scene. We thoroughly document the suspect's behavior, the actions, and any comments that were made. Then we provide the victim with referral information to the appropriate support agency. 

When you look at these protocols for our fire department, who is a partner with this and the act of strangulation is alleged or suspected within the city, the emergency medical personnel will conduct a medical evaluation based on the 21-item assessment for their strangulation protocols that's highlighted on the right side of this screen (Slide 21). I'm going to point out a couple notes here that I think of consequence. 

We tell the victim and the suspect that we're required to call medical in these circumstances per our ordinance. I know that Ken's mentioned that a couple of times and we can emphasize that enough. I think that takes some of the pressure off of them and it puts it back on us. We don't have a choice on this. The city has enacted an ordinance to do that. Another note, I think firefighters or EMS staff speaking with the victim does not seem to raise the concerns and the level that police officers speaking with the victim raise because we're asking questions and looking at criminal violations where they're asking medical questions on that. Then the most important part of all this is that the contact and the documentation from the medical experts creates credible information that becomes part of that case file that we file with the District Attorney's office. 

When we originally put this in place, there's one thing that we overlooked and we had to come back in on 6/10 of '19 and change our policy based on what we were seeing in the field and then the after advice from the medical director. When we started asking the right questions, as Ken said, a lot of times, they don't volunteer that information. We started asking the right questions. We found that the victims sometimes volunteered that they had been strangled in the past but not necessarily on this encounter where we were out speaking with them. But our ordinance did not specify a timeframe for that and we were contacting the medical staff to come out and talk to them sometimes a year after a strangulation had occurred. After consulting with the medical director, we refined the policy to summon a medical response only if the victim was strangled within the prior seven days. 

Let's look at a little bit about the cases that we had in Burleson on impede breathing.

We saw that they generally increased most of the years post ordinance. It does not represent strangulation incidents listed in different crimes on incident reports. But I think some of the important things here, the ordinance was enacted February 19th, 2018. And it took us about a month to get the training all taken care of and then we implemented it around March of 2018. As the slide shows, we went from 19 impede breathing in 2017 to 37 in 2018. From 2018 to 2023, we averaged 31 cases per year. So, impede breathing generally increased, as I said, at the start of this. I think what we have seen—and you got to understand, Burleson's a town of 51,000. We have our share of domestic violence when you look at it proportionally, but we were not asking the right questions until we went through the training and we trained our officers to be able to go out and serve our citizens better, serve the victims of violence better, and then bring in our medical professionals.

And like Ken said, I couldn't agree with him more. A police officer officer out asking a medical question is not in the best interest of helping that victim. But now we've got a situation where we believe that we were helping that victim and getting the referrals to them to our victim's assistance and being able to talk to them and follow up with them after this. And that allows me to turn it over to Dr. Shelley.

DR. TARA O'CONNOR SHELLEY: Thank you, Chief. Hello. My name is Tara Shelley, and I am the Director of the Institute on Violence Against Women and Human Trafficking at Tarleton State University, and I'll be walking through some of the highlights of the evaluation. 

First, I do want to thank Ken for envisioning the ordinance and Chief Cordell of the Burleson Police Department and Chief Davis of the Burleson Fire Department for implementing it. And I'd also like to thank NIJ for funding the evaluation research. I think a special shout out is deserving for our anonymous control site. It's never fun to be a control site. And so, I do want to give a shout out of thanks to them. We couldn't have done this research without them. I also want to acknowledge my co-principal investigators, Dr. Katherine Brown of Tarleton State and Dr. Cortney Franklin of Washington State University.

We also had a small army of graduate students. And again, without their assistance and helping hands, the work that I'm presenting on today would not be possible.

The evaluation process progressed across three different phases. First, we conducted an evaluability assessment, then a process evaluation, and then we concluded the study with an outcome evaluation. So, while the ordinance was designed to address all types of strangulation, whether it was intimate partner violence or not, just any strangulation would trigger the ordinance. Our focus for the study was primarily on intimate partner violence-related strangulation incidents that occurred between 2016 and 2018. We had to get back in time to get a baseline of what was going on before the ordinance.

In terms of our methodology, we utilized a quasi-experimental design where we examined Burleson cases pre-ordinance and then compared outcomes post-ordinance. Then we also compared Burleson versus a control site, a comparable control site. We also used an array of mixed methods that I'll describe shortly. 

But before I do that, I want to discuss our process to screen for intimate partner violence-related strangulation cases. In Burleson, we began with 867 family violence incidents that involved intimate partners. Then we screened each of those to determine if strangulation was present. This meant we read every single incident report, every report supplement, every family violence packet, every victim and witness statement that was available, any attachment that was available in the case file.

We reviewed flags in the RMS system to see if there were indicators of strangulation. We also reviewed CAD notes and things like that to see if there was anything coming in on that front. After this exhaustive process, we were left with 272 intimate partner violence-related strangulation incidents. This constituted about 32% of those cases. At the control site, we began with 833 family violence incidents involving intimate partners and identified 135 intimate partner violence-related strangulation incidents, roughly 16% of their cases. I know Ken presented some statistics earlier. In the published academic literature, strangulation prevalence ranges anywhere from 10% to 68%, even higher in some more recent studies. But it really depends on the location and the sample.

Generally, samples from victim service organizations will have higher prevalence in comparison to police samples. So, we're kind of right there in the middle. 

As you can see from the figure on the left (Slide 26), our study methodology utilized both qualitative and quantitative methods and data. Due to time limitations, we can only highlight findings from our examination of police case files, strangulation worksheet data from the fire department, and results from a survey on strangulation knowledge. But it is noteworthy to just indicate that we conducted stakeholder interviews. We administered numerous first responder surveys. We collected data from One Safe Place about Burleson and control site clients, and we fielded victim surveys.

We went further and examined body camera footage to help us understand and explain fidelity problems. As you can see on the figure on the right (Slide 26), our analytic strategy for both the process and outcome evaluation was multifaceted. We did a series of bivariate and multivariate analyses. We also conducted qualitative analysis of officer narratives to learn about how they document and describe strangulation incidents.

Then finally, in the outcome evaluation, we use propensity score weighting to estimate the average treatment effect of the ordinance on several study outcomes. I do think it's worth mentioning that the range of data that was collected for this study, coupled with various analytic techniques, really helped reinforce and contextualize our findings in both the process and outcome evaluations. 

This figure (Slide 27) demonstrates the range of outcomes that the study examined, but we really can only cover a few of these today. Today, we'll cover some highlighted findings about first responder strangulation knowledge, their identification of strangulation, medical, criminal justice, and victim engagement outcomes. 

I'm not going to say a lot about the process evaluation, but I did want to remark what we learned about fidelity during the early stages of the ordinance.

This slide (Slide 28) shows fidelity to key aspects of the strangulation protocol that chief previously discussed. The figure on the left and the table on the right show the same information, just in different formats. The big takeaway from this slide is just simply that fidelity to the ordinance was dependent on adherence to earlier steps in the strangulation protocol. For example, if the officers didn't use the strangulation checklist to determine if strangulation had occurred, then compliance to the rest of the protocol declined. One thing of note is that at first glimpse, you might think that fire and EMS response look ineffective, but we learned that early on in the ordinance we learned from the process evaluation that officers were not always calling medical when they should have.

That happened in about 59 of the cases. But when EMS and fire were called, they responded and completed their worksheet, their required worksheet, 94% of the time. In the cases where they didn't, they generally occurred early in the ordinance. And so, it's not uncommon when you're fielding a new project like this that you're not going to have a hundred percent fidelity, and I know many of our stakeholder partners were really striving to have a hundred percent fidelity, but it's just really unusual when you're doing something at this scale to see that happen right away. 

I wanted to find a way to incorporate things that we learned in our first responder interviews to show why mistakes sometimes occurred when implementing the ordinance. This quote is from a fire department supervisor who was reflecting about a fidelity problem that they detected early into the ordinance.

I'll go ahead and read this just for people that have called in. “We had a particular incident where the police department had arrived before us, figured out what was going on, allowed the patient to change clothes because the patient was embarrassed because they had urinated on themselves. My guys got there and assumed that the patient wasn't incontinent and answered the question that way. And then, at some point, it got caught and then that information was pushed up to me. So, we sent out communication to everyone. 'Hey, guys, you have to make sure that you ask these questions even though they are extremely personal.' We have learned from that situation.” Now the police detected this and reported to fire that this had happened, and so this eventually got corrected.

But I wanted to just show this because I think it exemplifies why data was occasionally missing on the fire department's strangulation worksheets. When items were skipped, it was typically just one item, which is really an indicator of just human error or sometimes they had tablet glitches out in the field. But we did do a missing item trend analysis, and we noticed that the item pertaining to urination and defecation was missing several times. And I think this quote speaks to as to why that can happen. And so that was corrected once it was detected. 

This slide (Slide 30) shows some results from our first responders' strangulation survey. First responders were surveyed about their strangulation knowledge across 31 items. We conducted the survey pre- and post-ordinance training in Burleson, and we also compared results to the control site and then to MedStar, the ambulance provider in Burleson at the time.

As you can see from the figure on the left, Burleson first responders significantly increased their technical knowledge scores pre- and post-strangulation training. The combined performance is in purple, the police are in blue, and the fire are in red. So, as a group, they improved and as separate entities, they improved their strangulation knowledge following this training that they participated in. If you want to look at the figure to the right, they also outperformed their counterparts at the control site and MedStar. And this is really important and impressive because MedStar participants were all EMTs and paramedics. The fact that Burleson as a whole, which includes all the police officers, all the firefighters, a subpopulation of firefighters who are EMTs and paramedics, they still outperformed a group of people that had more medical training than they did because of the power of this training and of the ordinance. We just aggregated this data in various ways and Burleson always scored higher. 

We were also interested in learning if knowledge obtained from the training would translate into better documentation of the signs and symptoms that Ken covered earlier. We wanted to see if that would show up in police report narratives. So, we did a content analysis of report narratives and that revealed that Burleson officers were significantly more likely to recognize and document more signs and symptoms of strangulation in their incident narratives pre- and post-ordinance. They also outperformed the control site. Another thing that we noticed is not only were they identifying and documenting more, but they were also doing so in greater detail, and they were covering a wider range of symptoms than what we were seeing early on. 

Continuing on with some of the voices from the field, one of the police participants in our first responder interviews, explains the importance of recognizing and documenting signs and symptoms of strangulation and also developing an understanding of how to do that. So, I'll read again this quote for anybody that's calling in.

“That's what the officer needs, they need the signs and symptoms, so that they can have enough awareness to know when to call for somebody to come check them out. Giving them, the police, straightforward training on the lethality of it and ringing those bells that they've already seen in their career. That's when you know, because the light comes on and you're like, ‘Wow, I've seen that a bunch of times, but didn't understand what I was looking at.’”

I'm covering a lot of ground here. In the interest of time, I just used arrows to quickly convey some of the key findings. What we learned about the identification of intimate partner violence-related strangulation is that that increased significantly in Burleson pre- and post-ordinance, they also identified significantly more strangulation incidents than the control site. 

When we looked at on-scene medical responses, this also increased significantly in Burleson pre- and post-ordinance. Burleson also significantly had more on-scene medical responses than the control site. In terms of medical assessment, this also increased significantly in Burleson pre- and post- ordinance. And then Burleson assessed more intimate partner violence-related strangulation victims than the control site did. Next, we looked at a variety of outcomes, not necessarily part of the ordinance, but that we felt could be important indicators. We looked at emergency protective orders, and we didn't see a big difference in Burleson pre- and post-ordinance. They were doing a pretty good job of getting those out beforehand.

However, Burleson did request and receive more emergency protective orders than the control site did. In terms of arrests, and so we're talking about any type of arrest here, those increased significantly in Burleson pre- and post-ordinance. And Burleson executed significantly more arrests than the control site. Moving to victim engagement, really some mixed findings here. The big takeaway is—we had a variety of indicators—but the big takeaway is that the ordinance had negligible impact on engagement for most of these indicators. Some exceptions would be activation of the criminal justice system was higher in Burleson and Burleson had more victims willing to complete written statements than the control site did. 

I think it's fitting to end our review of the research findings with a quote from a strangulation survivor who participated in our victim survey.

They say, “I do want to show appreciation that ultimately it was handled, and he was arrested because that saved my life. I just needed it a lot sooner. I made it out alive, but many women do not.” 

With the study findings and the survivor quote in mind, we offer a range of recommendations in our final report. But what you see here represents a larger message that we hope to jointly convey today. Some key recommendations for practice. We really need to continue to build awareness among first responders. We have known for well over 20 years now that strangulation is an indicator of violence escalation and one of the most lethal forms of intimate partner violence for victims. We have to do better. We just do. We need to educate and train.

Specialized training is necessary to increase recognition and improve response. There needs to be recognition that any pressure to the neck, chokeholds, headlocks constitute strangulation. Impeding breathing and/or circulation of the blood are equally important features of strangulation. We need to bolster evidence collection. We need to enact policies and ordinances like we saw today. Anything that you can do to require, facilitate, detailed documentation of signs and symptoms in police and in EMS reports. Using forensic cameras, using the toolkits from the IACP and from the International Association of Forensic Nurses, things like that are really important and can be helpful. In terms of policy, we really want to issue all of you here on this webinar a challenge to do something. Replicate this. Scale it up as Ken called for at the beginning.

Require and request response and assessment from fire and emergency medical services as part of an incident response. Make that routine practice. Facilitate and enhance ambulance transportation options. Go further than this ordinance did and do things to help facilitate that at a greater level. Encourage routine medical screening for strangulation in emergency rooms. There is some great research out there from Dr. Michelle Patch, Dr. Jackie Campbell, and many others on this topic and helpful resources are available from the International Association of Forensic Nurses and the Training Institute on Strangulation Prevention. In terms of research, we always want more but for good reason. We need additional strangulation research from the survivor standpoint and in partnership with family justice centers and shelters.

We need additional research on individuals who strangle others. We need to explore serial stranglers. Every community has them. They're going undetected. We need to do better in the research realm on that front. We need to understand repeat strangulation involving the same partner, involving different partners, other non-IPV individuals that that strangler may have a relationship with and assaults on first responders. And finally, we need more research. We need to do more research. We need to extend our hands out to fire and EMS first responders because they have valuable information about strangulation prevalence and injury. I think just anything we can do to enhance the research in that realm is really important so we can better respond to strangulation. 

At this point, we really want to acknowledge the good work of the Training Institute on Strangulation Prevention. We also want to acknowledge them for the use of some of their materials today that you saw Ken review at the outset of the webinar. 

CHRISTINE CROSSLAND: Thank you, Tara. First, I hope you all agree that this was an excellent presentation. I couldn't have come up with a better case study of where something happens with a policy, works its way to practice, and then the research that follows. We want to take a quick poll based on the information you've all heard. If you could take the next 20 to 30 seconds to answer. Now, based on the information that you just heard, what action will you take? I'm going to wait until that poll has been posted and we've had enough time for everybody to have an opportunity to think about it. And then we're going to go straight into the moderated discussion. We have a few questions that have come in.

As a reminder, everybody, if you do have specific questions or comments, please use the Q&A feature. We've been queuing those up. We'll give this another five seconds. And then we're going to close out this poll. Okay. Let's close it out. Let's see. Okay. We only had a few people, but they definitely are going to be sharing this information with their team. And that's most important, right? This is incredible information that we're seeing. So, we're going to head right into the moderated discussion now. As a reminder, everybody, it's helpful if you can put your questions in the Q & A box and I'll try to follow also monitor the chat box. We're going to take down the slides now so that we can see our panelists as they answer the questions. And I am going to the first question that came up; I believe this is going to be for you, Tara. “Was there an increase in victim engagement with victim advocacy services?”

DR. TARA O'CONNOR SHELLEY: That was something that we attempted to track through a victim survey. Unfortunately, the survey was being done during the COVID pandemic and so the response rates were very low, and we were just really hampered on what we can really say about that. That was something that we plan to look at. So, I don't have hard numbers to be able to say yes, that improved, or it stayed the same or declined. However, anecdotally, we know from conversations and interviews with the support team here, they had to hire another person to help engage in support mechanisms. I think Chief might be able to speak to that more specifically, if you don't mind, Chief, just because we couldn't do it with our victim survey.

BILLY CORDELL: Yeah, not at all. We have a full-time and then a part-time 20-hour a week victim assistance coordinators, and they do follow-ups with all of the crimes, especially our violent crimes.

But in particular, because of this research, they were brought in from the onset and were able to talk specifically with the victims themselves. They garnished a lot of information. We had a lot of victims that wanted to drop charges. So, they would walk through the processes with the victims that want to drop charges and do everything they can to support them. And then also referrals were an important part of that, that if they wanted to refer the victim to another organization for counseling or the children that were involved, and I think we said 40-something percent. Kids witnessed this and be able to refer those kids and get help for them as well.

CHRISTINE CROSSLAND: Great. “Was there an advocacy component to the response, or is that something that you have considered including to see if that improves survivor engagement?”

BILLY CORDELL: Okay. I think that one's for me or are you going to talk to that? Now we…

KEN SHETTER: I think we can all speak to it a little bit.

BILLY CORDELL: We give referrals out on the scene to the victims and to ensure that they know what services are available to them. Also, again, our victim assistance will re-emphasize those things and then, One Safe Place being a great partner with the City of Burleson, a lot of the referrals were made down to One Safe Place.

KEN SHETTER: I think the advocacy response is an important aspect of everything we're talking about. Follow-up advocacy for victims is a critically important part of a multidisciplinary approach to responding to an incident of strangulation. And so, the advocacy component was also part of the training that was provided to police and fire. And so that there—one is—I anecdotally will say is, I think there was already a pretty decent job being done by Burleson Police in trying really hard to make that referral to advocates, but I think post-adoption of the ordinance and just looking from the other side being at One Safe Place and having some perception of the calls we were getting. I do think there was sort of some increased competency around making that advocacy referral.

DR. TARA O'CONNOR SHELLEY: And then from the evaluation standpoint, we did look at the numbers in terms of whether those referrals were happening or not. And while they may have been happening, unfortunately, they were not doing a great job at documenting it. There's a place in the family violence packet where they're supposed to document this as a way to measure whether or not this was happening. And so, we talked about this early on in the evaluation that we were seeing that. And so, it's definitely something that if you're going to participate in evaluation, that documentation piece is so important for when you have a researcher come in at the back end, we can't count something that's not there. That's not objective. And so, I have great confidence that these things were happening.

We reviewed body cam footage, for cases where we weren't seeing certain things that we thought weren't happening on paper, but then we could watch the body cam footage and see that, “Oh, this was happening,” or it wasn't happening, but if it was happening, it just wasn't documented. And so understandably, police have a lot of paperwork in the field, and this was just one thing that was harder, I think, to document.

CHRISTINE CROSSLAND: Okay. We have another question. I'm going to read it as is. “It's been a fight from law enforcement administration to get them to do more on the scene for strangulation investigation. How do you get your city council, county commissioners on board with this, or even your law enforcement administrators?”

KEN SHETTER: I'm going to start with your policymakers, and I'll speak to the law enforcement a little bit, though, Chief is much better to speak to that than I do. And I think it's a general issue that a lot of folks in local government don't have a high level of awareness of a lot of things that surround public safety, but they don't have particularly specific awareness and knowledge of issues related to domestic violence. So, I think there is some training that has to be done, some work around awareness of particular issues. So, I think, first of all, I have actually done this kind of advocacy with elected officials around the country, around developing other types of domestic violence policy and domestic violence investments. So, I think there is a need to make policymakers aware, first of all, just of the degree to which domestic violence is driving the crime in communities.

It's not just that it is one of the most predominant categories of crimes that occur, but so much other crime that happens really has a foundation in domestic violence. So, for example, the majority of all of our criminals in this country grew up in homes where there was domestic violence. Our gang members grew up in homes where there was domestic violence. So, I think some general awareness around that. And then some specific training around the prevalence of strangulation in a given community, the risk of lethality that domestic violence represents. Every elected official, you give them the opportunity to be able to say that they're doing something to reduce homicides, and to reduce lethality in their community, and they're going to want to take that.

I think a lot of politicians think of domestic violence as something that's a big issue, and there's nothing we can really do about it. It's just a problem we have to live with. But if you can actually say, “No, actually there is a way to reduce lethality and domestic violence,” and the first thing we have to do is understand and address strangulation better. So, I think you have to do that kind of awareness and training to lay the right groundwork. Then also with elected officials and with law enforcement, I think another thing that helps is to make sure people understand the connection between intimate partner stranglers, and cop killers, because there have been multiple studies that have—every time this question has been asked and studies been done that have shown the same thing, which is that a majority of the people that kill or injure cops are people who have a documented history of having strangled an intimate partner.

So, if when we have an incident of strangulation, we not only do the work that helps the victim in the right way and gets them the medical help they need in the right way, but we also use it as an opportunity to make sure that we are doing the right kind of enforcement and we are prosecuting cases more effectively. And it's not just that we're reducing domestic violence lethality, but we are reducing other kinds of violence and harm in our communities as well.

BILLY CORDELL: Piggybacking on that, I think Ken said a lot of things that I was going to say with regards to the training and then the data, when he made the comment that majority of police officers killed in the line of duty are killed by a person that has previously strangled someone. That's the buy-in for our police officers. That was a buy-in for me. We are also seeing probably around the country, but we see it more in the Metroplex here where an officer is responding to a domestic violence situation and gets ambushed on the way up the door. So, we're seeing more and more of the connections between domestic violence and, broader violence, and I think for us training, training, training is everything.

We all want to be trained to do our jobs better. We already have the philosophy; we want to help victims. And, what a better way to combine two things. I think the data spoke for itself and when we present it to our council, we didn't have arguments on it. They looked at the data, they listened to what we were saying, and we enacted our ordinance. But I think it's important to point out to administrators—from what you're saying, Ken, pointing out to administrators in law enforcement, this isn't a hard project. This is getting your officers better trained, getting them ready to ask the right questions and Tarrant County being the largest jurisdiction around here, the Tarrant County District Attorney is already on board with this.

You don't have to sell this to that group. They have their own intimate partner violence team of people. So, I think what we need to make sure that we're presenting is that these administrators, the training footprint is already done. The data is there. It's just a matter of running your officers through that. And I know that takes time but running them through there when they're doing their other 40-hour training. You can put an hour-and-a-half, two-hour timeline on this and have your officers better trained and better equipped to be able to service the victims.

KEN SHETTER: I will also add to that. I think the great frustration for law enforcement is that they work their [expletive] off on these calls and they know that these are the calls that put them in the greatest danger. They're the most difficult scenes to clear. All of those things and then so often, too often, the cases go unprosecuted, or they are not prosecuted at the level that they should be.

I've heard so many law enforcement officers across the country. And by the way, victims have the same frustration, too. Frustrated that cases that involve strangulation are too often prosecuted or are plead out as misdemeanors. I can't imagine nothing more frustrating as a member of law enforcement. So, one of the real benefits of this ordinance that we didn't talk about, because it's kind of a side or unintended benefit, is that when you do the medical examination, you are effectively capturing the testimony of the victim that can be used in court, it's not hearsay or an exception to hearsay, so that even in cases where a victim decides not to participate and testify themselves, you have effectively salvaged their testimony and so that you can—using an evidence-based prosecution philosophy, you have a much better chance of moving forward with prosecution of the case as a felony strangulation case because the ordinance is in place, because you had the medical assessment, and because the testimony, effectively, of that victim was documented and saved.

BILLY CORDELL: I think one thing that goes along with that is we have in Burleson, and I think a lot of surrounding agencies have a no-drop policy. We do not drop the charges when the victim comes in. And I happened to be walking through the lobby one afternoon, like at 5:30 or 6:00 and a lady came in, she was trying to get in touch with the detective. And I said, “Well, the detectives are gone. How can I help you?” And she said, “I want to drop charges on,” and I said, “On what?” She said a domestic violence situation. And so, we talked a little bit and, cutting to the chase here, I asked her, I said, “In that encounter, were you strangled?” And she said, “Yes.” And I said, “Have you been strangled before?” She was, “Oh, yeah, many times.” And I said, “Well, we won't drop that charge. You'll have to speak with the appropriate district attorney to see if they'll drop that charge.” But I said, “Do you mind me giving you some advice?” And she said, “No, not at all.” I gave her some of the statistical data that you're 750 times more likely to be the victim of a homicide as you're going. And I said, “We know this from the data. And I said, “I know it's got to be tough, I can't even imagine, but sooner or later, we're going to make a call out there where you did not survive that strangulation.”

I said, “I would urge you to look for a support group, look for an advocate that can help you and get you in a better position.” And I don't think that's an unusual conversation in this area. And when you talk to our victims' assistance, a lot of them want to drop charges because of the things we all know, the financial instability that they're afraid of. “How am I going to provide for my children? How am I going to put food on the table? Where am I going to live?” And that gets us as a larger society where we need to be able to find better ways of helping someone through this very difficult time in their life.

DR. TARA O'CONNOR SHELLEY: If I could just jump in briefly. We did an independent assessment of first-responder views of all of what's being discussed. And what we learned is an overwhelming majority of them saw a need for the ordinance and also rated the implementation of the ordinance fairly highly. And so, I don't think it's a hard sell to the rank and file. It was also something that once the report was released, the control site fire department was mortified because they were never given the chance to go on scene and do anything in response to strangulation. I mean, they don't have this ordinance, that's why they're the control site, but they were mortified that they had never been called to scene to be able to render any type of medical care or advice to strangulation victims in that community.

If you're trying to get buy-in from administrators or from politicians, I think you ask them, “What are you doing about it right now?” And see what they say because chances are, they're not saying some of the things that you've heard today that matter and improve our experiences for survivors.

CHRISTINE CROSSLAND: We did have a question regarding medical response. And the question is, “Did you have any issues with medical staff creating a document and then using that for criminal prosecution?”

BILLY CORDELL: Well, I'm not going to speak on behalf of the medical team because I wasn't involved in that piece of it, and we apologize that the fire department's not here at the table. I don't know if any of these cases have gone to court yet that we've been doing. I'm sure some of them have, a lot of them may have been plead out where you never had courtroom testimony, so I'm not sure I can answer that question.

KEN SHETTER: I think, but generally speaking, just to take it step by step. So, you have a document that's created for medical purposes, for medical exam purposes, that then can be used as part of the prosecution of the case. And simply put, there is, generally speaking, there's not an issue with using that documentation as part of the process of developing the evidence to support the prosecution of a case or to present the evidence in court. And not only do I think that and so the purpose of the exam is not to create evidence, but it’s also not like some of the forensic exams that are done, it's not the purpose. But like I said, it is an unintended sort of side benefit that's just a reality. And I think over time, the thing that happens is you're going to have more cases that will be plead out because that evidence exists, and so you're going to have at least a few more criminal defendants and their attorneys that are not going to want to take that case to trial.

CHRISTINE CROSSLAND: Okay. Tara, I'm going to come back to you. And based on the information that you were able to glean from the evaluation and the presentation to all the stakeholders involved, are there any plans in place to make any changes to moving forward with any strategies or anything like that? That was one of the questions posed, I'm paraphrasing.

DR. TARA O'CONNOR SHELLEY: I mean, the report has just really recently been released, so I'm not aware of any immediate plans in Burleson to make any changes from lessons learned in the report or any immediate plans in the control site other than what I've just shared that I know for sure the control site fire department was really upset. And I think just being empowered with that information could help implement some change, but I mean, I think that's what the question was asking, if I understand it correctly. But I could turn it to Chief if he wants to comment if anything's changing in the immediate forefront.

BILLY CORDELL: Not that I'm aware of, either. I'm not aware of any change.

CHRISTINE CROSSLAND: Okay. Great. We are winding down. I want to be able to provide a few minutes so we can have some closing remarks. If we haven't been able to answer your question, we'll be able to do that with a follow-up. Again, I provided the contact information of our esteemed presenters today in the chat box, so that if you'd like to reach out to them, you can. As you can tell, they're extremely enthusiastic, well-informed, brilliant, and dedicated, and I know they'll get back to you. Again, we're going to be posting the slides and everything, so that will include the resources that were discussed; it will talk about bibliography and references to these specific settings that you all talked about. I just want to make sure that I have all of those concerns addressed.

Again, that should be within the next two to three weeks. I do want to provide Janine an opportunity to make a few closing remarks, if you're available. Thanks.

DR. JANINE ZWEIG: Thank you very much, Tina. And that was absolutely fascinating, thank you so much to our speakers. I am definitely taking a few things away from this conversation that I'd like to emphasize. The first being that implementing an ordinance, emphasizing the importance and seriousness of strangulation, training law enforcement and medical professionals on that ordinance, providing the necessary response protocols and delivering resources to address it can lead to better responses and outcomes.

And while the study did not examine prosecuted strangulation cases, this innovative approach shows that effective prosecution, which often hinges on evidence-based practices and training, will undoubtedly have better outcomes when a multi-disciplinary team works together to provide the necessary documentation that holds individuals accountable. More importantly, it's also imperative to remember that victims' and survivors' perceptions of justice and accountability may be different from those of the criminal justice system. So, this innovative response allowed survivors to obtain much needed medical attention that they may not have otherwise received.

Further, the additional training and education aspects of this effort emphasized the need to increase public awareness about the dangers of strangulation and its potential as an indicator of future violence. Understanding its implications can empower victims and their loved ones to seek help. Likewise, implementing similar strategies can significantly enhance the response to and prevention of strangulation in domestic violence scenarios. And lastly, in addition to enhancing our knowledge and understanding of the impacts of strangulation on domestic violence victims, this study demonstrates the effectiveness of approaching this problem with multidisciplinary lens that engages policymakers, law enforcement, medical, and advocacy actors in addressing this life-threatening problem.

It is not one actor, but a whole ensemble. Employing a multifaceted approach to address strangulation ensures comprehensive support for victims, and it also enhances the public safety and health response in combating domestic violence generally. So, thank you, Tina, for that opportunity to share some of what I've taken away from this conversation. And I'm wondering what are you taking away from this afternoon's presentation?

CHRISTINE CROSSLAND: Thanks, Janine, I really appreciate it. My big takeaway is we know that non-fatal strangulation cases are lethal. They have serious, immediate, and long-term health consequences. And I hope our webinar attendees see the potential of this innovative approach to address a life-threatening problem. It's a model that could be implemented nationwide in many jurisdictions that would ultimately foster improvement, collaboration, positive change, and more importantly, save lives.

So, I hope you can all join me in thanking our esteemed presenters and expressing appreciation for their valuable insight and dedication to addressing a significant problem. For our attendees, we hope you enjoyed attending this event and found it informative. We also want to thank you for your hard work, dedication, and service. I know many of you are practitioners yourselves. In addition, I know breaking away from a busy day is very challenging, so we do not take it for granted that you were able to join us in this space; again, thank you. And finally, I do want to send a special shout-out to my Department of Justice colleagues and contractors who helped plan, coordinate, and make this webinar possible. We appreciate your hard work and dedication. And with all that said, I hope everyone enjoys the rest of your day. Many thanks for joining us.

STACY LEE: This will end our presentation.