Title: Working With Victims of Gun Violence
Series: Bulletin
Author: Judith Bonderman
Published: July 2001
Subject: victims -- general, victim services, gun violence
30 pages
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U.S. Department of Justice
Office of Justice Programs
Office for Victims of Crime

OVC Bulletin 
July 2001

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About This Bulletin

Gun violence in America crosses the demographic lines of age, race, ethnicity,
religion, gender, and class--very few Americans have not been affected by the
scourge of gun violence. Gun violence corrodes the fabric of our communities,
traumatizing victims, witnesses, families, communities, and even our Nation, as
recent high-profile school shootings have shown. 

To understand and respond effectively to violence in our society, we must build
on many disciplines, including the victim assistance and criminal justice fields,
health care, social services, education, and the clergy. To guide our efforts in
serving victims of gun violence, the Office for Victims of Crime (OVC)
sponsored a multidisciplinary group of national experts in March 2000 to
identify key victim issues and needs, develop recommendations for using federal
funds to address victims' needs, and identify promising practices to serve
victims of gun violence.

Not surprisingly, this bulletin indicates that some demographic groups are
disproportionately victimized by gun violence and that many victims never
receive needed services. And while we typically think of gun violence victims as
victims of homicide, we were reminded that there are many more victims who
survive their injuries, often with long-term physical and psychological
disabilities. Addressing the needs of secondary victims, including children and
adults who witness violence, is another challenge for practitioners, and one that
we are just beginning to address systematically in the victim assistance and
compensation fields. This bulletin not only outlines the many challenges before
us but also describes some promising practices in communities across our
Nation to serve victims and stop the violence. We believe that the information
provided in this bulletin will advance the field's understanding of how gun
violence affects victims and their communities and will help OVC identify and
support improved services for victims of gun violence.

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Working With Victims of Gun Violence

by Judith Bonderman

Introduction

On March 3, 2000, the Office for Victims of Crime (OVC) sponsored a
roundtable discussion about the effects of gun violence on individual victims,
their families, and their communities. This 1-day meeting in Washington, D.C.,
brought together a diverse group of professionals who work with victims of gun
violence: physicians, social workers, mental health providers, prosecutors,
nurses, lawyers, teachers, school principals, victim compensation
administrators, and judges. Several gunshot victims and survivors who lost 
family members to gun violence also participated. This interdisciplinary 
discussion was designed to

o Identify key victim issues stemming from firearm violence.

o Increase understanding of the full range of gun victims' needs and how they
differ from the needs of other crime victims.

o Identify promising or successful assistance programs for victims of gun
violence.

o Develop recommendations for how federal and state crime victims' funds
could be used to address unmet needs.

The 18-person group reflected a wide range of expertise--from a trauma
surgeon who operates on gun victims to a counselor who accompanies families
to the morgue to a judge who hears victim impact statements. Although each
participant's contribution to the discussion was shaped by his or her unique
experience, the major concerns raised by all participants were remarkably
consistent and supported by the growing literature on gun victimization. This
bulletin highlights the issues raised and the recommendations developed by the
roundtable. While our focus was victims of gun crime, as mandated by the
Victims of Crime Act (VOCA) administered by OVC, we recognize that
victims of all types of gun trauma--including unintentional shootings and
suicides--have many of the same needs that can be met with help from victim
service providers.

Who Are the Victims of Gun Violence?

The Death Toll

When confronted with the question, "Who are the victims of gun violence?" we
usually think first about the fatalities. According to death certificate data
compiled by the National Center for Health Statistics, a part of the Centers for
Disease Control and Prevention (CDC), a total of 32,436 persons died from
firearm injuries in the United States in 1997. The majority of these deaths--54.2
percent--were suicides, 41.7 percent were homicides, and the remaining 4.1
percent were unintentional shootings or deaths of an undetermined nature.[1]
The effects of gun violence cross all socioeconomic and geographic
boundaries--from inner cities to remote rural areas to upscale suburbs and in
homes, public housing communities, schools, workplaces, recreational areas,
bars, and on the street. Gun violence victims are young and old, male and
female, African-American and white. In some cases, the shooter and victim are
strangers, but in many others, they are intimately related.

In spite of the pervasive nature of gun violence, some demographic groups are
disproportionately represented in the gun crime victim population. The 13,252
gun homicide victims recorded in the mortality statistics for 1997 included
5,110 who were 15 to 24 years old. Firearm homicide[2] was the second
leading cause of death for the 15- to 24-year-old group. In the 25- to
34-year-old group, there were 3,706 deaths from gun homicide; at younger
ages (5-14), there were 284 firearm homicides. In fact, firearm homicide was
within the top 10 causes of death for all age groups from 5 to 44 years.

Gun homicide victims are disproportionately young and predominantly male.
According to CDC, 84 percent were male in 1997. At ages 15 to 19 years, the
gun homicide rate for males was 8 times the rate for females in 1997.[3] The
Bureau of Justice Statistics (BJS) reports that males of all ages were 3.2 times
more likely than females to be murdered in 1998. Moreover, the circumstances
of firearm violence differ significantly for men and women. In contrast to men,
women are far more likely to be killed by a spouse, intimate acquaintance, or
family member than by a stranger.[4]

Firearm homicide also disproportionately affects African-Americans.
Approximately 52 percent of gun homicide victims are African-American, even
though they represent less than 13 percent of the total population.
African-American males between the ages of 15 and 24 have the highest
firearm homicide rate of any demographic group. Their firearm homicide rate of
103.4 deaths per 100,000 is 10 times higher than the rate for white males in the
same age group (10.5 deaths per 100,000). In 1997, 92 percent of homicides
of young African-American men occurred by firearms, compared to 68 percent
of homicides by firearms in the general population.[5] Even though violent crime
rates, including crimes committed with guns, have declined each year since
1993, according to Federal Bureau of Investigation trend reports,[6] guns
remain the leading cause of death for young African-American males.[7]

----------------------------

If all Americans were killed with firearms at the same rate as African-American
males between the ages of 15 and 24 (103.4 per 100,000), there would be
276,843 firearm homicide victims annually in the United States. (Based on
1997 CDC numbers and a total population of 267,636,061.)

----------------------------

The Nonfatal Gun Crime Victimization

For every firearm death, there are approximately three nonfatal firearm injuries
that show up in hospital emergency rooms. With no mechanism, such as a
national registry, to collect uniform national data on nonfatal firearm injuries, this
is, at best, an estimate based on a sample of hospitals.[8] There may be many
more nonfatal firearm victims who do not go to hospital emergency rooms for
treatment. Others have estimated four to six nonfatal injuries for each gun
death.[9] In addition, many crime victims may be traumatized by the presence
of a gun during a crime, whether or not the gun was fired. According to the
National Crime Victimization Survey (NCVS) in 1998, victimizations involving
a firearm represented 23 percent of the 2.9 million violent crimes of rape and
sexual assault, robbery, and aggravated assault. In 1998, 670,500 crime
victims reported facing an assailant with a gun.[10]

Secondary Victims

The number of deaths and injuries is just a crude index of the effects of gun 
violence in the United States. There is an even greater number of secondary
victims, sometimes called covictims or survivors of homicide. These are the
parents, children, siblings, spouses, and others who have lost a loved one or
friend to gun homicide. In the aftermath of a homicide, covictims must deal with
law enforcement, the medical examiner, the press, and the court system, among
others. They may have to clean up a crime scene, pay the homicide victim's
medical bills, and arrange for a funeral and burial.

Secondary victims also include those who are touched by or witness gun
violence in their homes, schools, or workplaces or on the street. In the Nation's
largest public housing projects, the damage goes well beyond the lives lost and
injuries inflicted. According to a report from the U.S. Department of Housing
and Urban Development, public housing residents are more than twice as likely
as other members of the population to suffer from firearm victimization, one in
five residents reports feeling unsafe in his or her neighborhood, and children
show symptoms of posttraumatic stress disorder (PTSD) similar to those seen
in children exposed to war or major disasters.[11] This is consistent with
numerous studies finding high rates of exposure to violence particularly among
youth in urban communities. In one study, almost two-thirds of high school
students had witnessed a shooting, and in another, 70 percent of the youth ages
7 to 18 in a public housing project had witnessed a shooting and 43 percent
had seen a murder.[12] Recent data also indicate substantial exposure to 
gun violence among suburban school-age children.[13]

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"It is estimated that each homicide victim is survived by an average of three
loved ones for whom the violent death produces a painful and traumatic grief."

--Deborah Spungen
Homicide: The Hidden Victims
Sage Publications, 1998

----------------------------

Multiple-Victim Shootings

While the number of crimes committed with firearms has been falling to levels
not seen since the mid-1980s,[14] media coverage and public awareness of
gun crime are increasing. In the past few years, a rash of multiple-victim
tragedies has erupted in schools, workplaces, churches, nursing homes, fast
food restaurants, shopping malls, and transportation. These are very public
venues--places that we frequent on a daily basis and where we should feel safe.
When a gun massacre interrupts play in a daycare center, prayer in a church, or
commuters going home from work, it shatters our most basic sense of security.
Consequently, even though the percentage of homicides involving five or more
victims was less than 0.05 percent in 1998,[15] these are the ones that receive
the overwhelming majority of the media's attention. In addition, the
multiple-victim shootings in public places may be ones that create the most
secondary victims as whole classrooms of first graders, cafeterias full of
teenagers, and hundreds of fellow workers witness a mass shooting. The media
coverage alone multiplies the number of persons victimized by the crime.

----------------------------

"Even those who have never encountered a gun are aware of the widespread
presence of guns in our communities, witness news reports of gun-related
crime, domestic murders, and high-profile shootings at schools, churches and
other public places. The ever-present fear that someone we love might be killed
or injured is another form of gun trauma."

-From The Bell Campaign's World Wide Web site at www.bellcampaign.org
The Bell Campaign is now referred to as The Million Mom March Foundation.

--------------

Needs of Gun Victims

The roundtable participants were asked to consider how gun victims may be
different from other crime victims and how the differences might affect the
services they need or receive. The main themes that emerged were 1) the gun
as the weapon of violence, 2) the young age of the victims, 3) the high cost of
gun violence, and 4) the extraordinary media attention given to a small subset of
gun crimes.

1. The Gun as the Weapon of Violence

Much has been written on why gun use increases the deadliness of attacks; for
example, because guns inflict more damage than other instruments, they can be
fired multiple times with little effort, firearms have a greater range, and 
assailants intending to kill choose the most efficient instrument.[16] Whatever 
the impact of these different factors, it is clear that the fatality rate from gun
assaults is much higher than that from other weapons. This is true regardless of
the relationship between the victim and shooter, as the presence of a gun can
turn a robbery, an argument, or an abusive relationship into a homicide.[17]

According to a 1996 BJS report, 29 percent of firearm homicide victims were
killed because of an argument; 21 percent were killed during the commission of
another crime, such as a robbery or drug crime; and 6 percent died as a result
of a gang-related shooting.[18] Offenders report firing a gun within 15 seconds
of brandishing it, even when they had not intended to shoot the victim.[19] Gun
victims include those shot during traffic altercations, gambling disputes, and
verbal disagreements.

The lethality effect is not lost on the victims. Participants repeatedly spoke of
the nature of the weapon used. "An important difference is the gun itself. Guns
are the only instrument developed to kill; victims facing a gun suffer the trauma
of death or the fear of death," said family bereavement counselor Kevin
O'Brien. Meanwhile, participant DeLano Foster, an OVC Program Specialist
and survivor of multiple homicides, offered that "the difference between an
armed robbery and a homicide could be the time it takes the victim to hand
over his wallet." Eyewitness accounts frequently report victims putting their
hands in front of them and "holding up articles of all kinds in their last moments
in the magical belief that even a sheet of paper might save them."[20]

----------------------------

Bystander Victims

Durham, North Carolina: April 7, 1998. While walking with his mother, a
5-year-old boy was hit by a stray bullet from a gunfight. The bullet severed his
spine, and Taquan Mikell may never walk again. The bullet struck him more
than half a block away from the gunfight.

Nashville, Tennessee: July 2, 1999. Nashville teenager Eric Harvey Hazelitt
was fatally shot in the chest when gunfire erupted at the John Henry Hale public
housing complex in Nashville. Just 14 years old, he was caught in the crossfire
of two groups shooting at each other.

Referenced from In the Crossfire: The Impact of Gun Violence on Public
Housing Communities, published by the U.S. Department of Housing and
Urban Development, February 2000.

Washington, D.C.: June 21, 1999. Helen Foster-El, a 55-year-old
grandmother, was outside her home in the 100 block of 56th Place SE.
watching neighborhood children play when gunfire erupted between two
groups. On hearing the gunfire, Ms. Foster-El began to shepherd the children
into one of the neighborhood homes for their safety. As she was doing so, she
was struck in the back by a stray bullet and died instantly.

Harrisburg, Pennsylvania: June 10, 1999. Raphael Rivera, 14, was in the
immediate area of an altercation involving several individuals. When the
altercation escalated into gunfire, Raphael, who was not involved in the
argument, sustained a fatal wound to the chest.

Referenced from The Death Toll Since Columbine, a report of the U.S.
Conference of Mayors, Washington, D.C., January 2000.

----------------------------

Gun violence also is frequently more random than other types of criminal
victimization. One participant noted that "bullets don't always have a name on
them. You can be shot from a great distance even with a bullet meant for
someone else." Young men can be "casualties of a war they did not partake in"
when gang members intent on retaliating shoot at random victims when they
can't find the rivals they intended to kill.[21] Other participants talked about
small children sleeping in bathtubs to hide from stray bullets penetrating
bedroom walls at night.

The bystander victim represents the most impersonal type of crime. But
participants commented that, even when the shooter targets a particular victim,
the gun crime is somewhat impersonal. The gun, as an instrument of both power
and detachment, allows the shooter to remain physically and emotionally
distanced from his or her victims. When the victims are shot in the back, as
many are, they never even see the shooter's face. This may increase the "Why
me?" response of so many gun victims, similar to the feelings of victims of drunk
driving.

The ability of mentally disturbed individuals to kill at a distance, together with
the enormous firepower of semiautomatic weapons, may have facilitated the
gun rampages that have taken so many lives in recent years. Participant
Michelle Scully Hobus was shot and her husband killed when a crazed gunman
armed with two semiautomatic TEC-9 pistols roamed a San Francisco,
California, law firm, shooting 15 people, killing 9 before taking his own life. It
was a long time before she could shake the feeling of danger. "Even though I
knew that the gun massacre at the law firm was an extremely rare event, I kept
having the feeling that it would happen again. I couldn't sit with my back to the
door; I thought someone would come in and blow everyone away."

o Just as Larry Gene Ashbrook did on September 15, 1999, when he shot 14
people (7 dead) in the Wedgwood Baptist Church in Fort Worth, Texas.

o Just as Mark Barton did on July 29, 1999, when he shot 22 people (9 dead)
at two brokerage firms in Atlanta, Georgia.

o Just as Kip Kinkel did on May 21, 1998, when he shot 24 people (2 dead)
at Thurston High School in Springfield, Oregon.

o Just as George Hennard did on October 16, 1991, when he drove his truck
into Luby's Cafeteria in Killeen, Texas, and opened fire on the lunchtime
crowd, killing 23 people before shooting himself.[22]

Moreover, gun victims face constant reminders of their trauma from the
ever-present gun seen on television programs and commercials and in films and
videos. Even American slang, for example, "one shot," "take aim," and "set your
sights," takes its toll on some victims. Some participants reported that any loud 
noise, like balloons popping and cars backfiring, could "trigger" a response. The
exorbitant media attention paid to each new multiple-victim shooting also is
retraumatizing for gun victims of similar tragedies. Security changes, such as
metal detectors in schools, hidden cameras, dress codes, and guards in the
halls, are constant visual reminders of school shootings.

Like other crime victims, gun victims seek redress against their shooters through
the criminal justice and civil justice systems. Many victims, like participants
Scully Hobus and Jaquie Algee, have become activists.

RECOMMENDATION: Clinical evidence supports the therapeutic value of
victims working as change agents, in grassroots or church activities, informal
support groups, and anticrime organizations.[23]

2. The Young Age of the Victims

As previously noted, gun crime disproportionately affects young people. Their
injuries and grief must be understood in this context. The participants who work
with adolescents spoke of the pessimism and despair, particularly in the inner
cities, where communities are losing children to gun violence daily. Youngsters
whose relatives and friends have been shot automatically think that sooner or
later it will happen to them. They plan their funerals, write their obituaries, and 
specify the clothing in which they want to be buried. A psychological counselor
for teenagers in Baltimore, Maryland, Dr. Rosetta Graham, spoke of the need
to do much more for this age group: "Around age 14 or 15 they become more
private and hold in their grief. They are caught between adults who know how
to make their needs known and young children whose caregivers speak for
them." Studies of urban youth show a high correlation between exposure to
violence and depression and PTSD.[24]

The hopelessness of this population was a recurring theme. The participants
agreed that one major shooting, or the daily loss of friends and classmates, can
have a profound effect on young people just beginning to explore their
independence and develop plans for their future. While some hold in their grief,
others become suicidal or act out their feelings on the street. Even in suburban
settings where violence is rare, a highly publicized school gun massacre can
have a significant impact. Counselors working with students at Columbine High
School in Littleton, Colorado, worried about kids who were somewhat
depressed and doing drugs before the shooting. In the months since the
shooting, they have seen an increase in drunk driving, suicide attempts, and
fighting. Disaffected students--or those who feel alienated or rejected--don't
trust anyone, don't feel safe, and don't do well in school. Similarly, after the
1998 shooting of 22 students at Thurston High School in Springfield, Oregon,
there was a 600-percent increase in referrals to the school nurse and a
400-percent increase in arguments and fights reported to the principal. Many
students, even some who were not present at the school but who watched the
news coverage, experienced a loss of control, a feeling of being violated, and a
sense of guilt that they survived.

For many students, the fear of gun violence is strong enough to interfere with
the quality of their lives and their performance in school; they also may suffer
from increased absentee, truancy, and dropout rates. Participants who work
with children explained the importance of getting them to talk about their fears.
They are hungry for information and may distort facts and think they could have
prevented the shooting. They need to understand that the school shootings on
the evening news are rare events and that schools are safe places.

Although exposure to violence will affect all adolescents to some extent,
different services are needed when the shooting is an isolated tragedy versus
when there is a daily threat of violence in the community.[25] In the high-profile
school and workplace shootings, crisis response teams "debrief" the victims and
witnesses, often in a group setting. The interventions for schools and
communities that witness violence are based on the assumption that the
incidents they witnessed are one-time horrific events. Participants who had the
benefit of this type of crisis response service felt a sense of security while the
teams were there and a great void when they left. In the absence of organized
training, teachers, school administrators, and guidance counselors are
scrambling to get up to speed on crisis response. Many professionals who
helped care for the students who were shot or witnessed a massacre of their
classmates also became depressed and suicidal. According to School
Superintendent Jamon Kent, the shooting at Thurston High took place May 21,
1998, and the aftershocks still occupy one-third of his time in the office.

RECOMMENDATION: Participants recommended that communities
victimized by gun massacres be offered long-term assistance and training so
they can more effectively be involved in the healing process.

Different problems arise and different types of interventions are needed to 
address chronic gun violence. For the past 10 years at least, young
African-American males have experienced violent crime at a rate significantly
higher than the rate for other age groups.[26] Sandra DeLeon, Director of the
Rise Above It violence prevention program in West Orange, New Jersey,
reported that 60 percent of the students they serve know someone who has
been shot. In their neighborhoods, gun violence is more predictable than
random. They come to school worrying about the gunshots they heard the night
before. The students need to hear, preferably from peer counselors, that there
is a future to look forward to and they are not destined to be either buried or
behind bars in jail. But the participants also agreed that this is an uphill battle.
The strong correlation between poverty and violent crime means that those with
the fewest resources are the most vulnerable. In some cases, the parents of
homicide victims are very young. An enormous amount of preventive counseling
is needed to keep them from exacting retribution while they struggle to get
daycare, buy food, and arrange for the burial of a loved one.

The literature on children and adolescent victims reinforces the group's findings
about the vulnerabilities of young gun victims. A Task Force on Adolescent
Assault Victim Needs, convened by the American Academy of Pediatrics,
recommends addressing the psychosocial needs of young victims along with
their physical injuries.[27] To do this effectively, the task force noted that health
care providers must acknowledge and address three myths: 1) that all
adolescent victims are "bad" kids who probably deserve what they got, 2) that
it is dangerous to care for adolescent victims who may be members of a gang,
and 3) that it is hopeless to help them because of the high risk of reinjury and
subsequent acts of violence by the victim.

The myth that all adolescent victims are "bad" kids is particularly harmful for
young African-American men growing up in neighborhoods rife with drugs and
gun violence. Generalizations about "predator youth" cause added grief for gun
victims and stigmatize them and their families unfairly. Future employers may
refuse to hire a young man with a bullet in his arm, assuming that he was a gang
member or a bad person because he'd been shot.[28] On the other hand, the
tendency to use violence is considered a serious potential consequence of being
a young victim of gun violence. In fact, "a new study by the National Center on
Crime and Delinquency finds that one of the best predictors of whether a
teenager will commit a crime is whether he or she has been a victim."[29]
Siblings of gunshot victims are frequently preoccupied with revenge fantasies
and may be encouraged and assisted by their peers in exacting vigilante justice.
Once having resorted to violence, young men engage in more risk-taking
behavior. Thus, a cycle of violence continues, and being shot once becomes the
greatest predictor for being targeted again.[30] However, the risk factors for
this group are often overcome by the resourcefulness and determination of 
families surviving in the inner city.

RECOMMENDATION: Participants agreed that assistance for gun victims,
particularly young African-American men, must include programs designed to
teach victims to regain their self-respect and status in the community without
resorting to more violence. Quick outreach and support to newly bereaved
families can help redirect their grief toward positive efforts to honor the memory
of their loved ones.

----------------------------

"After my 19-year-old son was shot in Chicago, I went to many support
groups, community organizations, and church-affiliated meetings, but I really
wasn't getting what I needed. I needed to be more active in the movement to
reduce gun trauma. I found comfort in joining The Bell Campaign, a grassroots 
victim-based organization, modeled after Mothers Against Drunk Driving."

--Jaquie Algee, Southeast Regional Director for The Bell Campaign

----------------------------

Although much of the roundtable discussion centered on teenage youth,
elementary school-age children also are frequent witnesses to gun violence and
often display symptoms of PTSD and other trauma-related disorders.[31]
Some children are afraid of school, and many become fatalistic. Some engage
in aggressive play and perform poorly in school,[32] while others become
desensitized to violence and lose the ability to recognize and avoid dangerous
situations. The few research studies that were available to participants
suggested that witnessing gun violence affects children in many different ways,
depending on the type of wound, the proximity to the shooter, the relationship
of the shooter and victim, and whether the shooting took place in a context
generally considered safe, among other things. Different reactions can be
expected from boys and girls. Child witnesses who have been raised in a
subculture of violence in the home may have additional risk factors for
long-term psychosocial consequences.[33] Effects also can be seen in somatic
disturbances. According to participant Marianne Z. Wamboldt, M.D., a child
psychiatrist in Denver, Colorado, clinicians have noted a relationship between
the general stress in the community after the shooting at Columbine High and an
increase in asthma cases and deaths among preschoolers.

RECOMMENDATION: The roundtable consensus was that much more
research is needed to develop services that take into account the full range of
effects that gun violence has on children. OVC should work with other offices
in the Office of Justice Programs (OJP), such as the National Institute of
Justice, the Office of Juvenile Justice and Delinquency Prevention (OJJDP), the
Violence Against Women Office (VAWO), and BJS, to develop a research
agenda concerning the needs of gun violence victims. The evaluation of
promising direct service programs for child victims of gun violence should be
encouraged and funded by OJP.

3. The High Cost of Gun Violence

Gunshot injury and death place a burden on the health care system in the United
States that far exceeds the toll of other types of criminal victimization. Because
of the traumatic nature and extent of their injuries, gunshot victims are more
likely than other crime victims to require overnight hospitalization and followup
care. BJS reports that gunshot victims represented only 5 percent of the
estimated 1.4 million hospital emergency department patients treated in 1994
for violence-related nonfatal injuries. But while the majority of crime victims are
treated and released, gunshot victims represent a third of those requiring
hospitalization.[34] The average cost of acute care treatment ranges from
$14,850[35] to $32,000[36] per hospital admission. Because of the young
average age of the victims and the frequent need for rehospitalization, the
lifetime medical costs are very high, around $35,500 per victim. For all victims
of firearm injuries (assaults) and deaths (homicides) in 1994, the lifetime
medical costs totaled $1.7 billion. Government programs, primarily Medicaid,
are the primary payers for 50 percent of hospitalized gunshot injury cases due
to violence.[37]

The growing cost of gun violence can affect the trauma care available for all
community members. At King/Drew Medical Center in Los Angeles,
California, hospital expenses, not including professional fees, were more than
$270.7 million for the 34,893 patients hospitalized for gunshot injuries from
1978 to 1992.[38] Some 96 percent of these costs were paid with public
funds.[39] Between 1983 and 1990, the financial strain of treating uninsured
patients contributed to the closure of 10 out of 23 trauma centers in Los
Angeles County.[40]

In addition to direct health care and related expenditures, gun violence exacts a
substantial economic toll on its victims and society in general in terms of lost
productivity, use of the criminal justice system, pain and suffering, and
diminished quality of life. Economists and public health statisticians estimate an
annual bill of more than $100 billion for all of these gun violence costs. An
examination of more than 1,000 jury awards in cases involving shooting victims
yields an average loss of more than $3 million for a single family of a homicide
victim.[41]

The economic loss is even more staggering for victims who sustain spinal cord 
injuries (SCIs) from gunshot wounds. These relatively rare catastrophic cases
account for the lion's share of the medical costs for gun injuries. Each year,
approximately 10,000 persons suffer an SCI and require hospitalization. Nearly
a quarter of these injuries are caused by acts of violence, primarily gunshot
wounds. Violence-related SCIs have increased dramatically since the early
1970s, overtaking falls as the second leading cause of SCIs (after motor vehicle
accidents) in the past 4 years.[42] The average first-year expenses have been
estimated at $217,868 (in 1995 dollars) for violence-related SCIs, although the
amount varies considerably depending on the extent of neurological damage.
With recurring annual charges for violence-related SCIs calculated at $17,275,
the lifetime charges are estimated to be more than $600,000 for each victim.
This includes charges incurred as a direct result of the injury, such as
emergency medical services, hospitalizations, attendant care, equipment,
supplies, medications, environmental modifications, physician and outpatient
services, nursing homes, household assistance, vocational rehabilitation, and
similar miscellaneous items. It does not include indirect costs, such as lost
wages, fringe benefits, productivity, pain and suffering, and diminished quality of
life, which could be twice as much as the direct costs.[43]

A handful of gunshot SCI victims have fared better than most. For example, the
SCI students from the Columbine shootings have had the benefit of a
communitywide effort to raise funds for remodeling living areas, paying for
medical and living expenses, specially equipped vans, and even college
scholarships. But these are atypical cases. The majority of people with
violence-related SCIs are young African-Americans with low socioeconomic
status. Many in this group have been targets of gun violence and have sustained
most of their injuries because of drug- or gang-related activity. Those who
return to their communities after surviving months with tubes in their bodies face
a daunting challenge in school. Paralyzed for life, they never will be the same
active teenagers again. The practical and social problems like calling ahead and
waiting hours for transportation, wheelchair access to classrooms, and dealing
with colostomy bags are difficult enough without the added fears of testifying in
court and being targeted again by the shooter. Those with violence-related
SCIs are more likely than other SCI patients to have intractable pain and
commit suicide. For others, the cost of acute care and rehabilitation, among
other things, can lead to the dim prospect of constant dependence on the
Government or family.[44]

4. The Extraordinary Media Attention to a Small Subset of Gun Crimes

On April 20, 1999, the world watched as two high school students, armed with
automatic weapons and shotguns, killed 12 students and a teacher and
wounded 23 others before turning the guns on themselves. The tragedy at
Columbine High School is considered a defining moment in the public's
consciousness about gun violence. The nonstop realtime media coverage of this
horrendous massacre, both on the air and in print, was traumatizing to the
victims' families and friends, the community, the state of Colorado, the United
States, and the world. The roundtable participants discussed this media
coverage, focusing on its impact on children and its message for those haunted
by the unpublicized loss of a loved one to gun violence.

RECOMMENDATION: Participants agreed that the media should be more
sensitive to how their coverage of gun violence affects victims and children.
OVC should develop training materials and guidelines for media coverage of
gun massacres.

School shootings in particular are traumatizing for children because they all go
to school.[45] After Columbine, preschoolers in Colorado began talking about
where they would be going to school as the place where they would die.
School systems around the country saw the phenomenon of school-phobic
kids, as both the news media and talk shows exaggerated a child's risk of being
shot at school. Although participants thought that such news coverage should
carry a warning caption for parents about the possible adverse effects on young
children, they also felt that older children are hungry to know what has
happened and have a great need for information. In all cases, parents and
teachers need to help children process the information they see on television, so
they can realistically assess their own safety in school.

Unfortunately, the misconceptions about the risk of school shootings are
pervasive in all age groups. A recent analysis of opinion polls taken after the
shootings in Jonesboro, Arkansas, and Littleton found a 49-percent increase in
parents' anxiety about children's safety in the classroom, even though statistical
studies by the U.S. Department of Justice (DOJ) and the National School
Safety Center showed a 40-percent decrease in school-associated violent
deaths in 1998-1999, the school year including the Columbine shooting. These
tragic events are truly rare--with 52 million students enrolled in public school,
the chance that a school-aged child would die in school in 1998-1999 was 1 in
2 million.[46]

The gap between public fear and reality is not surprising, as media coverage is
focused on less than 1 percent of homicides--those with multiple victims. Even
within a group of multiple-victim gun homicides, the rarest events get the most
media attention. For example,

o December 4, 1999: Sacramento, California. A 31-year-old Asian man shot
and killed his daughter and four sons, reportedly after having an argument with
his wife. A shotgun and a high-powered rifle were found in the apartment.

o December 5, 1999: Baltimore, Maryland. Five women were found shot to
death in their Northeast Baltimore row house. Police said the women, who
were not involved in drug activity, were shot to send a message to a relative
who was involved in the drug trade.

o December 6, 1999: Fort Gibson, Oklahoma. Five students were injured
when a 13-year-old opened fire at a middle school with a 9 mm handgun he
took from his home.

The family homicide, an all-too-common occurrence, was reported only by the
California press. The Baltimore shooting was prime-time news for a day and
then was eclipsed by the middle school shooting in a rural community in
Oklahoma.

Even among victims of the same shooting, the media may focus on one or two
to represent the face on the story. Perhaps because of their pronounced
activism on the gun issue or because of some other special attribute, these
chosen victims become the story of the massacre. In Homicide: The Hidden
Victims, A Guide for Professionals, Deborah Spungen describes how individual
victims of multiple-victim shootings "tend to get lost in the scale of the horror,"
while "covictims who have had a loved one selected for the [poster victim] may
experience feelings of reluctance, exploitation, loss of control, and anger."[47]

Services for Gun Victims

The roundtable participants were asked to consider how VOCA-funded
programs, both compensation and direct services, are useful for gun violence
victims. Two points made throughout the day were reiterated in this discussion:

o Communities most at risk for gun violence need ongoing prevention work.
Even though the Federal VOCA Victim Assistance Final Program Guidelines
preclude the use of Crime Victims Fund moneys for "activities exclusively
related to crime prevention," direct services and compensation for gun victims
could have a secondary preventive effect by minimizing the risk of retaliation
and repeat victimization. Comprehensive programs that provide direct services
and help break the cycle of violence in the community typically have more than
one funding source. For example, a program could receive VOCA funding to
support direct victim services and funding from another federal agency, such as
DOJ's OJJDP or the U.S. Department of Health and Human Services, to
support prevention initiatives.

o Gun violence disproportionately affects young African-American men. The
health care, criminal justice, and media response to these victims may be less
sympathetic than responses to other crime victims. Whatever the reason for the
disparate treatment of these victims, we must not ignore them. Assumptions
about the blameworthiness of young African-Americans and Hispanics
shortchange a large segment of the population and perpetuate racial
stereotyping.

Crime Victim Compensation

Crime victim compensation programs--operating in all 50 states, the District of
Columbia, the Commonwealth of Puerto Rico, the U.S. Virgin Islands, the
Commonwealth of Northern Mariana Islands, American Samoa, and Guam--
provide financial assistance to victims for crime-related out-of-pocket
expenses, such as medical care, mental health counseling, lost wages, and, in
cases of homicide, funerals, loss of support, and counseling for secondary
victims. Many programs also pay for crime scene cleanup, durable medical
equipment like wheelchairs and hospital beds, transportation to medical
providers, rehabilitation, physical therapy, and ramps or modifications to homes
for paralyzed victims. All state victim compensation programs are "payors of
last resort," covering losses not recouped from other sources such as public or
private insurance, employee benefits, offender restitution, or civil judgments.
The state programs set their own administrative rules and reimbursement
maximums, which average $25,000 and range from a low of $10,000 to no
limit for medical expenses (as in New York). A few states set higher limits for
catastrophic or permanent injuries that could be used for special home and
health aids. In view of the large medical, rehabilitative, and counseling expenses
faced by gun victims, participants agreed that VOCA- and state-funded
compensation programs provide much-needed financial assistance. Although
there is no available estimate of the number of gun victims who benefit from
these programs,[48] Program Director of the D.C. Superior Court's Crime
Victims Compensation Program Laura Banks Reed stated that 30 percent of
claims paid by her program are to gun victims.

We are in a new era of crime victim compensation: program funding is more
secure than ever before, and state administrators are more responsive to the
needs of crime victims and flexible in administering their programs. Participants
identified special needs of gun violence victims and made the following
recommendations for state crime victim compensation programs.

o Survivors of serious gunshot injuries may require long-term mental health
counseling. Currently, the states impose many different limits on mental health
claims, for example, limits on the total dollar amount and the number of
sessions. As a result, the percentage of compensation dollars spent by the
states on mental health claims varies enormously. Nearly all states pay for grief
counseling for survivors of homicide, and some pay for mental health counseling
for family members who witness the crime.

RECOMMENDATION: Where necessary, state compensation caps and limits
should be raised for mental health counseling to permit long-term counseling.
States should consider extending benefits to more secondary victims, such as
students or coworkers who witness a shooting, even if they are not family
members and were not threatened by the shooter.

o In addition to medical and mental health expenses, victims whose brains have
been damaged or spinal cords have been injured as a result of gun violence may
require long-term care, special transportation services, housing modifications,
and occupational therapy. For the most severely injured victims, durable
medical equipment such as a powered wheelchair can cost anywhere from
$20,000 to $25,000, in addition to other equipment that may be needed. Many
have living arrangements that can't be modified to meet their needs--their third-
or fourth-floor walk-up apartments are not wheelchair accessible, and they
cannot afford to move. In many cases, the parents or family members don't
have the resources or services to stay home and care for the injured person;
there are a large number of 21-year-olds on ventilators in nursing homes being
covered by Medicaid.

RECOMMENDATION: Limits on medical expenses should be raised for
catastrophic injuries, and programs should be flexible in defining eligible
expenses as the needs of gun victims become clear to them. For example, New
Jersey pays for childcare and daycare services along with domestic help at a
rate of $50 a day. This type of innovative benefit allows family members to
continue working rather than having to stay home to care for a minor victim or
an adult.

o Although eligibility requirements vary somewhat from state to state, they all
require victim (or claimant) cooperation with police and prosecutors. These
requirements may be difficult for gun violence victims in some cases and may
discourage them from applying for compensation benefits. 

RECOMMENDATION: Encouraging victim cooperation with law
enforcement is a valid goal of state compensation programs. However, the
Federal VOCA Victim Compensation Final Program Guidelines encourage
program administrators to be flexible about cooperation requirements in cases
where they may present special barriers for the victim. Law enforcement
personnel, prosecutors, and compensation program staff should be trained to
understand and be sensitive to the fears of these victims.

o Most compensation programs have time limits for filing compensation
applications. Although many states have specific exceptions or will waive filing
limits for minors, the time limits may still disqualify some teen and young adult
gun victims who need mental health counseling but are embarrassed to come
forward at first and admit they need help.

RECOMMENDATION: Compensation programs should waive time limits for
filing applications to avoid penalizing young victims.

Direct Victim Services

OVC makes annual VOCA crime victim assistance formula grants to all 50
states to support the provision of direct services to victims of crime. The state
VOCA administrators, in turn, subgrant the funds to victim service providers.
Ten percent of each VOCA state grant must be allocated to victims of violent
crime who have been previously underserved in that state. Underserved victims
include, but are not limited to, victims of federal crimes, survivors of homicide
victims, and victims of assault, robbery, gang violence, hate and bias crimes,
intoxicated drivers, and elder abuse. States also may define underserved victims
according to their status as senior citizens, persons with disabilities, racial or
ethnic minorities, and residents of rural areas or inner cities. Eligible direct
services include programs that 1) respond to the emotional and physical needs
of crime victims, 2) assist primary and secondary victims of crime to stabilize
their lives after a victimization, 3) assist victims to understand and participate in
the criminal justice system, and 4) provide victims of crime with a measure of
safety and security, such as boarding up broken windows and replacing or
repairing locks.

Many of the current VOCA subgrantees may provide services that are used by
victims of gun violence, such as homicide support groups and victim advocates
in prosecutors' offices. Because there are no data on how many existing
programs serve gun victims and no service directory of gun victim programs,
the roundtable participants identified a few promising practices and discussed
the types of programs they would like to see funded under VOCA to benefit
gun victims. Clearly, many innovative programs are not known outside their
limited geographical area.

RECOMMENDATION: Participants recommended that a database of
providers serving gun victims be established and that OVC increase efforts to
publicize promising programs and encourage states to fund them.

RECOMMENDATION: If gun violence victims have been underserved, states
should be encouraged to fund programs that serve gun victims as part of their
required 10-percent minimum allocation of VOCA subgrants for underserved
victim populations.

1. Holistic Care for Families of Homicide Victims

Participants who counsel surviving family members spoke of the need to assist
with day-to-day problems to reduce the immediate, ongoing, and long-term
effects of traumatic loss. Programs that operate at the community level and
provide a range of free services and referrals are preferred. They might be
administered by the law enforcement or prosecutor's office, a hospital, a
church, or an independent private agency. Three multiservice programs were
discussed in detail at the roundtable.

The Recover program in Washington, D.C., has a professional grief counselor
in the Office of the Chief Medical Examiner to offer emotional support before,
during, and after the process of identification of a loved one. Recover staff do
an early assessment of needs, including inquiring about children who may be
affected, and set up case management services. Staff or trained volunteers are
available for practical and emotional support, including planning a funeral,
explaining the grieving process, talking to children about death, driving the
family to the store, helping with paperwork, or simply listening. Recover also
makes referrals to mental health counseling and other services but recognizes
that these may be premature and/or insufficient for victims having trouble getting
out of the house, getting food on the table, and dealing with funeral homes and
police investigators.

The Family Bereavement Center in Baltimore, Maryland, is funded by a VOCA
subgrant and administered by the state's attorney's office. The center reaches
out to every homicide victim's family by sending a letter encouraging them to
call for services. Center staff provide liaison services with the police
department, the medical examiner, and the state's attorney's office. They offer
crime scene cleanup services, court support and escort services, notification of
case status and victims' rights, assistance in applying for victim compensation,
and individual and group grief counseling sessions. They also sponsor
educational and support activities such as memorial services, weekend camps
for adolescents and younger children who have lost family and friends to
violence, and a quarterly newsletter.

The Family Advocacy Program at the Washington Hospital Center in
Washington, D.C., also provides coordinated services for family members of
gun homicide victims. Program staff are available to assist families of all
emergency patients at the hospital. If the patient dies, the program advocates
help the decedent's family navigate the next steps--decisions about organ
transplant, hospital procedures, meeting with police officers, answering media
inquiries, and referrals to counseling or pastoral services. This program is
staffed primarily with retired D.C. homicide detectives.

RECOMMENDATION: OVC should support the development of promising
multiservice programs that reach families of gun victims within 24 hours after the
shooting and remain available to assist with longer term needs. State VOCA
administrators should be encouraged to fund programs like Recover, the Family
Bereavement Center, and the Family Advocacy Program. Evaluation studies for
these and similar programs should be encouraged and funded by OJP.

2. Support Groups for Nonfatal Gunshot Victims

Victims who had been shot and survived their wounds spoke of the need to tell
their stories many times. They stressed the importance of peer support groups.
But unlike for rape victims, victims of domestic abuse, victims with severe
SCIs, and parents/friends of murdered children, there are few, if any,
specialized services or organized support groups for "plain, old-fashioned
assault." These victims, who are shot, one by one, day in and day out, have
bullets removed in emergency rooms and then are released to carry on with
their lives.

Participants recommended developing gun violence assistance centers modeled
on the Thurston High Assistance Center in Springfield. This center was
established in the aftermath of the Thurston High shootings and functions as a
clearinghouse for services, activities, and resources related to healing individuals
and the community. The proposed centers could be located within a YMCA or
recreation center already functioning in the community and should be available
to secondary victims like friends, neighbors, and family. They would be
safe-haven drop-in sites where victims could meet with each other and with a
multidisciplinary support team. Ideally, the centers would coordinate all services
for gun victims in the community, such as medical and mental health evaluations,
counseling services, family assistance, help with schoolwork or job applications,
referrals to other programs, applications for victim compensation, emergency
housing, and victim/witness protection. The centers also could be integrated
with prevention efforts, such as community policing and afterschool programs. 

Participants who worked with young gun violence victims felt that the support
of other victims would help reduce the stigma associated with talking to the
police and testifying against an accused shooter. The centers could encourage
cooperation with the criminal justice system and nonviolent ways of solving
disputes.

RECOMMENDATION: OVC should fund the development of model gun
violence assistance centers that could be replicated in communities across the
country.

3. Multidisciplinary Hospital-Based Programs for Adolescent Gun Victims

Although virtually all U.S. trauma centers have some sort of counseling and
referral services for victims of violence and violence prevention clubs exist in a
majority of SCI units, there are fewer than a dozen hospital centers nationwide
that offer comprehensive counseling, intervention, and inpatient treatment
programs to victims of gun violence. Participants agreed that this should be a
high priority for DOJ funding. Urban trauma centers have reported the recurrent
nature of assaultive trauma, with hospital readmission rates as high as 44
percent in some areas and subsequent homicide rates as high as 20 percent.
Medical personnel working with social workers and counselors could turn the
crisis of injury into an opportunity to intervene and interrupt this pattern of
violence. According to participant Dr. Caesar Ursic, Director of Trauma
Services for the Alameda County Medical Center in Oakland, California, there
are anecdotal evidence and some data suggesting that such programs diminish
the psychological impact of the injury, prevent retaliatory violence, minimize
violent injury recidivism, decrease future involvement with guns, and increase
the likelihood of success in school.

The Caught in the Crossfire (CC) program in Oakland has been hailed as a
model program. It maintains a hotline for the Alameda County Medical Center
to call when a youth between the ages of 12 and 19 is admitted to the
emergency room with a gunshot wound. CC crisis intervention specialists visit
the patient at bedside and 

o Review the violent incident.

o Explore alternative strategies for conflict resolution.

o Provide information on risk factors for violence.

o Explore coping skills and safety plans.

o Arrange for followup contacts.

The recovery period in a hospital and rehabilitation center offers victims an
opportunity to be exposed to supportive services. After victims have been
discharged, followup visits are scheduled for a minimum of 12 months. The CC
program uses trained peer counselors, many in wheelchairs because they too
were victims of gun violence.

RECOMMENDATION: OVC should continue to recommend that VOCA
subgrants be awarded to hospital-based gun victim programs.[49] The
elements critical to a model program should be identified for replication. Where
funding is not available for comprehensive programs, emergency rooms should
implement protocols to assess the risk of recurrent injury and provide
counseling services for young gunshot victims and their families.

----------------------------

Recover, a program of the William Wendt Center for Loss and Healing
4880-A MacArthur Boulevard NW., Washington, DC 20007-1557
202-333-4880, www.lossandhealing.org

Family Bereavement Center, a program of the State's Attorney's Office for
Baltimore City
10 South Street, Suite 502, Baltimore, MD 21202
410-396-7351

Family Advocacy Program
Office of Decedent Affairs, Washington Hospital Center
110 Irving Street NW., Washington, DC 20010
202-877-8351

----------------------------

4. School-Based Peer Counseling for Violence Prevention

The power of peer counseling, evident in the hospital-based programs, also is
an important component of school-based violence prevention programs. The
Rise Above It program was launched in 1995 in direct response to an
increasing number of severe SCIs and gunshot wounds in young people in the
Newark, New Jersey, area. Program presenters, like Hashim Garrett, the
Violence Prevention Coordinator for Rise Above It, are individuals who were
paralyzed as a result of violent acts. They are teamed with able-bodied peer
educators to let the students see the long-lasting effects of gunshot wounds and
to teach them skills to deal with anger and prevent fights. The classes are part
of the public school health sciences curriculum and have reached more than
10,000 students. The program has been posttested--meaning that the program
surveyed students before and after they participated in the program, asking
questions about their behavior and their beliefs about the consequences of
fighting--and shows positive results as both students and teachers report a
decrease in arguments and violent incidents.

School-based peer counseling programs like Rise Above It are designed as
violence prevention initiatives. But roundtable participants found it difficult to
draw a line between the victim services provided and the prevention aspects of
the programs. The victim presenters are empowered by their ability to speak in
front of an audience and become whole again by sharing their stories and acting
as change agents for a violent school-age community. And many in the
classroom are also victims, suffering physical or emotional harm from the
violence they experience daily. These types of programs could be part of more
comprehensive victim service initiatives, including crisis intervention,
age-specific courses on victim trauma, and stress reaction training.[50] As Dr.
Enid Margolies with the New York City public school system observed,
violence prevention and victim response issues must be folded into a school's
core curriculum, as funding for separate programs is difficult.

RECOMMENDATION: OVC should recommend that VOCA subgrants be
awarded to qualifying school-based victim services programs. School boards
should be encouraged to include victim services and violence prevention as part
of a school's core curriculum.

----------------------------

Caught in the Crossfire
Youth Alive
3300 Elm Street
Oakland, CA 94609
510-594-2588

Rise Above It 
Kessler Anti-Violence Program
Kessler Institute for Rehabilitation
1199 Pleasant Valley Way
West Orange, NJ 07052
973-731-3600, ext. 2253

----------------------------

Next Steps

This roundtable was the first time that OVC focused exclusively on the needs of
victims of gun violence. Participants found the process extremely useful and
were satisfied that many key victim issues stemming from firearm violence were
identified. As indicated in this bulletin, gun violence victims have some unique
concerns and needs that differ from those of other crime victims. By sponsoring
this roundtable, OVC has opened the door for a full and frank discussion of
these issues. Participants expressed the hope that there would be other
opportunities to continue this discourse. For example,

o Once a national-scope search of providers and programs serving the needs of
gun trauma victims is concluded, OVC should reconvene this or a similar group
to identify unmet needs and make additional recommendations for funding new
programs.

o Smaller focus groups of gun victims should be held regionally to identify their
needs and learn about the services they used to meet those needs.

o Focus groups should be held on particular topics that were not fully covered
in the roundtable. For example, we know that guns and domestic violence
terrorize, injure, and kill women every day. On average, in 1997, more than
one woman a day (393 women total) was shot and killed by her husband or
intimate acquaintance during an argument.[51] The use of guns in domestic
violence situations and its impact on victims should be explored further by both
OVC and VAWO. Some key issues were raised during OVC's September
2000 Intimate Partner Homicide Forum. These issues and recommendations on
how to identify trends and factors associated with intimate partner homicide will
be addressed in a future OVC bulletin.

o OVC should develop training materials and sponsor training and technical 
assistance programs for state VOCA administrators and compensation
programs to help them identify the diverse needs of victims of gun violence and
how to respond to them.

Notes

1. Hoyert, D.L., K.D. Kochanek, and S.L. Murphy, "Deaths: Final Data for
1997," National Vital Statistics Reports, 1999; 47 (19).

2. The terms "gun homicide" and "firearm homicide" have the same definition
and are used interchangeably throughout the bulletin.

3. Available online at the National Center for Injury Prevention and Control's
database at www.cdc.gov/ncipc/wisqars.

4. Kellermann, A.L., and J.A. Mercy, "Men, Women, and Murder: Gender-
Specific Differences in Rates of Fatal Violence and Victimization," The Journal
of Trauma, 1992; 33:1-5.

5. Hoyert, D.L., K.D. Kochanek, and S.L. Murphy, "Deaths: Final Data for
1997," National Vital Statistics Reports, 1999; 47 (19).

6. Available online at www.ojp.usdoj.gov/bjs/glance/guncrime.htm.

7. Available online at www.cdc.gov/ncipc/wisqars.

8. "Nonfatal and Fatal Firearm-Related Injuries--United States, 1993-1997,"
Centers for Disease Control and Prevention, Morbidity and Mortality Weekly
Report, 1999; 48:1029-1034.

9. Annest, J.L., J.A. Mercy, D.R. Gibson, and G.W. Ryan, "National Estimates
of Nonfatal Firearm-Related Injuries: Beyond the Tip of the Iceberg," The
Journal of the American Medical Association, 1995; 273:1749-1754.

10. Available online at www.ojp.usdoj.gov/bjs/guns.htm.

11. In the Crossfire: The Impact of Gun Violence on Public Housing
Communities, U.S. Department of Housing and Urban Development, February
2000.

12. Bell, C.C., and E.J. Jenkins, "Exposure and Response to Community
Violence Among Children and Adolescents," in Children in a Violent Society,
Osofsky, ed., The Guilford Press, 1997.

13. Campbell, C., and Donald F. Schwarz, "Prevalence and Impact of
Exposure to Interpersonal Violence Among Suburban and Urban Middle
School Students," Pediatrics, 1996; 98:396-402.

14. Available online at www.ojp.usdoj.gov/bjs/guns.htm.

15. Available online at www.ojp.usdoj.gov/bjs/homicide/multiple.htm.

16. See, e.g, Reiss, A.J., and J.A. Roth, Understanding and Preventing
Violence, National Academy Press, 1993, pp. 260-261; Zimring, F.E., and G.
Hawkins, Crime Is Not the Problem: Lethal Violence in America, Oxford
University Press, 1997, pp. 106-123.

17. Saltzman, L.E., J.A. Mercy, P.W. O'Carroll, M.L. Rosenberg, and P.H.
Rhodes, "Weapon Involvement and Injury Outcomes in Family and Intimate
Assaults," The Journal of the American Medical Association, 1992;
267:3043-3047. (When a gun is involved in a domestic dispute, it is at least 12
times more likely that the dispute will end in death.)

18. Zawitz, Marianne, Firearm Injury From Crime, U.S. Department of Justice,
Bureau of Justice Statistics, 1996.

19. "Firearm-Associated Homicides Among Family Members, Relatives, or
Friends--Ohio," Epidemiologic Notes and Reports, Morbidity and Mortality
Weekly Report, 1989; 38 (15):253-256.

20. Larson, Eric, Lethal Passage, Vintage Books, 1995, p. 86. (Describing
student holding up French textbook to ward off bullets from a Cobray M 11/9
semiautomatic pistol shot by a fellow student.)

21. Slevin, Peter, "District Teen Gets 127 Years in Random Shooting of Four,"
The Washington Post, Jan. 6, 2000, p. B2.

22. A list of multiple-victim shootings in the United States is available online at
www.millionmommarch.com (formerly www.bellcampaign.org).

23. Temple, Scott, "Treating Inner-City Families of Homicide Victims: A
Contextually Oriented Approach," Family Process, 1997; 36 (2):133-149.

24. Schwab-Stone, Mary E., Tim S. Ayers, Wesley Kasprow, Charlene
Voyce, Charles Barone, Timothy Shriver, and Roger P. Weissberg, "No Safe
Haven: A Study of Violence Exposure in an Urban Community," Journal of the
American Academy of Child and Adolescent Psychiatry, 1995; 34
(10):1343-1352.

25. Duncan, David, "Growing Up Under the Gun: Children and Adolescents
Coping With Violent Neighborhoods," Journal of Primary Prevention, 1996;
16:343-356.

26. Bastian, Lisa, and B. Taylor, Young Black Male Victims, U.S. Department
of Justice, Bureau of Justice Statistics, 1994.

27. "Adolescent Assault Victim Needs: A Review of Issues and a Model
Protocol," Pediatrics, 1996; 98:991-999.

28. Slevin, Peter, "District Teen Gets 127 Years in Random Shooting of Four,"
The Washington Post, Jan. 6, 2000, p. B2.

29. Jackman, Tom, "Group Urges More Help for Victims of Crimes," The
Washington Post, Dec. 15, 2000, p. B5.

30. Christoffel, K.K., "Youth Violence Prevention: The Physician's Role," 
medical student Journal of the American Medical Association (msJAMA).

31. Nader, Kathi, Robert Pynoos, Lynn Fairbanks, and Calvin Frederick,
"Children's PTSD Reactions One Year After a Sniper Attack at Their School,"
The American Journal of Psychiatry, 1990; 147:1526-1530.

32. Bell, C.C., and E.J. Jenkins, "Exposure and Response to Community
Violence Among Children and Adolescents," in Children in a Violent Society,
Osofsky, ed., The Guilford Press, 1997.

33. Richters, John E., and Pedro Martinez, "The NIMH Community Violence
Project: I. Children as Victims of and Witnesses to Violence," Psychiatry,
1993; 56:7-21.

34. Rand, M.R., Violence Related Injuries Treated in Hospital Emergency
Departments, U.S. Department of Justice, Bureau of Justice Statistics, 1997.

35. Cook, P.J., B.A. Lawrence, J. Ludwig, and T.R. Miller, "The Medical
Costs of Gunshot Injuries in the United States," The Journal of the American
Medical Association, 1999; 282:447-454.

36. Kizer, K.W., M.J. Vassar, R.L. Harry, and K.D. Layton, "Hospitalization
Charges, Costs, and Income for Firearm Related Injuries at a University
Trauma Center," The Journal of the American Medical Association, 1995;
273:1768-1773.

37. Cook, P.J., B.A. Lawrence, J. Ludwig, and T.R. Miller, "The Medical
Costs of Gunshot Injuries in the United States," The Journal of the American
Medical Association, 1999; 282:447-454.

38. Ordog, G.J., J. Wasserberger, and G. Ackroyd, "Hospital Costs of
Firearm Injuries," The Journal of Trauma, 1995; 38:291-298.

39. Ibid.

40. Klein, S.R., I.J. Kanno, D.A. Gilmore, and S.E. Wilson, "The
Socioeconomic Impact of Assault Injuries on an Urban Trauma Center," The
American Surgeon, 1991; 57:793-797. 

41. Goldman, H., "Gun Violence in the U.S. Costs More Than $100 Billion a
Year," Bloomberg News, available online through Deseret News Archives at 
deseretnews.com.

42. Available online at
www.spinalcord.org/resource/Factsheets/factsheet2.html. 

43. DeVito, M.J., "Causes and Costs of Spinal Cord Injury in the United
States," Spinal Cord, 1997; 35:809-813.

44. Holicky, R., "Violently Acquired SCI: A Recipe for Inequity." Available
online at www.spinlife.com (reprinted from New Mobility, March 2000).

45. The National Education Association has issued Advice for Journalists
covering school shootings. See www.nea.org/issues/safescho.

46. Brooks, K., V. Schiraldi, and J. Zeidenberg, School House Hype: Two
Years Later, Justice Policy Institute/Children's Law Center, 2000. Available
online at www.cjcj.org/schoolhousehype/shh2.html.

47. Spungen, Deborah, Homicide: The Hidden Victims, A Guide for
Professionals, Sage Publications, 1998, pp. 110-111.

48. While a recent survey conducted for OVC indicates that 23 percent of the
programs enter information into their databases about whether the crime was
gun related, OVC does not require states to report the number of claimants
who were victims of gun violence, although states do report categories of
"assault" (34 percent of claims) and "survivors of homicide" (11 percent of
claims).

49. In October 1996, OVC recommended that hospital-based counseling and 
prevention programs be established in medical facilities that provide services to
adolescent gunshot victims and victims of gang violence. In May 1998, OVC
made the same recommendation in New Directions From the Field: Victims'
Rights and Services for the 21st Century.

50. Gregorie, Trudy, School Violence--Are You Prepared To Respond?
National Center for Victims of Crime, 1999. Available online at
www.ncvc.org/newsltr/schvio.htm.

51. Brock, K., When Men Murder Women: An Analysis of 1997 Homicide
Data: Females Murdered by Males in Single Victim/Single Offender Incidents,
Violence Policy Center, 1999.

----------------------------

Judith Bonderman, J.D., M.P.H., teaches a course on gun violence prevention
at the George Washington University School of Public Health and Health
Services. She thanks the roundtable participants for sharing their experiences
and for their candid and full discussion of the issues.

----------------------------

This document was prepared under the direction of the Office for Victims of
Crime, Office of Justice Programs, U.S. Department of Justice. The opinions,
findings, conclusions, and recommendations expressed in this document are
those of the author and do not necessarily represent the official position or
policies of the U.S. Department of Justice.

The Office for Victims of Crime is a component of the Office of Justice
Programs, which also includes the Bureau of Justice Assistance, the Bureau of
Justice Statistics, the National Institute of Justice, and the Office of Juvenile
Justice and Delinquency Prevention.

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NCJ 186155