Culture in nursing, nursing leadership, writing and rhetorical,

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Parts 6 and 7  have the same questions. However, you must answer with references and different writing, always addressing them objectively, as if you were different students. Similar responses in wording or references will not be accepted. 

Parts 8 and 9  have the same questions. However, you must answer with references and different writing, always addressing them objectively, as if you were different students. Similar responses in wording or references will not be accepted. 

Parts 10 and 11  have the same questions. However, you must answer with references and different writing, always addressing them objectively, as if you were different students. Similar responses in wording or references will not be accepted. 

1) Minimum 21 pages  (No word count per page)-   Follow the 3 x 3 rule: minimum of three paragraphs per page ( minimum 300 words per page)

You must strictly comply with the number of paragraphs requested per page.  

The number of words in each paragraph should be similar

24 hours: 7 pages

48 hours: 8 pages

72 hours: 6 pages

Part 1: minimum 3 pages (48 hours)

Part 2: minimum 1 page (24 hours)

Part 3: minimum 3 pages (48 hours) 

Part 4: minimum 3 pages (72 hours) 

Part 5: minimum 3 pages (72 hours) 

Part 6: minimum 1 page (24 hours)

Part 7: minimum 1 page (24 hours)

Part 8: minimum 1 page (24 hours)

Part 9: minimum 1 page (24 hours)

Part 10: minimum 1 page (48 hours)

Part 11: minimum 1 page (48 hours)

Part 12: minimum 2 pages (24 hours)

Submit 1 document per part

2)¨******APA norms

        The number of words in each paragraph should be similar

        Must be written in the third person

         All paragraphs must be narrative and cited in the text- each paragraph

         The writing must be coherent, using connectors or conjunctive to extend, add information, or contrast information. 

         Bulleted responses are not accepted

         Don’t write in the first person 

  Do not use subtitles or titles      

         Don’t copy and paste the questions.

         Answer the question objectively, do not make introductions to your answers, answer it when you start the paragraph

Submit 1 document per part

3)****************************** It will be verified by Turnitin (Identify the percentage of exact match of writing with any other resource on the internet and academic sources, including universities and data banks) 

********************************It will be verified by SafeAssign (Identify the percentage of similarity of writing with any other resource on the internet and academic sources, including universities and data banks)

4) Minimum 3 references (APA format) per part not older than 5 years  (Journals, books) (No websites)

Part 1:  Minimum 5 references (APA format) per part not older than 5 years  (Journals, books) (No websites) 

All references must be consistent with the topic-purpose-focus of the parts. Different references are not allowed 

5) Identify your answer with the numbers, according to the question. Start your answer on the same line, not the next

 Example:

Q 1. Nursing is XXXXX

Q 2. Health is XXXX

Q3. Research is…………………………………………………. (a) The relationship between……… (b) EBI has to

6) You must name the files according to the part you are answering: 

Example:

Part 1.doc 

Part 2.doc

__________________________________________________________________________________

Part 1: Culture in Nursing

Culture: Mexican

Health belief system: Santa Muerte- death ‘saint.’

 

1. Introduction and (One paragraph)

a. How the Health belief system impacts the culture

b. Explain the creation between Santa Muerte- death ‘saint’ and heath in this culture 

2. Explain the origins of the health beliefs in this culture (One paragraph)

3. How the  Health belief system  benefits the culture(One paragraph)

4. How the  Health belief system  affects  the culture(One paragraph)

5. Explain the potentially harmful in this Health belief system for the population (Culture)(One paragraph)

6. Explain the essential principles that nurses must understand to integrate this  Health belief system into their practices (One paragraph)

7. How can nurses integrate this Health belief system into their practices(One paragraph)

8. If the nurses integrate this  Health belief system,(One paragraph)

a. How will this culture benefit?

9. Conclusion(One paragraph)

Part 2: Nursing Leadership

 

1. Describe who should be involved in the organizational strategic plan. (One paragraph) 

2. Give an example of a strategic plan for increasing staffing on a med/surg unit that is only staffed at 50 percent.  (One paragraph) 

3. Describe the patient care model utilized and  (One paragraph) 

a. Why.

Part 3: Nursing Leadership

Topic: Conflict

1. Introduction and (One paragraph)

a. How does the conflict impacts the nurse’s activities

b. How does the conflict affect the leadership

2. Explain the conflict types (Two paragraphs: One paragraph for a and b; One paragraph for c and d)

a. Assertive

b. Aggressive

c. Passive

d. Passive aggressive

3. Describe whether or not conflict is constructive or destructive (One paragraph).

a. Give one example of  conflict constructive and destructive (One paragraph)

4. Explain the leadership role in facing the conflict in nursing (Two paragraphs)

5. How can good leadership affect the outcome of a conflict? (Two paragraphs)

6. What is the difference between problem resolution and negotiation (Two paragraphs)

7. Give one example in nursing under what circumstances you would use (Two paragraphs)

a. Problem resolution (One paragraph)

b. Negotiation (One paragraph)

8. How can nurses be trained to face any conflict type as leaders (One paragraph)

9. Conclusion  (One paragraph)

 

Part 4: Writing and rhetorical

Topic:  Is it possible that implementing a mental health program for students ages 11-17 in Florida high schools could reduce the incidence of shootings in schools? 

New Sources and My Rhetorical Purpose 

Research is a recursive process, meaning that we have to keep returning to it with fresh eyes. Each time we go back, we have new things we are looking for and new understanding of the ideas we’re reading about. At work and at school, as we get further along in a project, we will need more and different research to complete the different phases of the project and we may have revisit sources we already looked at. 

Check file 1, 2 and 3 (pending)

Task:

For this assignment, I want you to find 3 new sources to use in your Unit 3 project. 

1. Socurse 1 (Check file 1) (Three paragraphs)

a. Write a brief explanation (One paragraph)

b.  Why you are adding that source to your list (One paragraph)

i. What new information will be added to the project 

c. What section or portion of your document will it help you write? (One paragraph)

i. What specific part of source, or what specific information within the source, will you use? 

2. Socurse 2 (Check file 2) (Three paragraphs)

a. Write a brief explanation (One paragraph)

b.  Why you are adding that source to your list (One paragraph)

i. What new information will be added to the project 

c. What section or portion of your document will it help you write? (One paragraph)

i. What specific part of source, or what specific information within the source, will you use? 

3. Socurse 3 (Check file 3) (Three paragraphs)

a. Write a brief explanation (One paragraph)

b.  Why you are adding that source to your list (One paragraph)

i. What new information will be added to the project 

c. What section or portion of your document will it help you write? (One paragraph)

i. What specific part of source, or what specific information within the source, will you use? 

 Part 5: Writing and rhetorical

Topic:   Could legally recognizing female sex work in Florida increase the health indicator of this population due to free access to the health system?

New Sources and My Rhetorical Purpose 

Research is a recursive process, meaning that we have to keep returning to it with fresh eyes. Each time we go back, we have new things we are looking for and new understanding of the ideas we’re reading about. At work and at school, as we get further along in a project, we will need more and different research to complete the different phases of the project and we may have revisit sources we already looked at. 

Check file 1, 2 and 3 (pending)

Task:

For this assignment, I want you to find 3 new sources to use in your Unit 3 project. 

1. Socurse 1 (Check file 1) (Three paragraphs)

a. Write a brief explanation (One paragraph)

b.  Why you are adding that source to your list (One paragraph)

i. What new information add to the project 

c. What section or portion of your document will it help you write? (One paragraph)

i. What specific part of source, or what specific information within the source, will you use? 

2. Socurse 2 (Check file 2) (Three paragraphs)

a. Write a brief explanation (One paragraph)

b.  Why you are adding that source to your list (One paragraph)

i. What new information add to the project 

c. What section or portion of your document will it help you write? (One paragraph)

i. What specific part of source, or what specific information within the source, will you use? 

3. Socurse 3 (Check file 3) (Three paragraphs)

a. Write a brief explanation (One paragraph)

b.  Why you are adding that source to your list (One paragraph)

i. What new information add to the project 

c. What section or portion of your document will it help you write? (One paragraph)

i. What specific part of source, or what specific information within the source, will you use? 

  

Parts 6 and 7  have the same questions. However, you must answer with references and different writing, always addressing them objectively, as if you were different students. Similar responses in wording or references will not be accepted. 

Part 6: Introduction to recreational therapy

  

CASE STUDY #1: 

Mario is a young adult with Autism Spectrum Disorder who attends an Adult Day Training Program. He wears the same t-shirt every day and only eats pizza for lunch. During recreation activities, he focuses on the tasks without engaging with peers. He withdraws from activities that require him to talk or cooperate with others.

  

CASE STUDY #2

Robert is a home health care client who had a stroke and is experiencing emotional lability (rapid and exaggerated changes in mood). Also, he was recently provided with walker for safe ambulation. Every day for the last 5 days, Robert has forgotten that he has a walker and is often found walking around the house without it, increasing his fall risk and risk for injury.

1. For each case determine two goals (one paragraph)

a. Case 1

i. Goal 1: social domain

ii. Goal 2: leisure-based

b. Case 2:

i. Goal 1: physical domain

ii. Goal 2: emotional-based

2. For each case determine two objectives including (Condition; Behavior and Criteria) -one objective for each goal  (one paragraph)

a. Case 1

i. Objective 1

– Condition 

– Behavior

– Criteria

ii. Objective 2

– Condition 

– Behavior

– Criteria

b. Case 2:

i. Objective 1

– Condition 

– Behavior

– Criteria

ii. Objective 2

– Condition 

– Behavior

– Criteria

2. Explain why you chose these goal areas to focus   (one paragraph)

a. Case 1

i. Goal 1

i. Goal 2

b Case 2

i. Goal 1

i. Goal 2

Part 7: Introduction to recreational therapy

  

CASE STUDY #1: 

Mario is a young adult with Autism Spectrum Disorder who attends an Adult Day Training Program. He wears the same t-shirt every day and only eats pizza for lunch. During recreation activities, he focuses on the tasks without engaging with peers. He withdraws from activities that require him to talk or cooperate with others.

  

CASE STUDY #2

Robert is a home health care client who had a stroke and is experiencing emotional lability (rapid and exaggerated changes in mood). Also, he was recently provided with walker for safe ambulation. Every day for the last 5 days, Robert has forgotten that he has a walker and is often found walking around the house without it, increasing his fall risk and risk for injury.

1. For each case determine two goals (one paragraph)

a. Case 1

i. Goal 1: social domain

ii. Goal 2: leisure-based

b. Case 2:

i. Goal 1: physical domain

ii. Goal 2: emotional-based

2. For each case determine two objectives including (Condition; Behavior and Criteria) -one objective for each goal  (one paragraph)

a. Case 1

i. Objective 1

– Condition 

– Behavior

– Criteria

ii. Objective 2

– Condition 

– Behavior

– Criteria

b. Case 2:

i. Objective 1

– Condition 

– Behavior

– Criteria

ii. Objective 2

– Condition 

– Behavior

– Criteria

2. Explain why you chose these goal areas to focus   (one paragraph)

a. Case 1

i. Goal 1

i. Goal 2

b Case 2

i. Goal 1

i. Goal 2

Parts 8 and 9  have the same questions. However, you must answer with references and different writing, always addressing them objectively, as if you were different students. Similar responses in wording or references will not be accepted. 

Part 8: Inclusive recreation services

Topic:  Adaptations, Accommodations, and Advocacy

This list prioritizes these 10 actions from most to least important. 

Survey architectural barriers and share results

Conduct an evaluation of people who are oppressed and share results.

Discuss the problems that attitudinal barriers create.

Write to media outlets complimenting them on positive portrayals of diverse individuals.

Write letters to newspapers urging changes to attitudinal barriers.

Meet with a legislator and learn about civil rights policies and laws.

Form an advocacy committee to work on removing barriers.

Educate people about recreation services available to all people.

Organize a Diversity Awareness Day.

Teach awareness activities to community groups.

1. What is an advocate and why is advocacy necessary? (One paragraph)

2. Explain how do we advocate for those who have been oppressed? (One paragraph)

3. Look back at the 10 advocacy actions you prioritized (One paragraph)

a. Which one could you start immediately? 

b. And how could you accomplish that goal/what is your plan?

Part 9: Inclusive recreation services

Topic:  Adaptations, Accommodations, and Advocacy

This list prioritizes these 10 actions from most to least important. 

Select a recreation activity, choose a group of people that has been oppressed in some manner, and identify helpful accommodations.

Conduct an evaluation of people who are oppressed and share results.

Develop services to assist families who are oppressed.

Keep media informed of successes of members of an oppressed group.

Survey architectural barriers and share results.

Discuss ways to involve people in activities and remove barriers.

Sponsor an idea exchange on ways to promote inclusion.

Plan exhibits to create awareness about oppressed groups.

Write letters to newspapers urging changes to attitudinal barriers.

Meet with a legislator and learn about civil rights policies and laws.

1. What is an advocate and why is advocacy necessary? (One paragraph)

2. Explain how do we advocate for those who have been oppressed? (One paragraph)

3. Look back at the 10 advocacy actions you prioritized (One paragraph)

a. Which one could you start immediately? 

b. And how could you accomplish that goal/what is your plan?

Parts 10 and 11  have the same questions. However, you must answer with references and different writing, always addressing them objectively, as if you were different students. Similar responses in wording or references will not be accepted. 

Part 10: Inclusive recreation services

Topic: Make Adaptations 

It is important to focus on making reasonable adaptations to materials, activities, the environment, instructional strategies, and participant access/involvement to promote inclusion.  A skilled leisure professional should be able to anticipate needs for adaptations before delivering activities/programs, make adaptations and modifications during the activity, and evaluate activities after delivery to address barriers and address the varying needs and abilities of participants receiving services. 

 Here are some examples of items available:    

https://craighospital.org/programs/therapeutic-recreation/adaptive-sports-equipment-resources (Links to an external site.)

https://www.gophersport.com/pe/adapted (Links to an external site.)

https://www.flaghouse.com/Sports/Adapted-Sports/ (Links to an external site.)

https://www.disabledsportsusa.org/sports/adaptive-equipment/ (Links to an external site.)

Adapting the means in which a leisure professional instructs participants with disabilities is also important.  Dattilo provides some considerations for instructional strategies.  For those of you going into recreational therapy, you will learn more about task analysis, breaking down an activity/task into its core components to be taught separately.  I have had to use activity task analysis in every setting I have worked in, prior to every activity I implement.  If you don’t know the components to an activity

1. How can you properly teach it to someone else, and more importantly (One paragraph)

a. How can you adapt that activity so participants with disabilities can be successful?  

2. Explain your current experience with adapting an activity to participants with disabilities (One paragraph)

3. When you adapt an activity (One paragraph)

a. How do they react to the participants with disabilities

b. There is an emotional and physical benefit for participants with disabilities

Part 11: Inclusive recreation services

Topic: Make Adaptations 

It is important to focus on making reasonable adaptations to materials, activities, the environment, instructional strategies, and participant access/involvement to promote inclusion.  A skilled leisure professional should be able to anticipate needs for adaptations before delivering activities/programs, make adaptations and modifications during the activity, and evaluate activities after delivery to address barriers and address the varying needs and abilities of participants receiving services. 

 Here are some examples of items available:    

https://craighospital.org/programs/therapeutic-recreation/adaptive-sports-equipment-resources (Links to an external site.)

https://www.gophersport.com/pe/adapted (Links to an external site.)

https://www.flaghouse.com/Sports/Adapted-Sports/ (Links to an external site.)

https://www.disabledsportsusa.org/sports/adaptive-equipment/ (Links to an external site.)

Adapting the means in which a leisure professional instructs participants with disabilities is also important.  Dattilo provides some considerations for instructional strategies.  For those of you going into recreational therapy, you will learn more about task analysis, breaking down an activity/task into its core components to be taught separately.  I have had to use activity task analysis in every setting I have worked in, prior to every activity I implement.  If you don’t know the components to an activity

1. How can you properly teach it to someone else, and more importantly (One paragraph)

a. How can you adapt that activity so participants with disabilities can be successful?  

2. Explain your current experience with adapting an activity to participants with disabilities (One paragraph)

3. When you adapt an activity (One paragraph)

a. How do they react to the participants with disabilities

b. There is an emotional and physical benefit for participants with disabilities

Part 12:  Psychopharmacology 

Topic: Dementia Agents

Eleanor is a 77-year-old white female resident of a skilled nursing facility. Recently her daughter requested an evaluation from the staff psychologist because she noticed that her mother’s Alzheimer’s symptoms appeared to be getting worse. Eleanor was admitted to the facility six months ago with moderately severe cognitive and physical decline and had to be placed in a skilled facility since she could no longer manage herself at home. Her daughter is a single mother of four teens and works too many hours to care for her mother in her home. She had attempted to care for her until Eleanor left the stove on, resulting in a minor kitchen fire. Eleanor has no history of mental illness, but she began to show signs of cognitive decline in her late fifties. The symptoms became much more pronounced after her husband’s death five years ago.

Recently her daughter and other members of the nursing staff noticed that Eleanor has become rather restless and combative. When she gets confused over her surroundings, she wanders through the halls attempting to open fire doors. When nurses attempt to redirect her back to her room, she swears at them and even struck one of them in the face. Her PCP authorized the use of restraints one day after she managed to wander out the front door and was found standing in the middle of the street trying to take a dog away from a woman who was walking it. She yelled at the woman, telling her that she needed the dog to protect her from people who were stealing her clothing in the nursing home.

1. Create a list (In a paragraph) of the patient’s problems and prioritize them. (One paragraph)

2. According to DSM-V, explain what diagnosis should be considered (One paragraph)

a. Explain 

3. Explain three differential diagnosis  (One paragraph)

4. Explain three tests or screening tools that should be considered to help identify the correct diagnosis (One paragraph)

a. According to the case, explain the  expected outcomes for each test 

5. Treatment (One paragraph)

a. Pharmacology

i. Drug(s)

ii. Dosage

iii. Time

b. Psychotherapy

i. purpose

ii. Expected outcomes

c. Psychoeducation

i. purpose

ii. Expected outcomes

6. Explain two standard guidelines to assess or treat this patient (One paragraph)

Journal of Science Policy & Governance POLICY MEMO: SCHOOL SHOOTING CRISIS AND SEL

www.sciencepolicyjournal.org JSPG, Vol. 17, Issue 2, October 2020

Beyond Gun Control: Implementing Mental
Health Interventions for the School Shooting
Crisis in California

Agnes M. Varghese1, Danielle E. Delany1, Morgan L. Dundon2
1University of California, Riverside, Developmental Psychology Program, Riverside, CA
2University of California, Riverside, Materials Science and Engineering Program, Riverside, CA
http://doi.org/10.38126/JSPG170212
Corresponding author: [email protected]
Keywords: school shootings; mental health interventions; social-emotional learning; California

Executive Summary: Over the last 10 years, the United States has witnessed a striking
increase in school shootings (Riedman and O’Neil 2020). Most legislation addressing the issue
has been focused on gun control with liberal states such as California passing stringent gun
laws. However, it is important to acknowledge that the school shooting crisis is a multifaceted
problem that will not be resolved by gun regulations alone. California should establish social-
emotional learning programs in K-12 schools to help address the underlying issues that drive
individuals to gun violence. These programs will provide students with the skills necessary to
reduce aggressive behaviors as well as increase overall student well-being and academic
achievement (Espelage et al. 2013). Along with gun control measures, California’s
policymakers should establish social-emotional learning programs in K-12 schools to
reduce the number of school shooting incidents. Effective implementation of such
programs could transform California from the state with the highest rate of school shootings
in the country to an exemplary model for other states to follow in tackling the school shooting
crisis.

I. Statement of issue
More school shootings occur in the United States than
any other country—57 times more than other major
industrialized nations combined (Grabow and Rose
2018). The tragedies at Columbine High School
(1999), Sandy Hook Elementary School (2012), and
Marjory Stoneman Douglas High School (2018),
amongst many other K-12 institutions, strongly
signify the need to take action to resolve this national
emergency.

The Center for Homeland Defense and Security
defines school shootings as situations where “a gun is
brandished, is fired, or hits school property for any
reason, regardless of the number of victims, time, day
of the week, or reason (Riedman and O’Neill 2018).”
Using this definition, in the 50 years between 1970
and 2019, 1,508 shooting incidents have occurred on
K-12 school grounds, with a substantial spike in the
number of cases in the last few years. A record-high

number of 116 shootings occurred in 2018, followed
by a close second of 112 shootings in 2019 (Figure 1;
Riedman and O’Neill 2020).

Figure 1: K-12 school shooting incidents in the U.S. by
year; Figure adapted from Riedman and O’Neil 2020.

California leads the nation in the number of incidents
at 170 school shootings during the last half century,

Journal of Science Policy & Governance POLICY MEMO: SCHOOL SHOOTING CRISIS AND SEL

www.sciencepolicyjournal.org JSPG, Vol. 17, Issue 2, October 2020

with the next two highest states, Texas and Florida, at
138 and 94, respectively. California has had a 166%
rise in school shootings over the last ten years, with 8
occurring in 2019 alone (Riedman and O’Neill 2020).
The Golden State must heed these numbers and lead
the nation in developing effective methods to combat
this crisis. If not, the United States will continue to
witness the killing of innocent children along with the
fear and grief instilled in those communities who
have lost loved ones.

II. Political status
Guns are responsible for 15% of fatalities among
children and adolescents, second only to motor
vehicle crashes (Cunningham et al. 2018). In an
attempt to reduce the number of lives taken from
school shootings and other gun-related incidents,
left-leaning policymakers have proposed several
federal bills restricting the sale and circulation of
guns. They argue that the number of casualties is
devastatingly high because would-be perpetrators
can easily access this weaponry which are highly
effective killing tools. Right-leaning policymakers
have fought against this interpretation, claiming that
these restrictions threaten Americans’ Second
Amendment right to bear arms. This contention
between parties has stunted stringent gun laws from
passing at the federal level.

California has taken a different tactic. In the last year,
state lawmakers have enacted a suite of gun control
measures that:

• Prohibit individuals under 21 from buying
semi-automatic center-fire rifles (SB 61).

• Give teachers the ability to seek gun violence
restraining orders that would allow police to
remove guns from individuals who are
threatening to commit gun violence (AB 61).

• Enact charges/penalties for owners of
unlocked guns that are taken out of the home
by children (SB 172).

These new laws aim to decrease access to guns by
youths and individuals threatening school
communities. However, there is still widespread
illegal access available. Furthermore, as some
legislators have argued, these laws do not address the
underlying reasons individuals choose to commit
school shootings. To address both sides of this issue,
other measures that tackle the root of violent

behaviors need to be implemented in addition to gun
control.

These types of mental health interventions within the
education system can have a large impact in
addressing the school shooting crisis. A majority of
school shooters are current or former students of the
school where they commit shootings (Riedman and
O’Neill 2020). Many of these shooters (75%) report
depression, suicide ideation, and/or plans before the
act (Vossekuil et al. 2002). In 87% of cases, they also
describe low self-worth as a result of bullying
victimization (Lee 2013; Vossekuil et al. 2002).
However, these mental health-related issues are not
exclusive to school shooters. 1 in 5 young people
struggle with severe mental health problems, and
many more have less severe mental health issues
(Merikangas et al. 2010). Additionally, 24% of teens
report threatening or physically harming others as
acceptable behavior when angered (Josephson
Institute of Ethics 2012). Therefore, implementing
effective mental health programs in schools will not
only be a preventative measure against school
shootings, but a productive step towards increasing
the overall emotional stability and well-being of all
students. To kickstart these programs, funding
should come from The Mental Health Student
Services Act of 2019 (SB 75), which funds prevention
and early intervention programs for children and
youth in California schools, as well as the hiring of
additional mental health personnel.

III. Policy options

i. Option 1: Implementing a statewide social-emotional
learning (SEL) program
Social-emotional skills allow individuals to
understand and manage their own emotions, display
empathy for others, and develop positive
interpersonal relationships (Berman et al. 2018).
Various school-based SEL programs incorporate
these skills, including the Second Step Program (Frey
et al. 2000; Wike and Fraser, 2009; Paolini 2015).
This extensively researched, evidence-based
curriculum has been successfully implemented in
over 26,000 schools worldwide and is endorsed by
the Department of Education (Second Step 2020). In
this program, teachers are trained to implement
developmentally-appropriate lessons on topics such
as empathy, communication, emotion regulation,
problem-solving, and bullying (Frey et al. 2000). This

Journal of Science Policy & Governance POLICY MEMO: SCHOOL SHOOTING CRISIS AND SEL

www.sciencepolicyjournal.org JSPG, Vol. 17, Issue 2, October 2020

method of intervention proactively works to prevent
school shootings by teaching children non-violent
conflict resolution. Additionally, children who feel
more connected to others have less desire to harm
each other. The lessons in Second Step are age-
adjusted (Wike and Fraser, 2009) and administered
to students in 50-minute weekly sessions throughout
the school year (Espelage et al. 2013). California
should implement a mandatory SEL program
following the model of Second Step in all K-12 schools
throughout the state.

Advantages
This program would be inclusive to all K-12 students
in the California school system. Prior research has
constructed a typical school shooter profile (e.g.,
white male, interested in violence, history of trauma;
Langman 2009). However, predictive power is
limited. The vast majority of individuals fitting the
profile do not commit shootings, while some
shootings are committed by individuals not fitting the
profile (O’Toole 2009). Therefore, it is ideal to include
all students as an extensive preventative measure.
Also, through this curriculum students will gain skills
in empathy, anger management, problem solving, and
impulse control (Frey et al. 2000). While this program
has not been directly studied in connection to school
shootings, it is tied to reductions in aggressive and
violent behaviors (e.g., 42% decrease in physical
aggression; Espelage et al. 2013), which are evident
in school shooting perpetrators. It also shows a 20%
reduction in bullying, which is a known risk factor for
school shooters (Espelage et al. 2015). Additional
positive outcomes include increased prosocial
behaviors and academic achievement (Low et al.
2015; Wenz et al. 2018). Further, Columbia
University conducted a benefit-cost analysis on SEL
interventions and found that Second Step has an
average return on investment of $11 for every $1
spent (Belfield et al. 2015). Reducing incidents of
aggression helps decrease costs such as medical
expenses. The value of this reduction surpasses the
costs of SEL instruction (Belfield et al. 2015).

Disadvantages
This program would require a 4-hour training session
(Belfield et al. 2015) and additional responsibilities
on the part of the teaching staff. Given the plethora of
duties that teachers already have, this may be difficult
to include into their rotation. However, research
shows that 82% of teachers are interested in

obtaining training in SEL (Bridgeland et al. 2013). An
additional disadvantage is that parents may be
hesitant to have any of their children’s school
instruction time dedicated to the development of
skills that might not seem as directly “academically”
relevant. Yet, researchers have calculated that only
3% of instructional time will be dedicated to SEL
(Belfield et al. 2015).

ii. Option 2: Increasing counselor-to-student ratios
The Pupil Health: Mental Health Professionals bill,
introduced in 2019 (AB-8; currently awaiting hearing
in the Senate), aims to have one counselor available
for every 600 students during school hours.
California currently averages one counselor per 682
students, whereas the national average is one
counselor per 441 students (Mann et al., 2019). If this
bill passes, the state would still be behind the rest of
the nation in providing access to mental health
professionals. Moreover, according to the American
School Counselor Association (ASCA), there should be
one counselor for every 250 students to ensure
sufficient access to mental health resources (ASCA
2017). This bill should be amended to meet the
standards of the ASCA’s 1:250 counselor-to-student
ratio. Additionally, the amendment should instruct
counselors to assess and promote positive school
climate, foster social, behavioral, emotional, and
academic success for students, and be trained in
interventions to resolve conflicts and assist troubled
students (ASCA 2019).

Advantages
Increased counselor-to-student ratios provide
students with better access to mental health
professionals in the school atmosphere. This is linked
to stronger relationships between counselors and
students, and increased counselor effectiveness
(Reback 2010; Boser, Poppen and Thompson, 1988).
Counselors are often the first to be aware of students
who are experiencing problems or are at risk for
violence (Froeschle and Moyer, 2004; Mann et al.,
2019). While there is not research exploring the
effects of ratios on school shootings specifically,
research shows that reduced counselor-to-student
ratios are linked to decreased recurrences of student
disciplinary problems, and increased graduation and
school attendance rates (Carrell and Carrell, 2006;
Lapan et al. 2012).

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Disadvantages
Hiring more counselors may not be effective on its
own. Students who are experiencing mental health
difficulties may not seek out this resource or may be
deterred from doing so. In 2010, only 12.3% of youths
sought mental health treatment in schools (SAMHSA
et al. 2010), although the rate of mental illness is as
high as 46% (Merikangas et al. 2010). Additionally,
parents’ perceptions of mental health treatment and
counseling can impact whether a child gets service at
all or ends treatment prematurely. Moreover, these
negative perceptions correlate with cancelling or
missing sessions (Langer et al. 2015; Kern et al.
2017).

iii. Option 3: Inaction
Inaction would indicate a primary reliance on current
state gun legislation in California. While gun laws may
decrease legal access to guns and create legal
consequences for adults who allow children to obtain
guns, it is unclear if they will reduce school shooting
rates.

Advantages
Inaction would place no additional responsibility on
K-12 schools because they would not need to provide
SEL training to teachers or hire additional
counselors.

Disadvantages
If schools do not implement mental health
interventions that address the psychological roots of
violent behavior, it is likely that the increasing trend
of school shooting incidents will continue to climb.

IV. Policy recommendation
California legislators should pass effective means in
addition to gun control to address the school shooting
crisis. Gun regulation is only one facet of the issue.
The SEL program described in Option 1 will be the
most effective approach. It reaches every student and
provides the skills to implement non-violent methods
of conflict resolution. This is a program that directly
works to increase the psychological well-being of all
students, whether they are at risk of becoming a
school shooter or not and has potential for bipartisan
support.

However, the benefits of reducing the state’s average
counselor-to-student ratio must not be overlooked.
This practice should be implemented given adequate
resources. Measures in addition to mental health
services and gun regulation include heightened
school security and expanded scientific research on
gun violence. Public health emergencies, such as
school shootings, are multifaceted issues, requiring
multifaceted approaches.

For the good of our state and our nation, the school
shooting crisis must be examined from every angle.
While children are the most vulnerable stakeholders,
teachers, staff, parents, and the larger community are
all impacted. Legislators in California should enact
effective policies that the rest of the nation can model
in the fight against school shootings. This should
begin with SEL interventions that address the root
causes of violent behavior. Given that instating this
policy initiative takes time and resources, it is
imperative to act now. Lives are at stake.

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Wenz-Gross, Melodie, Yeonsoo Yoo, Carole C. Upshur, and
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Agnes Varghese is a graduate student researcher at the University of California, Riverside (UCR), pursuing a
PhD in Developmental Psychology. She holds a BS in Psychology and a BA in Broadcast Journalism from the
University of Maryland, College Park. Agnes is the Chair of External Affairs for the UCR Center for Science to
Policy’s student-led cabinet.

Danielle Delany is a graduate student researcher at the University of California, Riverside (UCR), pursuing a
PhD in Developmental Psychology. She holds a BA and MA in Psychology from California State University,
Fullerton. Danielle is the Chair of the Education and Events Committee for the UCR Center for Science to
Policy’s student-led cabinet.

Morgan Dundon is a graduate student researcher and National Science Foundation Graduate Research
Fellow at the University of California, Riverside (UCR), pursuing a PhD in Materials Science and Engineering.
She holds a BS in Forensic Chemistry and Chemistry from Towson University. Morgan is the Chair of
Government Relations for the UCR Center for Science to Policy’s student-led cabinet.

Acknowledgements
The authors would like to acknowledge the contributions of the Center for Science to Policy at the University
of California, Riverside in preparing this manuscript.

lable at ScienceDirect

Annals of Epidemiology 25 (2015) 366e376

Contents lists avai

Annals of Epidemiology

journal homepage: www.annalsofepidemiology.org

Policy Mini-Symposium

Mental illness and reduction of gun violence and suicide: bringing
epidemiologic research to policy

Jeffrey W. Swanson PhD a,*, E. Elizabeth McGinty PhD, MS b, Seena Fazel MBChB, MD, FRCPsych c,
Vickie M. Mays PhD, MSPHd,e

aDepartment of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC
bDepartment of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
cDepartment of Psychiatry, University of Oxford, Oxford, England
dDepartment of Psychology, University of California at Los Angeles, Los Angeles, CA
eDepartment of Health Policy and Management, University of California at Los Angeles, Los Angeles, CA

a r t i c l e i n f o

Article history:
Received 5 March 2014
Accepted 19 March 2014
Available online 29 April 2014

Keywords:
Mental illness
Psychiatric disorder
Guns
Firearms
Violence
Suicide
Policy
Law
Stigma
Risk

* Corresponding author. Department of Psychiatry a
University School of Medicine, DUMC Box 3071, Durh

E-mail address: [email protected] (J.W.

1047-2797/$ e see front matter � 2015 The Authors. Pu
3.0/).
http://dx.doi.org/10.1016/j.annepidem.2014.03.004

a b s t r a c t

Purpose: This article describes epidemiologic evidence concerning risk of gun violence and suicide linked
to psychiatric disorders, in contrast to media-fueled public perceptions of the dangerousness of mentally
ill individuals, and evaluates effectiveness of policies and laws designed to prevent firearms injury and
mortality associated with serious mental illnesses and substance use disorders.
Methods: Research concerning public attitudes toward persons with mental illness is reviewed and
juxtaposed with evidence from benchmark epidemiologic and clinical studies of violence and mental
illness and of the accuracy of psychiatrists’ risk assessments. Selected policies and laws designed to
reduce gun violence in relation to mental illness are critically evaluated; evidence-based policy rec-
ommendations are presented.
Results: Media accounts of mass shootings by disturbed individuals galvanize public attention and
reinforce popular belief that mental illness often results in violence. Epidemiologic studies show that the
large majority of people with serious mental illnesses are never violent. However, mental illness is
strongly associated with increased risk of suicide, which accounts for over half of US firearmserelated
fatalities.
Conclusions: Policymaking at the interface of gun violence prevention and mental illness should be based
on epidemiologic data concerning risk to improve the effectiveness, feasibility, and fairness of policy
initiatives.
� 2015 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY license

(http://creativecommons.org/licenses/by/3.0/).

Themassacre of schoolchildren in Newtown, Connecticut, in late
2012 stirred a wrenching national conversation at the intersection
of guns, mental illness, safety, and civil rights. In the glare of sus-
tained media attention and heightened public concern over mass
shootings, it seemed that policymakers had a rare window of op-
portunity to enact meaningful reforms to reduce gun violence in
America. And yet, the precise course of action was far from clear;
competing ideas about the nature and causes of the problemdand
thus, what to do about itdcollided in the public square.

On the one side, public health experts focused on the broader
complex problem of firearms-related injury and mortality in the
United States, where each year approximately 32,000 people are

nd Behavioral Sciences, Duke
am, NC.
Swanson).

blished by Elsevier Inc. This is an o

killed with gunsdabout 19,000 of them by their own handdand
another 74,000 are injured in nonfatal gunshot incidents [1]. These
experts recommended a range of prevention policies including
universal background checks for gun purchasers, a ban on military-
style assault weapons and high-capacity ammunition magazines,
and a crackdown on gun trafficking, through increased enforce-
ment and penalties and loosened evidentiary standards for prose-
cuting individuals charged with illegal gun sales [2]. On the other
side, the National Rifle Association, which arguably wields far
greater influence over national firearms policy than public opinion
does [3], laid the blame for mass shootings on untreated mental
illnessdrather than unregulated gunsdand proposed the creation
of a national database of persons with mental illness [4].

For their part, mental health stakeholders encountered a painful
dilemma. The goal of keeping guns out of the hands of seriously
mentally ill individuals was emerging as perhaps the only piece of

pen access article under the CC BY license (http://creativecommons.org/licenses/by/

J.W. Swanson et al. / Annals of Epidemiology 25 (2015) 366e376 367

common ground between gun rights and gun control proponents; a
post-Newtown public opinion poll found that a majority of Amer-
icans across the political spectrum favored “increasing government
spending to improve mental health screening and treatment as a
strategy to prevent gun violence” [5]. But mental health experts and
consumer advocates strongly rejected what they saw as the
scapegoating of people with mental illnessesdthe vast majority of
whom, epidemiologic data shows, will never act violently toward
othersdas if people with mental health disorders were somehow
responsible for gun violence in general. These stakeholders thus
faced the difficult prospect of debunking the public perception that
“the mentally ill are dangerous,” while attempting to leverage that
very perception to build support for (much-needed) public funding
to improve themental health care system in the United Statesdand
to achieve this goal without also spawning crisis-driven laws that
might overreach in restricting the rights and invading the privacy of
people with mental illnesses [6,7].

What is the role of epidemiologic evidence in such a moment?
Can epidemiology help policymakers craft firearms restrictions and
provisions that will more effectively prevent gun violence, while at
the same time protecting the rights of law-abiding gun owners as
well as people recovering from mental illnesses? In this article, we
describe available evidencedof what the public believes and what
science has learneddabout the risk of gun violence among people
with mental health disorders. We discuss the complex and con-
tested link between mental illness and violent behavior in general,
and with respect to gun violence in particular; the role of other
intertwined risk factors for violence, such as substance abuse, vi-
olent victimization, and neighborhood and social disadvantage; the
role of suicide in gun fatalities and the role of mental illness in
suicide; and the effectiveness of interventions and emerging pol-
icies to prevent violence in people with mental illness. Finally, we
offer principles to guide future policymaking at the interface of gun
violence prevention and population mental health, based on
epidemiologic data concerning individual risk, and with the goal of
improving the effectiveness, feasibility, and fairness of policy
initiatives.

Public perceptions of the relationship between mental illness
and violence

Negative public attitudes toward persons with serious mental
illnesses such as schizophrenia and bipolar disorder are pervasive
and persistent in the United States, and the assumption of
dangerousness is a key element of this negative stereotype [5,8]. A
2013 national public opinion survey found that 46% of Americans
believed that persons with serious mental illness were “far more
dangerous than the general population” [5]. Data from the 2006
General Social Survey suggest that Americans perceive persons
with schizophrenia as particularly dangerous: after reading a
vignette about an individual with common symptoms of schizo-
phrenia, 60% of respondents reported that they viewed the
described individual as likely, or very likely, to be dangerous toward
othersdalthough the vignette description did not include any in-
formation about violent behavior or risk [8].

The public perception of a strong link between mental illness
and violence is fueled in part by news coverage of mass shootings
and other violent events. Two studies have directly linked news
media coverage of high-profile acts of violence by persons with
serious mental illness to negative public attitudes toward this
group. First, in a 1996 study using national survey data from the
formerWest Germany, Angermeyer and Matschinger [9] found that
public desire for social distance from persons with schizophrenia
increased after two highly publicized violent attacks on politicians
by individuals who had been diagnosed with schizophrenia.

Second, in a 2013 study using a national US sample, participants
were randomly assigned to read a news story about amass shooting
reportedly committed by a man with mental illness or were
assigned to a control group who did not read any news story [10].
Compared with the control group, participants who read the news
story about a mass shooting reported significantly higher perceived
dangerousness of, and desired social distance from, people with
serious mental illness in general.

Public perceptions and attitudes toward persons with mental
illness are important to public policy, because people act on the
basis of their beliefs, and they tend to support policies that assume
those beliefs and perceptions to be true. Thus, if members of the
general public largely believe that people with mental illnesses are
dangerous and pose a threat to their personal safety, the public will
also be more likely to support policies and laws that restrict the
liberties of people with mental illnesses [11]dirrespective of
whether those policies are necessarily effective and fair. But what
does the epidemiologic evidence actually show about the link be-
tween violence and serious mental health disorders?

Epidemiologic evidence on the relationship between mental
illness and violence

Before the 1990s, empirical evidence of the relationship between
violence and mental illness derived largely from clinical forensic
studies and small surveys of highly selected populationsdresearch
that either examined violent behavior among hospitalized psychi-
atric patients or psychopathology among incarcerated violent of-
fenders [12]. Neither kind of study was designed to answer the basic
epidemiologic question of whether violence was actually more
prevalent among people with mental illness in the community
comparedwith the general population, orwhethermental illness per
se caused community violencedbecause the study populations were
already distilled for violence risk and thus not representative.

In 1990, the first large epidemiologic study was published that
reported the prevalence of any minor or serious violent behavior in
adults with and without diagnosable psychiatric disorders in
randomly selected community household samples irrespective of
treatment [12,13]. The National Institute of Mental Health Epide-
miologic Catchment Area (ECA) study measured violence using an
index of survey questions that asked about the occurrence of spe-
cific physically assaultive behaviors such as hitting with a fist,
pushing, shoving, kicking or throwing things at another person, or
using aweapon to harm or threaten another person. Specificmental
disorders were defined using Diagnostic and Statistical Manual-III
criteria [14] as elicited from a lay-administered structured diag-
nostic interview. The study collected data on a variety of social and
demographic characteristics including socioeconomic status, mak-
ing it possible to estimate the net relationship between mental
illness and violent behavior in the population, using multivariate
statistical analyses to control for covarying risk factors. The study
also assessed alcohol and illicit drug use and dependence disorder,
making it possible to examine the relationship of substance abuse
comorbidity to violence risk among people with mental illness
living in the community.

Analysis of ECA data from three sites (Baltimore, St. Louis, and
Los Angeles, with a combined total of n ¼ 10,024 participants)
identified a statistically significant but fairly modest positive asso-
ciation between violence and mental illness. The 12-month prev-
alence of any minor or serious violence among people with
schizophrenia, bipolar disorder, or major depression was about 12%
overall, and 7% in the subgroup with these disorders alone and no
substance abuse comorbidity. That was compared with a general-
population prevalence of about 2% in persons without mental
disorder or substance use disorder, for an adjusted relative risk of

J.W. Swanson et al. / Annals of Epidemiology 25 (2015) 366e376368

3:1 for mental illness alone. Lifetime violence rates (which could
include violence that occurred at any time and not necessarily
during a period of mental disorder) were estimated at 15% for the
populationwithoutmental illness, 33% in thosewith seriousmental
illness only, and 55% for those with serious mental illness and
substance abuse combined.

Perhaps most importantly, the 1-year population attributable
risk of violence associated with serious mental illness alone was
found to be only 4% in the ECA surveys. Attributable risk takes into
account both themagnitude of risk and the number of people in the
risk category within the population [13]. The ECA results implied
that even if the elevated risk of violence in people with mental
illness were reduced to the average risk in those without mental
illness, an estimated 96% of the violence that currently occurs in the
general population would continue to occur. The ECA study also
found a substantially increased risk of violent behavior within
particular demographic subgroups of participantsdspecifically,
younger individuals, males, those of lower socioeconomic status,
and those having problems involving alcohol or illicit drug use;
these risk factors were statistically predictive of violence in people
with or without mental illness [13].

The ECA study thus debunked claims on both extremes of the
debate about violence andmental illnessdfrom the stigma-busting
advocates on the one side who insisted that mental illness had no
intrinsic significant connection to violence at all, and from the
fearmongers on the other sidewho asserted that thementally ill are
a dangerous menace and should be locked up; both views were
wrong. The facts showed that people with serious mental illnesses
are, indeed, somewhat more likely to commit violent acts than
people who are not mentally ill, but the large majority are not vi-
olent toward others. Moreover, when persons with mental illness
do behavior violently, it is oftendalthough not alwaysdfor the
same reasons that nonementally ill people engage in violent
behavior. In short, violence is a complex societal problem that is
caused, more often than not, by other things besides mental illness.
(Suicide or self-inflicted harm, is strongly related to mental illness,
as will be discussed later in the article.)

After the ECA report, several other notable studies were con-
ducted in the United States examining violent behavior in psychi-
atric patients. The best known of these is the MacArthur Violence
Risk Assessment Study (MVRAS) [15], which followed up a cohort of
more than 1000 discharged psychiatric inpatients over 1 year in the
mid-1990s and used self- and family-report interviews to measure
violent outcomes. The MVRAS found that substance abuse comor-
bidity was responsible for much of the violence in discharged
psychiatric patients; indeed, patients who had only mental ill-
nessdthat is, without substance abusedhad no higher risk of vi-
olent behavior than their neighbors in the community, persons
selected at random from the same census tracts in which the pa-
tients resided. However, because many of the patients lived in
disadvantaged high-crime neighborhoods in the inner city and
because the base rates of violence among both the patients and
community comparison groups were substantially higher than in
the ECA study, one interpretation of the MacArthur Violence Risk
Assessment Study finding is that the social-environmental in-
fluences on violence are stronger than the effects of psychopa-
thology and tend to “wash out” those effects at the population level.

More recently, Van Dorn et al. [16] confirmed the basic pattern of
the ECA community findings with an analysis of the association
between violence and mental illness using data from the National
Epidemiologic Survey on Alcohol and Related Conditionsda na-
tionally representative household survey of 32,653 persons in the
United States. The National Epidemiologic Survey on Alcohol and
Related Conditions study found lower rates of violence than the ECA
study did (due in part to some sampling and methodological

differences between the studies), but reported the same general
pattern: 2.9% of persons with serious mental illness alone
committed violent acts in a year, compared with 0.8% of people
with no mental disorders or substance abuseda statistically sig-
nificant relative risk, despite a low absolute risk of violence in
people with serious mental illness. Those with cooccurring sub-
stance use disorder and serious mental illness had a higher rate of
violence, 10.0%, but this still meant that a clinician would be wrong
nine times of 10 with a blanket prediction that someone will
commit a violent act merely because they have a combination of, for
example, depression and alcohol use disorder. The inclusion of
demographic risk factors in the prediction calculus would improve
its accuracy, just as it would for those in the general population
without mental illness.

A series of population studies from Nordic countries [17,18] and
Australia [19] also confirmed that there is a modest but significant
link between mental disorders and violence in the community. The
landmark Dunedin birth cohort study reported similar findings
using more sensitive measures of exposure and outcome [20]. At
least 20 studies have examined violence in patients with schizo-
phrenia spectrum disorders in various clinical and community
settings. A meta-analyses of this literature reported that the risk of
violence was on average three to five times higher for men with
schizophrenia, and four to 13 times higher for women with
schizophrenia, compared with their counterparts without schizo-
phrenia in the general population [21]. Odds are substantially
higher when homicide is considered as the violence outcome, and
for any violence in studies comparing first-episode psychosis
patients to population controls. The overall risk increase for
violence is similar in bipolar disorder, where a recent meta-analysis
synthesized nine studies and reported increased odds of violent
outcomes in bipolar patients in the range of 3:1 to 6:1 compared
with the general population [22]. Other disorders with increased
risks compared with population controls are traumatic brain injury
[23], personality disorders [24], learning disability or mental
retardation [25] and depression [19,20]. Two diagnoses appear to
have higher odds of violence than most psychiatric disorders,
substance abuse (with odds of 7e9) [21] and antisocial personality
disorder [24]. Assuming causality, population attributable risk
fractions for violence range from 2% to 10% for the psychoses [21],
around 20% for personality disorders (including antisocial person-
ality disorder) [24] and between 20% and 25% for alcohol and drug
use disorders [26].

Studies that have examined the prevalence of violence in psy-
chiatric patients vary widely and systematically by the clinical
setting in which the studies are conducted [27]. As shown in
Figure 1, meta-analytic studies have found the lowest rates of
violence, on average, in surveys of outpatients in treatment (8%).
Higher average rates are seen in studies of discharged hospital
patients (13%), and those who present in psychiatric emergency
settings (23%). Even higher rates tend to be reported in retrospec-
tive studies of involuntarily committed patients (36%) [27] and
studies of first-episode psychosis patients during the period pre-
ceding their first treatment encounter (37%) [28]. Violence risk in
people experiencing a first episode of psychosis is of concern,
because these tend to be young adults whose symptoms may go
untreated for an extended period before contact with a mental
health treatment provider who could intervene; firearms restric-
tion regimes based on background checks of records also will not
find them.

With respect to the correlates and hypothesized mechanisms
that may lead to violence in people with mental illness, some
scholars have theorized that social and economic risk factors such
as poverty, crime victimization, involvement with illegal drugs and
drug markets, early life trauma exposure, and ambient

Fig. 1. Average prevalence of minor to serious violence among persons with serious mental illness by setting of study: meta-analysis of many studies. Sources: Adapted from (1)
Choe JY, Teplin LA, Abram KM. Perpetration of violence, violent victimization, and severe mental illness: balancing public health outcomes. Psychiatric Services. 2008; 59:153e164;
(2) Large MM, Nielssen O. Violence in first-episode psychosis: a systematic review and meta-analysis. Schizophrenia Research 2011; 125:209e220

J.W. Swanson et al. / Annals of Epidemiology 25 (2015) 366e376 369

neighborhood crime largely account for the apparent link between
mental illness and violent behavior toward others [29]. These
studies have reported that persons with serious mental illnesses in
the community are often socially disadvantaged over their life
course and thus exposed tomany covarying risk factors for violence.
Along these lines, Swanson et al. [30] published a study on the
prevalence and correlates of interpersonal violent behavior in a
five-state pooled sample of n ¼ 802 adult psychiatric outpatients
with serious mental illness who were receiving services in the
states’ public behavioral health care systems. The study painted a
picture of a group of individuals with serious and disabling mental
health conditions, but also a marginalized group with very low
social capitaldmostly unemployed, economically impoverished,
typically residing in disadvantaged neighborhoods, often misusing
alcohol and illicit drugs, and reporting alarmingly high rates of
trauma and violent victimization over their life course. Many of
these characteristics and experiences were found to be highly sig-
nificant correlates of violent behavior. Conversely, participants in
the study who merely had a diagnosis of serious mental illness but
did not have a history of violent victimization, were not exposed to
neighborhood violence, and were not abusing drugs or alcohol, had
annual rates of violent behavior in line with the general population
without any mental illnessdabout 2% [30]. Evidence from studies
in criminology and developmental epidemiology has shown that
risk factors for crime and violence are similar in persons with
mental illness and in the general population, and that risk exposure
often begins early in life [31,32]. The ECA, MVRAS, and five-state
findings tended to support that view, in part.

At the same time, there is evidence that psychiatric symp-
tomsdand particular combinations of symptoms such as delusions,
suspiciousness, and extreme angerdcan increase violence risk
under certain conditions in certain individuals, and that treatment
such as antipsychotic medication to reduce these symptoms can, in
turn, reduce violence risk [33,34]. A recent large meta-analysis
identified a range of risk factors for violence in persons with psy-
chotic symptoms, which notably included concurrent substance
abuse (especially polysubstance abuse) along with antisocial or
criminal history, but also identified treatment nonadherence as a
significant risk factor in these individuals [35]. Common risk factors
for violence can be potentiated bymajor psychopathology that goes
untreated. Persons with a psychotic disorder and cooccurring

substance misuse, in particular, tend to have compounding prob-
lems: they may “use the wrong drugs” [36] while also failing to
take prescribed medication to manage their primary psychiatric
symptoms, with the result that psychotic symptoms such as
excessive threat perception and hostility can be exacerbated and
become more likely to precipitate violence. Cognitive distortion
combined with intoxication may also create or worsen conflict in
social relationships; aggressive impulses may be disinhibited; and
criminogenic social influences that attend the procurement of
illegal drugs may, at the same time, increase risk of violent behavior
[30,37].

Problems with mood and behavioral regulationdimpulsivity (a
few studies show) [38] and excessive anger [39], for exampledcan
combine with cognitive distortion to precipitate violent behavior in
persons with symptoms of psychosis. A recent study by Coid et al.
[39] in the United Kingdom examined violence in first-episode
psychosis patients and reported that the link between psychotic
delusions and violence wasmediated by anger. Specifically, when an
acutely psychotic individual harbors delusional beliefs that others
are threatening to harm him, this may kindle extreme irrational
anger toward the object of the imagined malevolence, leading in
turn to aggressive or violent behavior, as the normal cognitive
controls are impaired. The findings of Coid and associates are not
inconsistent with Link’s theory of “rationality within irrationality”
and “threat/control-override” as an explanation of violence in some
persons with psychotic symptoms [40].

A complex picture of the violence-psychosis link emerged in the
mid-2000s in findings from the National Institute of Mental Health
Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE)
[41]. The CATIE project investigated violent outcomes in n ¼ 1445
schizophrenia patients as part of a large multisite randomized
clinical trial. The study identified distinct subgroups of schizo-
phrenia patients with different levels of risk for violence and who
appeared to behave violently for different reasonsdnotwith-
standing they all had “the same”mental disorder. Specifically, about
one-third of the sample had a history of antisocial behavior that
preceded the onset of adult psychotic illness and were about twice
as likely to have engaged in recent violent behavior (28.2% vs.14.6%)
as their counterparts who did not have antisocial history. Their
violent behavior was not significantly correlated with acute psy-
chotic symptoms such as delusions and hallucinations but rather

J.W. Swanson et al. / Annals of Epidemiology 25 (2015) 366e376370

was associated with a history of early life victimization and trauma.
Furthermore, their risk of violence did not significantly decline
when they were adherent with prescribed antipsychotic medica-
tions [42]. At the same time, it seems clear that psychosis clearly
contributed to violence in some CATIE participants. The study
found, overall, that patients with acutely elevated psychotic
symptoms involving a combination of delusional thinking, suspi-
ciousness, and perceived persecution were approximately three
timesmore likely to commit a serious violent act thanwere patients
in whom these symptoms were absent or controlled [41].

Although the existing research on aggressive or violent behavior
and psychopathology is informative as far as it goes, the goal of
synthesizing the evidence into a coherent, comprehensive expla-
nation of violence risk in people with serious mental illnessesdand
thus to render gun violence, in particular, somehow predictable and
preventable in psychiatric patientsdremains elusive. An important
reason is that people with schizophrenia andmajor mood disorders
represent highly heterogeneous clinical populations. Scientific ex-
planations of violent behavior in these populations, from the
perspective of epidemiology and cognitive neuroscience, may
require a synthesis of theories and evidence regarding “instru-
mental” and “reactive” violent behavior, in the context of what is
known regarding the social-environmental and developmental
determinants of violence, from social disadvantage to trauma
exposure and the lifespan consequences of early childhood
victimization [30,43,44].

Mental illness, guns, and suicide

When suicide is examined as a part of the picture of gun
violence, mental illness legitimately becomes a strong vector of
concern; it should become an important component of effective
policy to prevent firearm violence. Suicides account for 61%of all
firearm fatalities in the United Statesd19,393 of 31,672 gun deaths
recorded by the Centers for Disease Control and Prevention (CDC) in
2010 [1]. Suicide is the third leading cause of death in Americans
aged 15e24 years, perhaps not coincidentally the age group when
young people typically go off to college, join the military, and
experience a first episode of major mental illness if it is bound to
happen. Data from the CDC’s National Violent Death Reporting
System showed that a substantial proportion of suicide victims had
identified mental health problems (21%e44%) and a documented
history of some psychiatric treatment (16%e33%), varying by racial
or ethnic background with non-Hispanic white suicide victims
being most likely to have documented mental health problems and
treatment [45]. Across the population, many studies have shown
that suicide risk is substantially increased in persons with mental
disorders. Standardized mortality ratios for suicide are in the range
of 10e20 for bipolar disorder and depression [46] and 13 for
schizophrenia spectrum disorders, as reported in a recent meta-
analysis [47]. Population attributable risk proportions for suicide
associated with mental disorders are in the range of 47%e74%
[48,49].

What is the mechanism by which mental illness increases sui-
cide risk? A number of systematic reviews have summarized sui-
cide risk factors in different patient groups. “Self-harm”dwhich
seems related to suicide on its facedhas consistently been the
strongest association, but many studies have reported that con-
current substance abuse and specific psychological symptoms, such
as hopelessness, also have strong links with suicide. In those with
psychosis or bipolar disorder, concurrent depressive symptoms
increase risk [50,51]. However, one of the clearest findings in the
suicide literature is the substantial contribution of environmental
factorsdnotably including the availability of lethal means such as
firearms [52]dand exposure to media reporting of suicide [53].

New research demonstrates that household gun ownership in
the United States makes a strong independent contribution to
increased suicide risk, above and beyond the effects of other
covarying risk factors for suicide [54]. A recent large study in
Switzerland found that an enduring decrease in the population
suicide rate was attributable to an army reform that halved the
number of firearms available in the homes of military reserve
personnel. Moreover, it was estimated that only about one in five of
the prevented gun suicides resulted in a substitution of suicide by
other means [55]. The importance of access to other kinds of lethal
means in suicide has also been demonstrated in a series of longi-
tudinal studies in the United Kingdom. Pack sizes for paracetamol (a
mild analgesic like acetaminophen) were reduced, leading to sig-
nificant decreases in suicide in the general population without
obvious substitution of methods. The same pattern of findings was
obtained when coproxomol (mild to moderate analgesic) was also
restricted [56]. In Australia, in 1996, access to firearms was broadly
restricted after the Port Arthur massacre when 35 people were
killed in a rampage shooting. A research study subsequently
compared the numbers of mass killings before and after the gun
control legislationwas introduced: no shooting massacres occurred
in the following 10 years, compared with 13 shooting sprees that
had occurred in the 18 years before. Large decreases in fatal suicides
from guns were also reported. There was no evidence of substitu-
tion by other methods for homicides or suicides [57].

There has been limited research evaluating the effects of states’
gun restrictions on firearms-related violence and suicide. A recent
study used state-level multivariate panel regression analysis to
examine variations in states’ gun-related fatality rates over time as
a function of whether states enacted several specific gun control
measures. The analysis suggested that gun permit and licensing
requirements significantly lowered suicide rates among males [58].
An earlier study by Ludwig and Cook [59] examined the effects of
the Brady Law across all states and found that gun background
checks and waiting periods significantly reduced suicide in the
older population; these results, too, suggested that suicide is pre-
ventable by removing or restricting (or even delaying) access to
lethal means. In their analysis of the effects of restrictive handgun
licensing in the District of Columbia, Loftin et al. [60] found that the
handgun ban was followed by an abrupt decline (six per month or
23%) in suicide by firearms in the DC. No similar reductions were
seen in suicides by other means, and no reductions were seen in
neighboring jurisdictions that were not subject to the law. There
were also no increases in suicides by equally lethal means, as would
be expected if suicidal individuals simply substituted other means
for the firearms they could not obtain [60].

Gun access and mental illness

Are people with mental illness more likely to acquire, possess
and carry guns? The National Comorbidity Study-Replication
examined rates of gun access, gun carrying, and safe storage
among people with and without lifetime mental disorders in the
community and found no statistically significant association [61]. In
a large, nationally representative sample of adults residing in the
community (n¼ 5692), the National Comorbidity Study-Replication
study found that 34.1% of persons with lifetime mental disorders
had access to a gun, 4.8% carried a gun, and 6.2% stored a gun in an
unsafe manner. Among those without lifetime mental disorders
(n ¼ 2034), rates were not significantly different: 36.3% had access
to a gun, 5.0% carried a gun, and 7.3% stored a gun unsafely. How-
ever, persons who reported a prior suicide attempt were signifi-
cantly less likely to have access to a gun than those who had never
attempted suicide (23.8% vs. 36.0%).

Fig. 2. Violence risk varies among people with serious mental illness who are invol-
untarily committed: characteristics of violent behavior in 4 months before involuntary
hospital admission (Duke Mental Health Study; n ¼ 331). Source: Swanson J, Borum R,
Swartz M, Hiday V. Violent behavior preceding hospitalization among persons with
severe mental illness. Law & Human Behavior. 1999; 23:185e204.

J.W. Swanson et al. / Annals of Epidemiology 25 (2015) 366e376 371

Predicting risk of future violence

In the aftermath of mass shootings and other violent events, the
public and policymakers look for answers to the question of how
such an event could have been prevented. When the perpetrator is
reported to have had a mental illness, questions arise about why he
was not identified and treated before committing a major act of
violence. The issue of predicting risk of future violence among
people with mental illness is central to the development of policy
responses to mental illness and violence. Policies intended to keep
guns out of the hands of people with mental illness who are likely
to be violent depend on clinicians to accurately identify which in-
dividuals are likely to be violent. However, research evidence shows
that risk prediction, particularly for statistically rare events like
mass shootings, is a very inexact science.

In a study conducted by Charles Lidz et al. [62] in the early 1990s,
the researchers prospectively followed a sample of 357 psychiatric
patients who were seen in emergency settings and clinically
assessed as likely to be violent, along with a matched sample of
patients who were not predicted to be violent. They conducted
structured interviews with the patients and collateral informants to
assess the occurrence of violent behavior over a 6-month period,
and they compared the rates of violence in the two groups. The
study found that psychiatrists’ predictions of which patients would
be violent, based on their clinical assessments in the emergency
setting, turned out to be only slightly more accurate than flipping a
coin; and they were no better than chance at predicting violence in
female patients. Subsequent studies have found that actuarial
prediction schemes and structured risk-assessment instruments
can moderately improve the accuracy of violence prediction in
persons with mental illness, and that psychiatrists are at least
better at ruling out who is not going to be violent than they are at
predicting who is going to commit a violent act [63]. But such
elaborate protocols are time consuming, expensive, and far from
standard in practice.

The federal policy approach to preventing gun violence
involving people with serious mental illness

Policy options to prevent gun violence in the United States are
constrained by a constitutionally protected individual right to own
firearms, as the second Amendment to the US Constitution has
been interpreted by the US Supreme Court in the Heller [64] and
McDonald [65] decisions striking down broad handgun bans in the
District of Columbia and in Chicago, respectively. However, the
Court’s opinions left in place longstanding prohibitions on firearms
for persons with a history of a felony conviction or mental health
adjudication such as involuntary civil commitment to a psychiatric
hospital. Federal firearm restrictions related to mental illness have
existed since 1968, but largely remained unimplemented until
the 1990s. In 1968, following the assassinations of Sen. Robert
F. Kennedy and Dr. Martin Luther King, Jr., Congress passed the Gun
Control Act [66], which categorically prohibited people from buying
firearms if they had ever been involuntarily committed to a mental
hospital or “adjudicated as a mental defective.” As defined specif-
ically in the federal regulations, the exclusion covers anyone who
has been determined by an authoritative legal process to be
dangerous or incompetent to manage their own affairs due to a
mental illness and also covers criminally accused individuals found
incompetent to stand trial or acquitted by reason of insanity. In the
1960s, the exclusion would have applied to a massive number of
people in the United States. Large state mental hospitals were still
the primary locus of care for people with serious and disabling
disorders such as schizophrenia and bipolar disorder. Since then,
civil commitment reforms and deinstitutionalization have radically

diminished and reshaped the ranks of the involuntarily committed
[67,68], but the original mental healthefocused firearm pro-
hibitions that were enacted in 1968 remain unchanged.

The rationale for linking legal gun restrictions to involuntary
commitment history rested on several assumptions. First, the law
assumed that serious mental illnesses, of the sort that landed
people in mental hospitals against their will, were strongly and
causally associated with risk of violent behavior. Second, it assumed
that people with these dangerous mental health conditions would
inevitably come to the attention of psychiatrists, who could then
reliably discern risk of violence and would confine the appropriate
patients to a mental hospital. Third, it assumed that discharged
involuntary psychiatric patients would always carry with them
some risk of relapse of their dangerous mental health conditions
and thus should be prohibited indefinitely from obtaining firearms.
And the final assumption was that a mere “law on the books,” even
without a background check database in effect to implement it,
could deter most prohibited individuals from purchasing firearms
from a licensed gun dealer; either they would not try to buy a gun
or they would truthfully disclose their gun-disqualifying mental
health histories in the attempt and thus be stopped. As it turned
out, epidemiologic research found flaws in all of these assumptions,
pointing to the need for policy reforms and more concerted
implementation efforts [69].

As we have already discussed, subsequent large epidemiologic
studies of community-representative samples reported that mental
illnesses only moderately increased the relative risk of any violence,
that is, assaultive behaviors ranging from slapping or shoving
someone to using a weapon in a fight [12,16]. Moreover, the abso-
lute risk was very low; the vast majority of people with diagnosable
serious psychiatric disorders, unless they also had a substance use
disorder, did not engage in violent behavior. Even among thosewho
were involuntarily committed, violence risk varied widely (as
shown in a North Carolina study with findings illustrated in
Figure 2). As for the remaining assumptions underlying the 1968
Gun Control Act’s mental health prohibitions, it turned out that
dangerous individuals with mental health conditions often did not
seek treatment before they did something harmful. Clinicians could
not reliably predict violence in the patients they saw and may often
have committed the wrong people for the wrong reasons. At the
state level, idiosyncratic commitment policies and practices
evolved [70], resulting in wide variations in rates of involuntary
admissions from state to state. Considering the most recent US data
available, among patients readmitted to state psychiatric hospitals
in 2012 the proportion of involuntary versus voluntary admissions

Fig. 3. Accumulation of MH records in National Instant Check System. Sources: (1) Federal Bureau of Investigation. National Instant Criminal Background Check System (NICS)
operations 2012; 2013; http://www.fbi.gov/about-us/cjis/nics/reports/2012-operations-report; (2) Federal Bureau of Investigation (FBI). Active Records in the NICS Index. 2013;
http://www.fbi.gov/about-us/cjis/nics/reports/active-records-in-the-nics-index-113013.pdf

J.W. Swanson et al. / Annals of Epidemiology 25 (2015) 366e376372

varied by state from 26% to 100%, with the state average being 83%
[71]. Thus, patients with the same moderate risk of violence would
likely be committed in one state and not another, and thuswould be
gun-disqualified in one state and not another. Furthermore, there
were many people with a history of involuntary commitment who
did not have a continuing risk of violence or at least no higher risk
than that found in the general population.

In 1993, Congress passed the Brady Handgun Violence Pre-
vention Act [72], which instituted federal background checks for
people attempting to buy guns from licensed dealers and reaf-
firmed the prohibited categories that the Gun Control Act had
promulgated. The Brady law also provided for a national electronic
registry in which states could deposit their records of persons
prohibited from having a gun, and in 1998, the National Instant
Criminal Background Check System (NICS) went into effect.
However, many states failed to report mental health records to the
NICS system due to concerns about confidentiality and lack of data
systems connecting mental health and criminal justice agencies
[72]. In 2007, the mass shooting at Virginia Polytechnic Institute
and State University motivated Congress to swiftly pass the NICS
Improvement Act (NICSA), which was signed into law by President
George W. Bush on January 5, 2008 [73]. The NICSA used
Department of Justice grants to incentivize states to report their
gun-disqualifying mental health records to the NICS and also
required states receiving the grants to institute Federal Bureau of
Investigationeapproved “relief from disabilities” programs for
restoring gun rights to nondangerous persons whose rights have
been rescinded due to a disqualifying mental health record.

Some advocates believe that the answer to preventing gun
rampages by disturbed individuals is merely to continue to extend
the reach of states’ reporting to the NICS. Mayors Against Illegal
Guns released a report in 2012 tallying the number of mental health
records each state has submitted to the NICS and ranking each
state’s reporting performance [74]. The report stated that nearly 5
years after Congress enacted the NICSA, only about half the states
have submitted more than a negligible proportion of their mental
health records. The not-so-implicit message was that states’ spotty
reporting of mental health records to the background check data-
base is partly to blame for the senseless deaths in mass shootings.

But as we have seen, evidence suggests that even if we could
completely eliminate mental illness as a violence risk factor, the
population prevalence of violent acts toward others would go down
by less than 4%.

As shown in Figure 3, the number of gun-disqualifying mental
health records submitted to the NICS has increased nearly 10-fold in
the 5 years since the Virginia Tech shooting and enactment of the
NICSAdfrom about 300,000 (7% of federal disqualifying records in
the NICS index) in 2007 to about 3 million (nearly one-third of
federal disqualifying records in the NICS index) by the end of 2013
[75,76]. During the 3 years from 2000 through 2013, the system
processed over 50 million background checks on prospective gun
purchasers. However, more than 99% of gun-disqualifying mental
health records archived in the NICS have not resulted in any denials
of attempted firearms purchases by prohibited individuals [75].

Meanwhile, a growing body of scientific evidencewould seem to
call into question the efficacy of our current federal gun laws and
their state-level implementation as a reliable and comprehensive
way to identify the small proportion of persons with serious mental
illnesses who do pose a risk of gun violence toward others or self
and to effectively deter such individuals from obtaining access to
firearms and committing violent crimes or harming themselves
[69]. There are several plausible reasons why mental health re-
strictions on firearmsdas currently implemented in the cursory
background-check systems that many states usedmay fall short of
their intended goal and thus need to be improved.

In the first place, some people who are at risk of harming others
or themselves, such as those experiencing a first episode of psy-
chosis, have no official record in the courts, mental health, or
criminal justice systems; record searches for “red flags”will not find
them. Others who are at risk, such as individuals who contemplate
suicide, may have a record in the mental health treatment system
but no history of mental health adjudication that would legally
prohibit them from firearms; even an involuntary admission to a
hospital during a mental health crisis does not, by itself, restrict a
person’s right to buy a gun in most states, unless the person is
formally committed in a court proceeding. And some individuals
who are legally disqualified may have been committed to a private
facility whose records are not made available to the state

Fig. 4. Mean monthly predicted probabilities of first violent crime for persons with serious mental illness with and without a gun-disqualifying mental health record, before and
after NICS reporting began in Connecticut (n ¼ 23,282). Note: analysis excludes persons with disqualifying criminal records. Source: Adapted from Swanson JW, Robertson AG,
FrismanLK, NorkoMA, Lin HJ, Swartz MS, Cook PJ. Preventing gun violence involving people with serious mental illness. In Webster DWand VernickJS editors. Reducing gun violence
in America: informing policy with evidence and analysis. Baltimore: Johns Hopkins University Press; 2013:33e51.

J.W. Swanson et al. / Annals of Epidemiology 25 (2015) 366e376 373

authorities to report to the background check database. Even when
a person has a gun-disqualifying record reported to NICS, this does
not necessarily limit his or her ability to purchase a gun from a
private party, online, or at a gun show; for that, we would need
universal background checks. Finally, it must be noted that a sub-
stantial proportion of Americansdover 50%, in some states [77]d
live in households with existing guns and thus may not need to
legally purchase a new firearm to carry out a violent act if so in-
clined. Household gun ownership rates at the state level are a sig-
nificant positive predictor of both homicides and suicides [52,78].

Effectiveness of background checks: the Connecticut NICS
study

Despite all the barriers to the effectiveness and implementation
of background checks, what has been missing until recently is a
direct evaluation of the law and policy in a single state, using lon-
gitudinal individual-level outcome data for people with serious
psychiatric disorderswhohavebeen subjected to the law’s strictures
and exposed to theNICS-reporting policy, comparedwith thosewho
have not. A new study in Connecticut [69] has nowprovided the first
empirical evaluation of the effectiveness of gun-purchaser back-
ground checks based on the federal mental health prohibited cate-
gories and a state’s policy of reporting records to theNational Instant
Check System. Researchers matched records from the Connecticut’s
mental health, criminal justice, and court systems over an 8-year
period for 23,292 adults who had been diagnosed with schizo-
phrenia, bipolar disorder, or major depression, and hospitalized
either voluntarily or involuntarily. The study first examined the
prevalence of gun-disqualifying criminal records and mental health
adjudications, aswell as the overlapbetween these two categories of
disqualification in the sample. The researchers then used quasi-
experimental analysis to compare month-by-month trends in vio-
lent crime outcomes among the gun disqualified and not dis-
qualified, before and after NICS reporting began in 2007.

The Connecticut study reported a difference in effectiveness be-
tween two key groups: people who are clients of the public behav-
ioral health care system and do not have criminal records, and those
who are dually involved with the criminal justice system and the

behavioral health system. In the first group, the study found that the
Brady Lawwas not effective until after Connecticut began reporting
gun-disqualifying mental health records to the NICS in compliance
with the NICSA. After 2007, when comprehensive NICS reporting
began, the risk of violent crime in gun-disqualified persons was
reduced to levels slightly below the risk found in their counterparts
whowerenever disqualified. Specifically, violent crime risk declined
from 6.7% to 3.9% annually, or 53%; violent crime declined signifi-
cantly less in the comparison group with only voluntary (not gun
disqualifying) hospitalizations, from 5.9% to 3.9% annually, or 34%,
as shown in Figure 4. The NICS reporting effect could be credited
with the prevention of an estimated 14 violent crimes per year
among the 1118 people with a mental health disqualification.
However, because only a small fraction (about 7%) of the study
populationof personswith seriousmental illnesswas affectedby the
disqualifying policy, the overall impact on violent crime was very
smalldless than one half of 1% reduction: 598 crimes instead of 612
expected crimes among 15,524 people with mental illness.

In the second groupdthose who had gun-disqualifying criminal
recordsdthe researchers found that the Brady Law strictures had
no effect on reducing risk of violent crime recidivism. Indeed, being
criminally disqualified was a marker for significantly increased risk
of committing a future violent crime. To the extent that guns were
involved in the commission of these crimes by people who could
not legally buy a gun, it is clear that the perpetrators did not need to
patronize a federally licensed gun dealer and undergo a background
check; other means and suppliers abound for those willing to
exploit them.

Thus, the existing federal criteria for gun-disqualifying mental
health records are far from perfect; they are both overinclusive and
underinclusive. Still, the criteria are correlated with increased risk
of violent crime [69]. The results from this study, limited to a single
state, also show that the laws can work to reduce violent crime
initiation in people with serious mental illness, but only when
enforced through a background check system that contains the
records of disqualified individuals. Merely having a law on the
books that rescinds gun rights in conjunction with involuntary
commitment is not effective in reducing risk of a first violent crime.
However, for people not already disqualified from purchasing a gun

J.W. Swanson et al. / Annals of Epidemiology 25 (2015) 366e376374

by dint of a criminal history, having a mental health adjudication
record archived in the NICS can significantly reduce risk of a first
violent crime.

State policy approaches to preventing gun violence involving
people with mental illness

Many state laws mirror federal mental illness gun prohibitions,
but states have also implemented a variety of additional policies.
California prohibits firearm purchase and possession for 5 years for
individuals subjected to short-term emergency involuntary hospi-
talizations, in addition to those subject to full involuntary com-
mitments [79]. Florida prohibits people from accessing firearms if
they have been initially admitted involuntarily to a psychiatric
hospital, even if they subsequently agree to remain in the hospital
voluntarily [80]. In the aftermath of the Newtown shooting, New
York enacted the NY Secure Ammunition and Firearms Enforce-
ment Act of 2013, a controversial law that required mental health
professionals to report to law enforcement any patients considered
to pose a substantial risk of violence, so that the police could check
the reported patient’s name against the state’s handgun permit
registry and remove his or her handguns [81].

Indiana [82] and Connecticut [83] both have laws that allow law
enforcement to remove firearms from individuals exhibiting
dangerous behavior (who may or may not have mental illness). Il-
linois, in 2013, passed a “concealed carry” law [84] that included
extensive new requirements for mental health clinicians and others
to report persons to the Firearms Owner Identification system.
Persons who must be reported include individuals who have been
admitted to a psychiatric hospital and those determined to have a
developmental or intellectual disability [85]. To date, the effec-
tiveness of such policies has not been studied. These laws may be
well intentioned but could risk unintended adverse consequences,
such as deterring peoplewithmental health problems from seeking
care voluntarily, and reinforcing stigma associated with mental
illness [6,7].

Lessons learned and new opportunities for policy

Epidemiologic and other research data on the prevalence and
correlates of gun violence involving people with mental illness
make it clear that this is a multifaceted problemwhose solutionwill
require a range of policy approaches and reforms working together.
As we have demonstrated throughout this article, there are a
number of gaps in our knowledge about mental disorders, gun
violence, and effective policies to reduce the risk of gun violence
and suicide. President Obama recently issued a Presidential Mem-
orandum directing the CDC and other scientific agencies to conduct
such research, but it will take time and appropriation of funding to
address the knowledge gaps, a challenging task under any cir-
cumstances, but particularly difficult in a political environment
where firearms policy (whether evidence-based or not) remains a
highly contentious field of discourse.

Gallup polling data from January, 2013 showed that 48% of adult
Americans blame the mental health system “a great deal” for mass
shootings in the United States, whereas fewer (40%) blame easy
access to guns; an inadequate mental health system is perceived as
the top cause of mass shootings [86]. Our failing mental health-care
system on the one hand and gun violence on the other are each
complex, important, but different public health problems facing the
USdproblems that intersect at their edges. More research to sup-
port effective policies and implementation is needed in both arenas.
Public attention to the mass shootingsdtoo often fueled by ill-
informed and sensationalized media portrayals that

overgeneralize the connection between mental illness and vio-
lencedmust be redirected and channeled to build support for
evidence-based policies both to improve mental health care and
reduce gun violence, in ways that will promote public safety
without increasing stigma and unnecessarily infringing on the
rights and privacy of people with mental health conditions.

Calls for increased research funding on gun violence prevention
and policy development are being heard from several quarters. A
gun policy summit of national experts (including two of the au-
thors) convened at the Johns Hopkins Bloomberg School of Public
Health in January, 2013, and recommended that “[t]he federal
government. provide funds to the Centers for Disease Control and
Prevention, the National Institutes of Health, and the National
Institute of Justice adequate to understand the causes and solutions
of gun violence, commensurate with its impact on the public’s health
and safety” [87]. Similarly, a 2013 report from a partnership of the
National Physicians Alliance and the Law Center to Prevent Gun
Violence recommended “[b]uilding an evidence-based approach to
gun violence prevention, which includes restoration of robust
funding and training for epidemiologic research in this area (e.g.,
through the National Institutes of Health and the Centers for Dis-
ease Control and Prevention) and gathering data that track gun-
related deaths and injuries, safety interventions, and the impact
of measures to reduce the incidence of gun violence over time” [88].
An article authored by physicians in family medicine and internal
medicine calls for “Federal legislation or rule making [that] could
help define national standards and guidelines on what constitutes
mental and physical competence to carry a concealed weapon and
who can make those assessments [along with] additional research
[to] help establish standards . ” [89].

In 2013, the Consortium for Risk-Based Firearm Policy, a group of
the nation’s leading researchers, practitioners, and advocates in gun
violence prevention and mental health, convened to review the
relevant research evidence and formulate policy recommendations
[90,91]. The groups’ recommendations, which are based onmuch of
the epidemiologic evidence summarized in this article, include the
following:

Recommendation 1: The federal government should clarify and
refine existing mental health firearm disqualification criteria
relating to involuntary commitment, and state laws should be
strengthened to temporarily prohibit individuals from pur-
chasing or possessing firearms after a short-term involuntary
hospitalization. Concurrently, the process for restoring firearm
rights should be modified to better protect the public while
being fair to individuals who seek to regain their rights.

Recommendation 2: Congress and state legislatures should
enact new restrictions on purchase and possession of firearms
by individuals whose behavior presents evidence-based risk
factors for violence. Categories of persons prohibited from fire-
arms on a temporary basis should be expanded to include in-
dividuals convicted of a violent misdemeanor, subject to a
temporary domestic violence restraining order, convicted of two
or more offenses for driving while intoxicated or driving under
the influence of alcohol or drugs in a period of 5 years, or con-
victed of two or more misdemeanor crimes involving a
controlled substance in a period of 5 years. Focusing on these
and other known and identifiable risk factors as the criteria for
limiting firearm access, rather than relying primarily on existing
status-based mental health criteria, will more effectively target
those who are likely to be a danger to others or themselves.

Recommendation 3: States should develop a mechanism to
authorize law enforcement officers to remove firearms when
they identify someone who poses an immediate threat of harm

J.W. Swanson et al. / Annals of Epidemiology 25 (2015) 366e376 375

to self or others. States should also create a mechanism autho-
rizing law enforcement officers to request a warrant authorizing
removal of firearms when the risk of harm to self or others is
credible, but not immediate. In addition, states should create a
new civil restraining order process to allow family members and
intimate partners to petition the court to authorize removal of
firearms and to prohibit firearm purchase and possession
temporarily based on a credible risk of physical harm to self or
others, even when domestic violence is not an issue.

Conclusions

We do not know in advance the specific form and features of the
most effective policies that will address the national problem of gun
violence and suicide at its interface with mental health problems,
services, and systems. We do know that such policies must work
together to target the diverse web of causal pathways that are
involved with the problem, and we do know that the strategy must
balance a commitment to public safety and respect for persons with
serious mental illness as well as the constitutionally protected
rights of lawful gun owners [92]. Policies must be pursued, which
do not further stigmatize individuals with serious mental illness or
discourage them from seekingmental health treatment. Evidence is
clear that the large majority of people with mental disorders do not
engage in violence against others, and that most violent behavior is
due to factors other than mental illness. However, psychiatric dis-
orders, such as depression, are strongly implicated in suicide, which
accounts for more than half of gun fatalities. An emphasis on time-
sensitive risk for violence or suicide, as the foundation of evidence-
based criteria for prohibiting firearms access, would be a more
productive policy approach to prevent gun violence than focusing
broadly on mental illness diagnoses and a record of involuntary
psychiatric hospitalization at any time in one’s life.

Acknowledgment

Dr. Swanson’s research effort was support by grant funding from
the National Institute of Mental Health (K02-MH67864), the Na-
tional Science Foundation (SES-1060949), the RobertWood Johnson
Foundation’s program on Public Health Law Research, the Brain and
Behavior Research Foundation, and theElizabethK.Dollard Trust. Dr.
Fazel received funding from theWellcome Trust (095806). Dr. Mays
was supportedby theNational InstituteofHealth’sNational Institute
for Minority Health and Health Disparities (MD006923).

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  • Mental illness and reduction of gun violence and suicide: bringing epidemiologic research to policy
    • Public perceptions of the relationship between mental illness and violence
    • Epidemiologic evidence on the relationship between mental illness and violence
    • Mental illness, guns, and suicide
    • Gun access and mental illness
    • Predicting risk of future violence
    • The federal policy approach to preventing gun violence involving people with serious mental illness
    • Effectiveness of background checks: the Connecticut NICS study
    • State policy approaches to preventing gun violence involving people with mental illness
    • Lessons learned and new opportunities for policy
    • Conclusions
    • Acknowledgment
    • References

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EL PASO • SAN BRU

HOUSTON • CH
• ALEXANDRIA

NATIONAL COUNCIL
MEDICAL DIRECTOR INSTITUTE

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MASS VIOLENCE IN AMERICA

National Council Medical Director Institute
The National Council for Mental Wellbeing (National Council) is the largest organization of mental
health and addictions treatment programs in the United States, serving 10 million adults, children and
families with mental health and substance use disorders. In this capacity, it performs important orga-
nizational, educational and advocacy functions and serves as a unifying voice for its 3,000 member
organizations. The National Council is committed to all Americans having access to comprehensive,
high-quality, affordable care that provides every opportunity for recovery.

In 2015, the National Council Board of Directors commissioned the Medical Director Institute (MDI) to
advise National Council members on best clinical practices and to address major priorities in care for
mental illnesses and substance use disorders. The MDI develops policies and initiatives that serve mem-
ber behavioral health organizations and their constituent clinicians and the governmental agencies and
payers that support them.

The MDI is composed of medical directors of organizations who have been recognized for their out-
standing leadership in shaping psychiatric and addictions service delivery and draws from every region
of the country. One of the ways the MDI fulfills its charge is by developing technical documents that
highlight challenges at the forefront of mental health and addictions care, providing guidance and
identifying practical solutions to overcome those challenges. Topics of prior scholarly reports and white
papers include “The Psychiatric Shortage — Causes and Solutions” and “Medication Matters — Causes
and Solutions to Medication Non-Adherence.” This report addresses the problem of mass violence in the
United States and, specifically, the extent to which mental illness is or is not contributing to this social
pathology. The report was done because mass shootings are increasing in frequency and severity, and
they have captured the national attention.

The Mass Violence Expert Panel Process
The MDI convened a panel of individuals with diverse expertise pertaining to mental health care and
violence — including clinicians who treat individuals with mental illnesses and substance use disorders,
administrators, policymakers, researchers, educators, advocates, law enforcement personnel, judges,
parents and payers — for a two-day meeting focused on an in-depth review and analysis of mass
violence that integrated multiple perspectives. Panel members provided input from their practical expe-
rience and research from their area of expertise, including their unique perspectives on the problem of
mass violence. (See Expert Panel on page 73 for a full list of participants.)

The agenda was structured to review specific topics, vet relevant content and build consensus through
discussion and debate. The meeting resulted in practical solutions that meet the test of feasibility and
effectiveness based on the conclusions of the expert panel.

A technical writer and co-editors served as recorders for the proceedings, compiled the literature sub-
missions from the panel members and drew on other sources for the background material. While we
did not use a formal scoring system that weighted each publication or source of information, we syn-
thesized what we believe are the best substantiated and consistent findings across the literature, while
relying on the consensus of the panel members for areas with less empirical research.

The technical writer and co-editors completed a first draft that was circulated to all panel members.
Their written comments and feedback were incorporated into a second draft. The process was repeated
until the final document was completed.

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The goal of this paper is to examine existing data and expertise on mass violence, provide an analy-
sis about its causes and impacts and make recommendations to inform policy and practice for a wide
range of stakeholders. These include the federal Departments of Justice and Health and Human Services
and the Substance Abuse and Mental Health Services Administration; provider organizations; profes-
sional trade organizations for psychiatrists, psychologists, social workers and other behavioral health
professionals; consumer and family advocacy groups; state mental health authorities; policymakers in
the behavioral health arena; educators; judges; law enforcement officers; and workplace representatives.

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EXECUTIVE SUMMARY

EXECUTIVE SUMMARY
Among advanced countries, the US has a unique problem with mass violence — defined as crimes
in which four or more people are killed in an event or related series of events. A substantial majority
occurs by shooting. Both the rate at which mass shootings occur and the number of people killed are
increasing. Frequently, in the wake of such tragedies, policymakers and the public raise the specter of
mental illness as a major contributing factor.

The National Council for Mental Wellbeing Medical Director Institute convened an expert panel to ana-
lyze the root causes of mass violence, its contributing factors, the characteristics of perpetrators and
the impacts on victims and society. The panel specifically examined the extent to which mental illness is
or is not a contributing factor to this social pathology and developed recommendations for a broad
range of stakeholders. A summary of their deliberations and conclusions follow.

Mass Violence Is a Rare Event
Despite the fear and public scrutiny they evoke, mass shootings are statistically rare events. Mass
shootings accounted for less than two-tenths of 1 percent of homicides in the United States between
2000 and 2016. Even school shootings, the most tragic of such events, are infrequent. People are more
likely to intentionally kill themselves with a gun than to be killed by a gun in a mass shooting or other
type of homicide.

Perpetrators Share Certain Characteristics
While perpetrators of mass violence can be categorized with respect to motivation, the characteris-
tics of individual perpetrators cut across demographic, sociologic, cultural and occupational groups.
The characteristics that most frequently occur are males, often hopeless and harboring grievances that
are frequently related to work, school, finances or interpersonal relationships; feeling victimized and
sympatizing with others who they perceive to be similarly mistreated; indifference to life; and often
subsequently dying by suicide. They frequently plan and prepare for their attack and often share infor-
mation about the attack with others, though often not with the intended victims.

Mental Illness Plays an Important but Limited Role in Mass Violence
Incidents of mass violence — especially those that appear to be senseless, random acts directed at
strangers in public places — are so terrifying and traumatic that the community responds defensively
and demands an explanation. After such events, political leaders often invoke mental illness as the
reason for mass violence, a narrative that resonates with the widespread public belief that mentally ill
individuals in general pose a danger to others. Since it is difficult to imagine that a mentally healthy
person would deliberately kill multiple strangers, it is commonly assumed that all perpetrators of mass
violence must be mentally ill.

The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edi-
tion (DMS-5), provides a catalog of diverse brain-related health conditions that impair a person’s normal
ability to reason and perceive reality, regulate mood, formulate and carry out plans and decisions, adapt
to stress, behave and relate to others in socially appropriate ways, experience empathy, modulate con-
sumption and refrain from intentional self-injury — or various combinations of such problems. While a
subset of people perpetrating mass violence has one of the more severe mental illnesses or personal-
ity disorders, many do not. Lumping all mental illness together, and then assuming that acts that seem

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EXECUTIVE SUMMARYEXECUTIVE SUMMARY

incomprehensible to the average person are due to mental illness, results in millions of harmless, nonvio-
lent individuals recovering from treatable mental health conditions being subjected to stigma, rejection,
discrimination and even unwarranted legal restrictions and social control.

Simplistic conclusions ignore the fact that mass violence is caused by many social and psychological
factors that interact in complex ways; that many, if not most, perpetrators do not have a major psychi-
atric disorder; and that the large majority of people with diagnosable mental illnesses are not violent
toward others.

While there is a modest link between mental illness and violence, there is no basis for the public’s
generalized fear of people with mental illness. Having a psychiatric diagnosis is neither necessary nor
sufficient as a risk factor for committing an act of mass violence. For that reason this report has a
broader range of considerations and recommendations beyond the subset of all mass violence with a
link to mental illness.

While there is increasing demand to identify potential perpetrators of violence and develop preven-
tive measures, there has been insufficient research on the root causes of the problem or resources to
address them. Such causes include social alienation and social problems (including deficiencies in the
educational system, poverty, discrimination, the lack of job opportunities, etc.), as well as the lack of
quality and comprehensive mental health care.

Threat Assessment and Management May Help Prevent Mass Violence
Threat assessment, a term that originated in law enforcement, is a strategy to prevent violence targeted
at public figures and other people who are threatened by someone. Threat assessment is no longer
considered a single assessment but rather an ongoing assessment process with interventions designed
to prevent violence.

A threat assessment team within a business or school is a multidisciplinary group that includes rep-
resentatives from security and law enforcement, behavioral health care, human resources, legal and
management, among others. Rather than examine individual characteristics, the team looks at where a
person is on the pathway to violence and assesses the individual’s risk factors. There are many points
along that pathway at which the situation can be defused. For example, school-based teams identify the
need for services and offer in-house or referral services.

Mass Violence in Schools Prompts Ill-considered Policy Decisions
Though schools are much safer than the public might believe, school shootings grab national headlines
that lead to some ill-considered policy decisions. One example is the use of zero-tolerance policies
in schools. The result is that students are suspended for a variety of minor misbehaviors, sometimes
unnecessarily, potentially creating isolation and resentment that can lead to more and more serious,
problematic behaviors.

In addition, excessive security measures include bulletproof building entrances, electronic door locks,
metal detectors and panic rooms with video monitors. The use of school-shooter drills, in some cases
not announced in advance, may lead students and staff to believe that an active shooting is occurring
and can be psychologically traumatizing. Though some safety drills are warranted, those that evoke fear
and create trauma do more harm than good.

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EXECUTIVE SUMMARY

A Communitywide Problem Demands a Communitywide Solution: The
Role for Health Care Providers, Law Enforcement and the Courts
Mass violence is a communitywide problem that can’t be solved by any one organization or system
alone. The following play a key role.

Primary Care Providers

Primary care offers a potential opportunity to uncover, diagnose, refer and treat underlying mental
disorders (e.g., conduct disorder, depression, psychosis). In response to mass violence, primary care and
behavioral health teams have developed innovative ways of working together to support children and
their families.

Behavioral Health Providers

Although there is a modest link between mental illness and violence, the timely availability of qual-
ity mental health treatment can be limited, especially in some areas of the country, but communities
can assist in identifying the best access points. Community mental health centers and mental health
treatment providers play an essential role in the systems of care for individuals with mental health
symptoms, especially those with the greatest, often unmet, needs. Additionally, they play a vital role
in the community response to a mass violence incident. Behavioral health providers offer support to
victims and their families, to first responders and to the community at large and deliver a variety of evi-
dence-informed, trauma-specific therapies. They play an important role in the critical incident response
and command structure and leverage key relationships to support a reeling community. Sometimes they
are called on to define the role that mental illness may have played in the incident.

Law Enforcement

In many parts of the country, local, state and federal law enforcement officials are being trained to
respond to calls that involve people in crisis, including but not limited to those with mental illnesses. The
goal is for officers to divert these individuals from the legal system by diffusing the situation, working
collaboratively with their mental health colleagues and the individuals’ natural supports and linking the
individuals to services.

Courts

There are now more than 3,000 problem-solving courts (e.g., drug courts, mental health courts) across
the country. These interdisciplinary and collaborative courts help fill gaps in psychosocial services, pro-
vide early identification and intervention with individuals who may be at risk for violence and extend the
reach of an often under-resourced and overworked behavioral health treatment system. In an increasing
number of states, judges can order extreme-risk protection orders resulting in the temporary removal
of firearms when there are high levels of concern that gun violence could occur. The legal system across
the spectrum — from family/juvenile courts to domestic violence, truancy, veterans’, mental health and
DWI courts — may be viewed as early interveners in identifying potential dangerousness.

Working with the Media Can Help Educate the Public

In the age of 24-hour cable news and the internet, it has become increasingly difficult to control the narra-
tive about a mass violence event. Before many facts can be gathered, real-time speculation of the role of
mental illness — by reporters, pundits and mental health professionals with little concrete information —
can lead to unjust characterizations of all people with mental illness, as well as unfair speculation about
the links between violence and mental illness.

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EXECUTIVE SUMMARYEXECUTIVE SUMMARY

But subject matter experts may have an opportunity to help educate the media and the public about
mental illness by dispelling myths about mental illness and violence, providing a framework for under-
standing these rare but disturbing events and offering general information about mental illness
treatment and services and the problems caused by lack of access to them.

Recommendations

The National Council Expert Panel on Mass Violence developed a number of specific recommendations
for key stakeholders. Highlights of the recommendations follow.

General Recommendations

• Identify root causes of mass violence and develop strategies to alleviate them instead of focusing
only on quick fixes downstream from the sources of the problem.

• Mental health providers and advocacy groups must acknowledge the role mental illness plays in
mass violence and support efforts to prevent the subset of mass violence perpetrated by people
with mental illness.

Recommendations for Health Care Organizations

• Establish multidisciplinary threat assessment and management teams that include representatives
from security, human resources, legal and law enforcement.

• Implement ongoing quality improvement around the issues of violence risk assessment and threat
assessment and management.

• Train staff in lethal means reduction. This is a rational strategy for lethal violence reduction and very
helpful in combating suicide.

• Prepare staff for vicarious trauma and compassion fatigue. Provide resources for self-care rituals and
support for staff needs.

Recommendations for Schools

• Revise zero-tolerance policies and the effects of suspensions and expulsions as they are ineffective
and harmful practices. Rely instead on a well-trained multidisciplinary threat/risk assessment and
management team.

• Avoid measures that create a correctional facility-like atmosphere such as bulletproof glass, armed
security guards and metal detectors. More commonsense measures such as limited entry points into
the school can be just as effective and cost little to implement.

• Refrain from high-stress security drills (for example, those in which students are not informed they
are participating in a drill), which can themselves be traumatizing.

• Encourage an emotionally connected safe-school climate where each student can feel comfortable
coming forward to a responsible adult with matters of concern.

• Emphasize and train staff in interpersonally based and emotionally supportive prevention measures
that include the impact of trauma and indications for referral for mental health treatment, such as
Child and Youth Mental Health First Aid, bereavement support and academic accommodations.

• Implement universal social-emotional learning and add mental health to the school
health curriculum.

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EXECUTIVE SUMMARY

Recommendations for Communities for Identifying and Intervening with Higher-Risk Groups
and Individuals

• Create and support broad community partnerships that include behavioral health, law enforcement,
schools, the faith and medical communities, etc., to strengthen the connections among those sys-
tems that interact with individuals who have mental illnesses and addictions and may be at risk for
committing violence.

• Prioritize as high risk those individuals with narcissistic and/or paranoid personality traits who
are fixated on thoughts and feelings of injustice and who have few social relationships and recent
stresses and those with new onset psychosis.

• Establish threat/risk assessment and management teams. These multidisciplinary teams should
include representatives from mental health, security, human resources, legal and law enforcement.

• Provide training in Mental Health First Aid, which teaches skills to respond to the signs of mental and
substance use disorders.

Recommendations for Judicial, Correctional and Law Enforcement Institutions

• Develop a basic educational toolkit for judges on the nuances of risk assessment, the role of trauma
and the need for additional supports for individuals who may pose risks for violence.

• Involve mental health professionals in threat assessments conducted by law enforcement and imple-
mentation of red flag laws.

• Provide training in Mental Health First Aid, which teaches skills to recognize and work with individu-
als who have mental illnesses, for law enforcement, corrections and public safety officials.

Recommendations for Legislation and Government Agencies

• Pass legislation to increase the availability of threat assessment training at the local, state, tribal and
national levels.

• Develop a payment methodology for threat assessment and management.

• Promote expansion of the Certified Community Behavioral Health Clinic (CCBHC) model because
these clinics are required to provide extensive crisis response capability, and the CCBHC prospective
payment model can support the development and operation of threat assessment teams.

• Enact state red flag or extreme-risk protection orders that allow the temporary removal of guns from
individuals who are known to pose a high risk of harming others or themselves in the near future.

• Fully implement the existing federal background check requirement for firearms purchases.

Recommendations for Research

• Support research on the nature and factors that contribute to mass violence, including neurobiologi-
cal, psychological and sociological factors.

• Support research on methods and instruments for identifying and predicting perpetrators of
mass violence.

• Support research on methods of intervention and prevention of mass violence.

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EXECUTIVE SUMMARY

• Create a standardized, mandatory investigation/analysis of each mass violence incident conducted
by a multiagency team lead by the Department of Justice.

• Evaluate extreme-risk protection orders in states that have enacted them to assess both the process
of implementation and their effectiveness.

Recommendations for Working with the Media

• Build close working relationships with media representatives ahead of any crisis situation.

• Choose and disseminate existing guidance, such as that offered at https://www.reportingonmass
shootings.org/, and encourage reporters to follow these guidelines.

• Train behavioral health staff who will respond to the media. Develop protocols about who should
respond to what type of request and what they should say. Develop these messages well in advance
of a tragic event.

• Talk about the role of treatment in helping people at risk of violence. Highlight the fact that most
people with mental illnesses will never become violent. Speak to untreated or undertreated mental
illness in combination with other risk factors.

• Work with the media to develop guidance for the general public on risk factors for violence. Help the
public understand the importance of “see something, say something.”

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INTRODUCTION ……………………………………………………………………………………………………………………………….. 1

Terminology …………………………………………………………………………………………………………………………………………. 4

SCOPE OF THE PROBLEM …………………………………………………………………………………………………………………….. 5

Prevalence of Mass Violence …………………………………………………………………………………………………………………… 5

Characteristics of Mass Violence Perpetrators ……………………………………………………………………………………………. 9

The Role of Mental Illness in Violence in General …………………………………………………………………………………….. 12

The Role of Mental Illness in Mass Violence …………………………………………………………………………………………….. 14

IDENTIFYING HIGH-RISK PERSONS …………………………………………………………………………………………………… 17

Threat Assessment and Management ………………………………………………………………………………………………………. 17

METHODS OF MASS VIOLENCE…………………………………………………………………………………………………………… 21

VENUES OF MASS VIOLENCE ………………………………………………………………………………………………………………. 29

Mass Violence in Schools ……………………………………………………………………………………………………………………… 29

Policy Mistakes ……………………………………………………………………………………………………………………………. 29

A Safe, Supportive School Environment ……………………………………………………………………………………… 30

Threat Assessment and Management in Schools ………………………………………………………………………… 31

Recognizing and Responding to Trauma in the Wake of a School Shooting ……………………………….. 34

Helping Families Heal ………………………………………………………………………………………………………………………….. 35

A PUBLIC HEALTH MODEL OF PREVENTION ……………………………………………………………………………………… 37

Opportunities for Prevention ………………………………………………………………………………………………………………… 37

See Something, Say Something …………………………………………………………………………………………………… 38

Community Intervention Programs ……………………………………………………………………………………………… 38

A Role for Treatment Providers ……………………………………………………………………………………………………………… 38

Prevention …………………………………………………………………………………………………………………………………… 39

Response …………………………………………………………………………………………………………………………………….. 41

A Role for Primary Care Providers …………………………………………………………………………………………………………. 43

Courts and Law Enforcement Working with Youth ……………………………………………………………………………………. 44

IMPACT ON COURTS AND LAW ENFORCEMENT ………………………………………………………………………………… 46

Therapeutic Jurisprudence in Problem-solving Courts ………………………………………………………………………………. 46

Law Enforcement Training and Co-responder Models ……………………………………………………………………………….. 48

Involuntary Commitment ……………………………………………………………………………………………………………………… 49

MEDIA AND MASS VIOLENCE ……………………………………………………………………………………………………………… 50

Working with Reporters ……………………………………………………………………………………………………………………….. 52

CONCLUSIONS …………………………………………………………………………………………………………………………………….. 54

RECOMMENDATIONS ………………………………………………………………………………………………………………………….. 55

General Recommendations …………………………………………………………………………………………………………………… 55

Recommendations for Health Care Organizations ……………………………………………………………………………………. 55

Recommendations for Schools ………………………………………………………………………………………………………………. 57

Recommendations for Communities ………………………………………………………………………………………………………. 58

Recommendations for Judicial, Correctional and Law Enforcement Institutions ……………………………………………. 59

Recommendations for Legislation and Government Agencies …………………………………………………………………….. 60

TABLE OF CONTENTS

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Recommendations for Research …………………………………………………………………………………………………………….. 60

Recommendations for Working with the Media ……………………………………………………………………………………….. 63

SUMMATION ……………………………………………………………………………………………………………………………………….. 64

REFERENCE LIST ………………………………………………………………………………………………………………………………….. 65

EXPERT PANEL …………………………………………………………………………………………………………………………………….. 73

ONLINE RESOURCES …………………………………………………………………………………………………………………………… 75

RESOURCES …………………………………………………………………………………………………………………………………………. 78

TABLE OF CONTENTS

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MASS VIOLENCE IN AMERICA

INTRODUCTION

INTRODUCTION
In the United States, the National Violent Death Reporting System produces counts of homicides by
mechanism, stratified by a single victim or two or more victims. The United States has more mass
violence, when defined as crimes in which four or more people are shot in an event or related series
of events, than any other country in the world (Wintemute, 2015). For the states reporting for the past
five years, guns were used in 82 percent of multiple victim incidents and 68 percent of single victim
incidents; thus, in the United States, mass violence is often synonymous with gun violence. A large
majority of the perpetrators are males who use guns to kill, act alone and ultimately either die by sui-
cide or are killed by law enforcement officers or civilians at the scene of the attack. In some instances
when officers kill the perpetrator, the perpetrators may have intentionally provoked law enforcement
to kill them in a phenomenon known as “suicide by cop” or “law enforcement-assisted suicide.” In still
other scenarios, the perpetrators are captured alive and subsequently tried and incarcerated or insti-
tutionalized, depending on the legal verdict.

Studies indicate that the rate at which mass shootings occur has tripled since 2011. Between 1982 and
2011, a mass shooting occurred roughly once every 200 days. However, between 2011 and 2014, that
rate accelerated greatly, with at least one mass shooting every 64 days (Cohen, Azrael, & Miller, 2014;
Lemieux, 2014; Blair & Schweit, 2014).

Mass Shootings Since 2011: Every 64 Days on Average

600

200

400

0

800

1,000

1982 1999 2011 2014

Year Data analysis by Harvard School of Public Health

Average Number of Days between Shootings1 Incident

D
ay

s
Si

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e

P
re

vi
o

us
M

as
s

Sh
o

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ti

ng

Stockton schoolyard

Luby’s massacre

Long Island Rail Road

Columbine

Virginia Tech

Fort Hood

Giffords/
Tuscon

Aurora

Newtown

DC Navy Yard

Since Sept. 6, 2011
(IHOP shooting)

200

64

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MASS VIOLENCE IN AMERICA

INTRODUCTIONINTRODUCTION

Moreover, the number killed and injured during these incidents increased as well (Stanford Mass
Shootings in America, 2015).

Number of Victims of U.S. Mass Shootings, 1966–2015

And this is happening against the backdrop of an overall decline in violent crime in the United States
(Asher, 2018).

Murders per 100,000 Population

40

20

0

60

80

100

120

1976 1978 1980 1982 19841966 1968 1970 1972 1974 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014

Year Data Source: Stanford Geospatial Center, Mass Shootings in
America Database (accessed in June of 2015)

Number of Victim Fatalities Number of Victims Injured

0

2

4

6

8

10

12

1960

1961

1962

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1964

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1968

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2008

2009

2010

2011

2012

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2014

2015

2016

2017

M
ur

de
rs

p
er

1
0

0
K

Year Jeff Asher / @CrimeAnalytics

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MASS VIOLENCE IN AMERICA

INTRODUCTION

While mass shootings accounted for less than one-tenth of 1 percent of homicides in the United States
between 2000 and 2016 (Follman, Aronsen, & Pan, 2019; Centers for Disease Control and Prevention,
2018), mass violence evokes disproportionately greater public, media and government reaction than
other forms of violence (gang, organized crime, robbery, etc.).

Mass violence occurs in various settings, including schools, universities, workplace and domestic set-
tings and public buildings (e.g., movie theaters, shopping malls, retail stores, etc.). While each mass
violence incident has its unique motivations and circumstances, the perpetrators of mass violence pre-
dominantly fall into several motivational categories: ideologically extreme individuals (e.g., terrorists);
current or former disgruntled employees, students or domestic partners seeking revenge; disaffected
loners; and people with mental illness (mostly psychosis, depression, posttraumatic stress disorder and
substance use) whose symptoms may have played a role. These categories are useful for descriptive
purposes but are not wholly precise in that there is considerable overlap among them. For example,
some individuals with illnesses may be more susceptible to solicitation by extremist groups and ideol-
ogies or to becoming marginalized by society and thus disaffected, lonely and alienated. Mental illness
is not the main driver of mass violence and there are many misunderstandings and much speculation
about the role of mental illness.

Following events involving mass shootings, reaction predictably breaks along two lines in the United
States: gun-centric — those who call for either broader use of guns or greater restrictions on specific
firearms, the most common means of mass violence — and mental illness-centric — those who, blaming
mass violence on mental illness, call for a series of actions that include restricting people with mental
illnesses from possessing firearms and re-institutionalizing people with mental illnesses. These positions
gloss over certain complexities and available data on mass violence in the United States.

People with mental illness account for a very small amount of all violent crime in the United States.
However, individuals with a diagnosis of mental illness (previously diagnosed by a mental health pro-
vider) are overrepresented in the category of mass violence crimes. At the same time, policies that
propose to restrict their access to firearms, or that require data on individuals receiving Social Secu-
rity Disability for reasons of mental illness as part of the National Instant Criminal Background Check
System (NICS), ignore the fact that there are many other risk factors for criminal violence, such as
substance use, poverty, gang affiliation, employee disgruntlement, poor peer influences, etc. No single
policy or program is going to address the complex problem of mass violence, so no individual interven-
tion should be discounted for not solving the whole problem.

In the criminology literature, mental illness is not identified as one of the major factors associated with
criminal recidivism. Generally, the factors associated with criminal recidivism involve antisocial personal-
ity traits, behavior, substance use and peers, as well as limited structured activity through school, work
and leisure and family discord (Andrews and Bonta, 1995).

Those who attribute mass violence to mental illness often erroneously assume that psychiatric eval-
uation and diagnosis alone should be able to prevent such events from happening. There are two
problems with this assumption. First, although researchers have identified many individual risk factors
for violence in the general population and developed standardized instruments and protocols that are
useful in evaluating the violence potential in people, their ability to determine exactly who will be, and
when they will be, violent is still limited. Applying these risk factors in clinical settings to evaluate the
potential for violence in people with mental illness is useful but not fully reliable. While there are iden-
tified risk factors for violence among those with mental illness, they are sensitive but not specific, and
because of the low incidence, there is a problem of false positives. In addition, the risk assessments can

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SCOPE OF THE PROBLEMINTRODUCTION

identify people at greatest risk but not when their violent actions may occur. Moreover, only a small por-
tion of those people identified as having increased risk ever perpetrate mass violence.

The second, perhaps more important, problem is the fact that the availability of quality treatment
for people in need is limited. Thus, individuals who could be treated, thereby potentially preventing
an act of violence, go wanting. So, while there is increasing demand to identify potential perpetra-
tors of violence and develop preventive measures, there have been insufficient efforts and progress
toward identifying the root causes of the problem or resources to address them. Causes include social
problems (including deficiencies in the educational system, poverty, discrimination, the lack of job
opportunities, etc.), as well as the lack of quality and comprehensive mental health care. In this context,
mass violence is the tip of an iceberg of more fundamental social problems in our country.

Terminology
“Mass violence” is a term that encompasses all physical assaults with implements to cause injury
(including knives, clubs, motor vehicles, guns, assault weapons, bombs, etc.). In the context of the MDI
Expert Panel Meeting, mass violence is used broadly to include a wide range of violent acts and events.
While there are many means by which mass violence can be committed, much of the research pre-
sented and discussion that follows refers specifically to mass shootings, because they result in greater
loss of lives and emotional impact on the public and will be so noted.

Unless otherwise specified, the term “mental illness” specifically refers to the more serious disorders
in the American Psychiatric Association’s (2013) Diagnostic and Statistical Manual of Mental Disorders,
Fifth Edition (DSM-5), including psychotic disorders (e.g., schizophrenia), mood disorders (e.g., bipolar
and major depressive disorder), anxiety disorders (e.g., panic disorder), obsessive-compulsive disorder,
post-traumatic stress disorder, dissociative disorders, autism spectrum disorders and developmental
disabilities and dementias (e.g., Alzheimer’s disease). Substance use disorders are also considered when
co-occurring with mental illnesses. While the term mental illness broadly refers to those conditions in
DSM-5, it is known that only a very small number of diagnoses are actually associated with violence
potential as the result of the illness itself. As will be seen, different definitions of what constitutes a men-
tal illness yield different conclusions about the role that mental illness plays in mass violence incidents.
The definitions used by different organizations and studies of mass violence are numerous and varied.

Along with mental illness, additional language around mental wellness or resilience reflects a pattern of
adaptive thoughts, emotions and behaviors. Most individuals will acknowledge that they live somewhere
between these two poles and where they land at any particular moment will depend on the current con-
text and their past experiences. The fact that someone occasionally acts impulsively or angrily does not
mean they have a mental illness.

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SCOPE OF THE PROBLEM
How mass violence is defined affects not only the prevalence and scope of the problem, but also how
one describes the characteristics of the perpetrators. Researchers have used different definitions for
mass violence that consider the motivation of the perpetrator, the number of victims and the setting for
the crime. Most definitions are limited to mass shootings, where there are at least three victims killed
in one event, often killed indiscriminately in a public place, such as a school, concert or movie theater.
Definitions also vary between mass murder (fatalities) and mass shootings (fatal and nonfatal injuries).
For example:

• Federal Bureau of Investigation (FBI) report, 2008: A mass murderer — versus a spree killer or a
serial killer — [is one who] kills [by any method] four or more people in a single incident (not includ-
ing himself), typically in a single location.

o Shifting fatality criterion: In 2013, criterion was revised down to three or more deaths.

• Congressional Research Service report, 2013: Public mass shooting incidents [other methods
excluded] occurring in relatively public places, involving four or more deaths — not including the
shooter(s) — and shooters who select victims somewhat indiscriminately.

o Motivational criteria: “The violence in these cases is not a means to an end — the gunmen do not
pursue criminal profit or kill in the name of terrorist ideologies, for example.”

• Stanford Mass Shootings of America project, 2015: Mass shootings [are incidents with] three or more
shooting victims (not necessarily fatalities), not including the shooter.

o No fatality threshold — counts shooting survivors — and excludes “ordinary” street violence: “The
shooting must not be identifiably gang, drug or organized crime related.”

• Mother Jones Guide to Mass Shootings in America: The perpetrator took the lives of at least four
people…The killings were carried out by a lone shooter [with a few exceptions]…in a public place.

o Excludes most family/domestic homicides: “The shooting occurred in a public place.”

The majority of definitions consider a mass violence incident to be one in which more than three or
four people are killed by shooting in a single event by an individual or individuals who are not engag-
ing in the act as part of an organized political group. In addition, these definitions do not include mass
violence linked to family violence, either in the form of domestic abuse or violence with intent to kill
family members.

Prevalence of Mass Violence
Overall violence in the United States is declining. As noted, data over the past 50 years show a down-
ward trend in the homicide rate, with a slight upward tick in 2015–2016. Much of the upward trend in
2015–2016 appears to be firearms related; other methods of killing someone have remained stable over
time (Pifer & Minino, 2018).

6

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Rates of Homicide by Method 2010–2016

However, it is important to note that certain forms of violence that are less recognized, most notably
firearm suicide, are related and often present in acts of mass violence, display strong geographic vari-
ation and have been increasing substantially in the past decade (Branas, Nance, Elliott, Richmond, &
Schwab, 2004).

Research trends of mass shootings and single active shooter incidents as variously defined indicate an
increase in number and frequency. In addition, the intervals between them seem to be getting shorter
and the toll of injuries and deaths seems to be becoming greater. Data from Fox and DeLateur (2014),
Stanford Mass Shootings in America, (2015, p. 6), Blair & Schweit (2014) and Mother Jones (based on
press reports) attest to this fact.

Mass Killings with Firearms in the U.S., 1976–2014

0

2,000

10,000

12,000

14,000

16,000

2010 2011 2012 2013

Year
2014 2015 2016

N
o.

o
f

H
o

m
ic

id
es

CDC MMWR 67(29);806

Firearms Cutting/Piercing Suffocation

40

20

0

60

80

100

120

140

160

1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1997 1998 2000 2002 2004 2006 2008 2010 2012 2014

Year

Incidents Victims

Fox & Delateur, Homicide Studies, 2014

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MASS VIOLENCE IN AMERICA

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A Study of 160 Active Shooter Incidents in the United States Between 2000–2013
Incidents Annually

Mass Shootings

10

5

0

15

20

25

30

2002 2003 20042000 2001 2005 2006 2007 2008 2009 2010 2011 2012 2013

Year Blair & Schweit / FBI, 2014

1

6
4

11

4

9
10

14

8

19

26

10

21

17

40

20

0

60

80

100

120

1986 1988 19901982 1984 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 2017†

Year
*Shootings with three or more fatalities excluding perpetrator(s). Before January 2013, with four or more fatalities. Not comprehensive. †At 6am CST, November 6

Individual Incident Individual Incident with More than Ten Fatalities

Sources: Mother Jones; press reports

21 McDonald’s
restaurant

San Ysidro, CA

14 Post Office
Edmond, OK

23 Luby’s cafeteria
Killeen, TX

13 Columbine
High School
Littleton, CO

32 Virginia Tech
Blacksburg, VA

13 American Civic Association Centre, Binghamton, NY

12 Movie theatre, Aurora, CO

27 Sandy Hook Elementary School, Newton, CT

12 Navy Yard, Washington, DC

14 Inland Regional Centre, San Bernadino, CA

49 Pulse nightclub, Orlando, FL

58 Las Vegas Strip, Las Vegas, NV

26 First Baptist Church, Sutherland Springs, TX

13 Army
base,
Fort
Hood, TX

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Data indicates the United States has more mass shooters and more guns per capita than other econom-
ically developed countries (Wintemute, 2015; Fisher & Keller, 2017).

National Rates of Mass Shooting and Gun Ownership in 2007

In spite of enormous media attention focused on public mass shootings, these are rare events. Most
homicides in the country are committed one at a time, often secondary to domestic violence, an inter-
personal dispute or in the commission of a crime. Many of these killings are reactive or impulsive versus
predatory or planned.

Even school shootings, the most tragic of such events, are a statistically rare phenomenon. For every
shooting in a school, there are more than 1,600 outside of a school (Cornell, 2018a). Considering homi-
cide in general, people are more likely to be killed in their own home or on the street. Restaurants are 10
times more dangerous than schools.

10

0

20

30

40

20 40 60 80 100

Lankford’s data as interpreted by NY Times, 2017; NB — Uses 2007 SAS gun dataGuns per 100 People

M
as

s
Sh

o
o

te
rs

p
er

1
0

0
M

ill
io

n
P

eo
p

le

France

Canada

Iraq

Afghanistan

United States

Yemen

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MASS VIOLENCE IN AMERICA

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2005–2010 Homicides in 37 States

Using the definition of a mass shooting incident from the Gun Violence Archive (four or more shot and/
or killed in a single event [incident], at the same general time and location, not including the shooter),
there were 692 deaths and 1,803 injuries in 347 incidents in 2017. This compares to the following causes
of death:

14,415 Firearm homicides 2016 (CDC, 2018)

16,617 All homicides 2017 (FBI Uniform Crime Reporting Database [UCR], 2018)

21,808 Firearm suicides 2016 (CDC, 2018)

72,287 Drug overdoses 2017 (CDC, 2018)

250,000 Medical errors (Makary, BMJ, 2016)

Suicide is a serious issue when it comes to risks related to firearms and often gets overlooked in reports
related to mass violence. People are more likely to intentionally kill themselves with a gun than to be
killed by a gun in a mass shooting or other type of homicide (Wintemute, 2015).

Characteristics of Mass Violence Perpetrators
While perpetrators of mass violence can be categorized with respect to motivation, as previously
mentioned, characteristics of an individual perpetrator often cut across demographic, sociologic,
cultural and occupational groups. A general profile emerges of males who are often hopeless, harbor-
ing grievances that are frequently related to work, finances or interpersonal relationships; who feel
victimized and relate to others whom they perceive to be similarly mistreated; who are indifferent
to life and often subsequently die by suicide; who plan and prepare for their attack; and who often
share information about the attack with others, though often not with the intended victims. Here is
where the boundaries between categories overlap. Among such individuals are those who exaggerate

Restaurant/Bar

Store/Gas Station

Public Building/Business

Hotel/Motel

School

Outdoors

Parking Lot/Garage

Street

Residence

4,000 6,0000 2,000 8,000 10,000 12,000

Source: FBI National Incident-Based Reporting System (NIBRS) database. Selected locations.
School includes colleges. See Nekvasil & Cornell (2015) Psychology of Violence, 5, 236-245.

9,847

4,445

1,209

629

533

492

288

211

49

Restaurants are 10x more
dangerous than schools.

Homes are 200x more
dangerous than schools.

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and personalize slights and misfortunes, and others whose anger and fear stems from symptoms of
psychosis. Still others act out of a misguided desire to end the financial/physical/mental suffering of
loved ones, as well as themselves.

Numerous studies and databases provide common demographics associated with people who commit
mass violence. The FBI (Blair & Schweit, 2014) identified 160 active shooter incidents, a subtype of mass
violence, in the United States between 2003 and 2013 and found that:

• All but two involved single shooters.

• Seventy percent of incidents involved either a commercial or educational location.

• In at least 5–6 percent of incidents, the shooter killed family member(s) before moving to a public
location.

• In only 3.75 percent of incidents, the shooter was female.

• In 56 percent of the incidents, the shooter ended the incident (e.g., suicide, stopped shooting,
fleeing).

• In 40 percent of the incidents the shooter died by suicide — 84 percent of them at the site of the
shootings.

Lankford (2018) found characteristics that mass shooters share:

• Male (approximately 24:1 male to female).

• Race is equally distributed by population representation for white/black.

• Attacks are often premeditated and planned.

• Weapon choice may largely reflect access, convenience, familiarity with the weapon.

• Suicidal or life indifference.

• Perceived victimization of themselves and/or a group with which they identify.

• For many, they are seeking personal notoriety and/or attention to a group or a cause.

• For many, they perceive acute social and/or situational factors that contribute to drive to attack.

• For many, they leak to others regarding their intent to attack.

• For some, narcissistic personality features (e.g., attention seeking, feeling unvalued).

• For many, they have paranoid traits (e.g., deep sense of disgruntlement, injustice) or symptoms.

• For some, they have deep empathy/identification for people perceived as similarly victimized and/
or who responded to their victimization with violence.

• Psychological fixation (e.g., rumination on victimization, hopelessness, meaningless).

• High likelihood of one or more diagnosable mental illnesses.

It is important to note that the high likelihood of having more than one diagnosable mental illness defines
about 18 percent of the general population — more than 40 million people in the United States — the

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overwhelming majority of whom are never violent. Also, many people with mental illnesses have diagno-
ses such as anxiety disorder or obsessive-compulsive disorder that are not associated with violence.

In addition, Lankford notes that previous distinctions made between mass shooting attackers and
suicide terrorists are less clear as more mass shooters are motivated by ideological, religious and rac-
ist considerations, and suicide terrorists rely less on bombings and specific organizational support and
more on firearms as weapons capable of inflicting mass casualties. The attributes of an incident and the
characteristics of the perpetrator interact in a myriad of ways to create idiosyncratic situations that are
difficult to predict in advance.

The U.S. Secret Service compiled information on 28 mass attacks in public spaces during 2017 (National
Threat Assessment Service, 2018). The incidents were identified and researched through open source
reporting (e.g., media sources and law enforcement records); the resulting report included acts of
intentional violence in public or semi-public places during which significant harm was caused to three
or more people. It excluded violence related to criminal acts, failed attempts at a mass attack or sponta-
neous group violence. The authors found the following about the attackers:

• All were male.

• Ages ranged from 15 to 66 years old with average age of 37 years.

• Twenty-three attacks were with firearms, three with vehicles, two with knives.

• Fifteen attackers had histories of substance use disorders.

• Twenty attackers had prior criminal histories, nine with domestic charges or police responses.

• Eighteen had prior histories of violence.

• Eighteen had mental health symptoms prior to attack (one-half psychosis, one-third suicidal ideation
and one-fifth depression), with seven individuals having prior known mental health treatment.

• Motives included personal grievances (13, with five of them domestic), ideology (one), racial beliefs
(five).

• Five of seven attackers motivated by belief systems also had psychotic symptoms.

• Eleven exhibited a fixation with a person, activity, or beliefs with themes including personal vendet-
tas, romantic conflicts, personal failures, perceived injustices, delusions, political ideologies, other
incidents of mass violence.

• Sixteen harmed only random people, four harmed people that the attacker preselected, six harmed
both random and specifically targeted individuals; all four attacks resulting in harm only to targeted
individuals arose from workplace grievances; all four attacks influenced by psychotic symptoms
harmed only random people.

• Eight attackers died by suicide at the scene or shortly after leaving the scene.

Recent stressors were identified in all 28 attacks. Stressors included those related to family/romantic
relationships, personal problems (e.g., unstable living conditions, physical illnesses), work or social
environments, contact with law enforcement and financial instability. Additional themes included the
following:

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Ideological or racial beliefs 7

Evidence of fixation 11

Aggressive narcissism traits 23

Threats or concerning communication 22

Had elicited concern by others 22 (13 specifically about safety)

An in-depth study of 37 incidents of targeted school violence involving 41 perpetrators, which took
place in the United States from January 1974 through May 2000, found the following (Vossekuil, Fein,
Reddy, Borum, & Modzeleski, 2004; Fein et al., 2004; Pollack, Modzeleski, & Rooney, 2008):

• Prior to the incidents, other people knew about the attacker’s idea and/or plan to attack. In over
three-quarters of the incidents, at least one person had information that the attacker was thinking
about or planning the school attack. In nearly two-thirds of the incidents, more than one person had
information about the attack before it occurred.

• Incidents of targeted violence at schools rarely were sudden impulsive acts.

• Most attackers did not threaten their targets directly prior to advancing the attack.

• There was no useful or accurate profile of students who engaged in targeted school violence.

• Most attackers had difficulty coping with significant interpersonal losses or personal failures. More-
over, many had considered or attempted suicide.

• Many attackers felt bullied, persecuted or injured by others prior to the attack.

• Most attackers had access to and had used weapons prior to the attack.

• Despite prompt law enforcement responses, most shooting incidents were stopped by means other
than law enforcement interventions.

• In many cases, other students were involved in some capacity, some with prior knowledge of the
event before it occurred.

• Most attackers engaged in some behavior prior to the incident that caused others concern or indi-
cated a need for help.

• Few of the attackers had prior psychiatric care or formal diagnoses.

The Role of Mental Illness in Violence in General
People with mental illness account for a small amount of the overall violent behavior in our society.
Swanson (1994) analyzed community-representative data from the National Institute of Mental Health’s
(NIMH) Epidemiologic Catchment Area surveys and found that the population’s attributable risk of any
violent behavior associated with serious mental illness (i.e., a DSM diagnosis of schizophrenia spectrum
disorder, bipolar disorder or major depression) alone is about 4 percent.

This means that if we could eliminate the elevated risk of violence that is attributable directly to hav-
ing schizophrenia, bipolar disorder or major depression, the overall rate of violence in society would
go down by only 4 percent; 96 percent of violent events would still occur, because they are caused by
factors other than mental illness. These other factors linked to violence include being young and male,

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living in poverty, having a history of childhood abuse, being exposed to abuse and violence in the social
environment, having a history of antisocial behavior beginning in childhood or adolescence and becom-
ing involved with the criminal justice system (Swanson, McGinty, Fazel, & Mays, 2015).

Substance use disorders account for 34 percent of the risk of committing violence toward others. They
can exacerbate the effects of certain kinds of psychiatric symptoms, like excessive threat perception,
and expose people to toxic social factors. Overall, the best predictor of future violence is past violence
(Elbogen & Johnson, 2009; Rozel, Jain, Mulvey, & Roth, 2017; Rozel & Mulvey, 2017).

The MacArthur Violence Risk Assessment Study (MVRAS) (Steadman et al., 1998) followed a cohort of
more than 1,136 discharged psychiatric inpatients over one year in the community and examined the
occurrence of violent behavior in relation to numerous predictors. The MVRAS found that substance use
disorder comorbidity, likely a marker for poor coping, was responsible for much of the violence in these
patients. Study participants who had only mental illness — that is, without substance use disorder — had
no higher risk of violent behavior than their neighbors in the community, people selected at random
from the same census tracts in which the patients resided.

The MVRAS’s findings have often been cited as evidence that “people with mental illness are no more
violent than the general public.” However, the study was not designed as a population-representative
epidemiological study of the association between violent behavior and mental illness. Many of the study
participants lived in disadvantaged urban neighborhoods where violent crime was relatively common.
The base rates of violence among both the patients and comparison groups living in these areas were
substantially higher than in the community-representative studies like the Epidemiologic Catchment
Area Program of the NIMH or the National Epidemiologic Survey of Alcohol and Related Conditions
(Van Dorn, Volavka, & Johnson, 2012). One interpretation of the MVRAS’s finding is that social-environ-
mental influences on violence are stronger than the effects of psychopathology and tend to wash out
those effects at the population level (Swanson, McGinty, Fazel, & Mays, 2015).

The risk of violent behavior tends to fluctuate over time and recedes over the adult life course — in
people who have a mental illness and in those who do not. Numerous studies have shown that violence
risk in people with mental illness is generally very low but is significantly elevated at certain times in the
course of a serious mental illness. This pattern is reflected in studies that focus selectively on clinical
and legal settings where individuals are seen during a mental health crisis. In particular, patients seen
in psychiatric emergency departments, as well as those who have been involuntarily hospitalized, and
those experiencing their first episode of psychosis are at higher risk of violent behavior (Choe, Teplin, &
Abram, 2008; Large & Nielssen, 2011; Brucato et al., 2019). Those with co-occurring substance use disor-
ders, untreated psychosis, a history of oppositional defiant disorder as children or a history of antisocial
personality disorder as adults are also at increased risk (Witt, van Dorn, & Fazel, 2013). (It is important
to note that the U.S. Supreme Court held in Foucha v. Louisiana that antisocial personality disorder
alone does not meet the legal definition of a mental illness.) But risk declines substantially over time, for
example, in a person with a single involuntary hospitalization occurring in young adulthood (Felthous &
Swanson, 2018).

Certain psychotic symptoms such as paranoid delusions and delusions or hallucinations of threat from
others, command hallucinations and impulsive anger increase the risk of violence. In many cases, people
with mental illnesses who engage in violent behavior are not receiving any or adequate treatment at the
time of their violent acts. In most of these cases, the mentally ill perpetrators are untreated and actively
symptomatic. The lack of treatment and role of symptoms should be a powerful argument for more and
better mental health treatment to prevent this subset of mass violence.

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Overall, while there is modest relative risk of violence associated with serious mental illness, the over-
whelming majority of people with diagnosable psychiatric conditions in the community do not engage
in violent acts toward others but are more likely to be victims of violence (Swanson & Belden, 2018).
Further, violence risk is increased by many individual-level factors that interact in complex ways with
precipitating incidents and environmental exposures over the life course. In short, there is a modest link
between mental illness and violence, but there is no basis for the public’s generalized fear of people
with mental illness.

The Role of Mental Illness in Mass Violence
Incidents of mass violence — especially those that appear to be senseless, random acts directed at
strangers in public places — are so terrifying and traumatic that the community demands an explanation
and the incidents often provoke a defensive response from mental health advocates. After such events,
political leaders often invoke mental illness as the reason for mass violence, a narrative that resonates
with the widespread public belief that mentally ill individuals in general pose a danger to others. Since
it is difficult to imagine that a mentally healthy person would deliberately kill multiple strangers, it is
commonly assumed that all perpetrators of mass violence must be mentally ill. And when mental illness
becomes the accepted putative reason for mass violence, the conclusion follows that restricting the lib-
erty of people with mental illnesses — even removing them from the community — or preventing them
from owning guns are solutions. This simplistic conclusion ignores the facts that mass violence is caused
by several different social and psychological factors that interact with each other in complex ways, that
many if not most perpetrators do not have a diagnosable mental illness and that the large majority of
people with diagnosable mental illnesses are not violent toward others.

However, rather than being sympathetic to the plight of people who are mentally ill, the public dis-
course about mass violence and “mental illness” often dehumanizes them. In reality, mental illness is a
highly elastic clinical term that can mean many things but is often used without definition in the mass
violence narrative. In considering the role of mental illness in mass shootings, it is important that it be
clearly defined.

As the following table demonstrates, the degree of increase depends on how mental illness is defined in
a particular study. Studies looking at signs or stressors report much higher rates than studies requiring
an actual diagnosis.

LIKELIHOOD OF “MENTAL ILLNESS”

4.7% NICS-disqualifying mental illness PMSs (Silver et al 2018)

11% Evidence of prior MH “concerns” (Everytown, 2015)

17% Pre-incident dx (diagnosis), school shooters (Vossekuil/SSI 2004)

25% Pre-incident diagnosis of any kind, AS (Silver/BAU, 2018)

28% Evidence of MI, ISIS-influenced (Gill & Corner, 2017)

55% Lifetime risk, DSM-IV Disorder, all of USA (Kessler, 2006)

59% “Signs of serious mental illness” (Duwe, 2007)

61% Documented hx (history) extremely depressed (Vossekuil/SSI 2004)

62% Mental Health “stressor,” AS (Silver/BAU, 2018)

78% History of suicidal ideation &/or attempt (Vossekuil/SSI 2004)

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In a study of the pre-attack behaviors of 63 active shooters (Silver, Simons, & Craun, 2018), the FBI
found that 16 (25 percent) had a confirmed diagnosis of mental illness, including mood disorder, anxiety,
psychosis, personality disorder and autism. The researchers were unable to determine a psychiatric his-
tory for 37 percent of their sample but concluded that “declarations that all active shooters must simply
be mentally ill are misleading and unhelpful.” In part, this is because if efforts at reducing mass violence
are only focused on people with mental illness, they may miss those who are acutely distressed and
perhaps more likely to commit violence. Many of those who are acutely distressed could be helped with
mental health services.

Of the individuals who kill three or more people, it appears that about 60 percent (Follman, Aronsen, &
Pan, 2019) have evidence of some sort of unspecified psychological distress, even if they do not meet
formal diagnostic criteria.

Corner & Gill (2015) and Gruenewald, Chermak, & Freilich (2013) found that mass casualty offenders/
lone actor terrorists are significantly more likely to have a mental disorder than group actors. Thirty-two
percent of lone actors have evidence of mental illness, compared to 3 percent of group actors. The
greater the isolation of the individual in terms of co-offenders/social network, the greater the likelihood
of mental illness.

While individuals diagnosed with mental illness only account for 4 percent of all violent crime in the
United States, a higher portion of perpetrators of mass homicides are mentally ill in comparison to per-
petrators of other types of violence.

Having any diagnosis is not the same as having a diagnosis that is associated with a greater likeli-
hood of mass violence. The American Psychiatric Association’s DSM-5 provides a very broad catalog
of diverse brain-related health conditions that impair a person’s normal ability to reason and perceive
reality, regulate mood, formulate and carry out plans and decisions, adapt to stress, behave and relate
to others in socially appropriate ways, experience empathy, modulate consumption and refrain from
intentional self-injury — or various combinations of such problems. Almost all of these mental illnesses
have no increased risk of violence, unlike a diagnosis of severe personality disorder that is applied to a
remorseless killer whose compulsive, aberrant behavior manifests in willfully destroying others.

In addition, there is a difference between mental illness and urgent emotional distress (e.g., a person
with a mental illness like schizophrenia, bipolar disorder or psychotic depression whose delusional
thoughts impel them to violence, in contrast to a disgruntled employee who is fired and becomes so
enraged that they seek violent revenge). When such different meanings of mental illness are conflated
in the public discussion — and people act on the basis of their fears — the result is that millions of
harmless individuals recovering from treatable mental health conditions can be subjected to stigma,
rejection, discrimination and even unwarranted legal restrictions and social control.

However, the absence of a prior documented diagnosis of mental illness is not a guarantee that one
does not exist. There has been limited retrospective research on the mental health status of mass vio-
lence perpetrators, which likely underestimates the proportion that may have suffered from a mental
illness and the role the illness may have played, or not, in their crime. In addition to the lack of efforts
to determine whether perpetrators may have had histories of mental illness, the fact that they often go
unrecognized and untreated adds to further underestimation, especially in young people who may not
have been diagnosed yet.

Apart from establishing a diagnosis, there is the question of whether the symptoms of the person’s
illness caused the violent behavior in question. Correlation is not causation — even when a person who
commits mass violence is found to have a diagnosable mental illness, it is not clear that mental illness

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IDENTIFYING HIGH-RISK PERSONSSCOPE OF THE PROBLEM

was the precipitating factor in the crime. Having a psychiatric diagnosis is neither necessary nor suffi-
cient a risk factor for committing an act of mass violence.

In the same way as motivation for a crime must be established in law enforcement, the way in which
symptoms of mental illness contribute to violent behavior must be determined on a case-by-case basis.
Unless we define the specific conditions and symptoms referred to and posit some causal model for
how these problems could motivate violent behavior, it is difficult to meaningfully characterize the role
that various kinds of psychopathology could play in acts of mass violence. Merely to assert that “all
mass violence perpetrators are mentally ill” is an empty and misleading statement.

Of course, there are particular violent acts with a clear connection to a psychiatric condition — for
example, a multiple-casualty shooting by a person with acute paranoid schizophrenia manifested in
persecutory delusions and homicidal command hallucinations. Another example would be a perpetra-
tor with compelling nihilistic delusions and suicidal thoughts who kills his family and/or others before
ending his own life or dying in a “suicide by cop.” In the instances of disgruntled employees, one violent
perpetrator might have had a pre-existing “intermittent explosive disorder” and was thus predisposed
to violence while another, because of particular circumstances, may have been especially impacted by
their termination.

The stereotype of an individual with a severe and persistent mental illness such as schizophrenia, where
schizophrenia is the sole factor contributing to mass violence, is unfounded. At the same time, perpe-
trators of mass violence, specifically, are more likely to suffer from mental illness (whether it has been
diagnosed or not) and usually are receiving no or inadequate treatment.

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IDENTIFYING HIGH-RISK PERSONS

IDENTIFYING HIGH-RISK PERSONS
It is important to recognize that mass violence is a rare event, difficult to characterize, which makes
it virtually impossible to predict (Swanson, 2011) but still preventable. Mass shootings accounted for
less than two-tenths of 1 percent of homicides in the United States between 2000 and 2016 (Follman,
Aronsen, & Pan, 2019; Centers for Disease Control and Prevention, 2018). Much research has gone into
identifying risk factors for violence and assessment of threat. From this, research protocols and instru-
ments for assessing risk of violence have been developed and usefully applied. While these instruments
are valid at the group or population level, they are limited in their ability to identify specific individu-
als who are truly positive for risk and determine when they might act with sufficient precision. Studies
reveal that the relevant characteristics of mass violence perpetrators are many and shared by large
numbers of people who will not commit acts of mass violence.

Perpetrators of mass violence may share some characteristics but are a sufficiently heterogenous group
that models relying on profiles will almost certainly result in high rates of both false negative and false
positive identifications. In addition, many of the risk factors for violence apply to individuals in the pop-
ulation with and without mental illness. Mass shooters who bear diagnoses of mental illness, whether
schizophrenia or bipolar disorder or simply symptoms of urgent emotional distress, also commonly
exhibit putative risk factors for violence shared by nonmentally ill people, such as poverty, substance
use disorders, prior violent criminal conduct, recent stressors and nondelusional belief systems that may
trigger violence.

Profiling is especially problematic when the suggestion is made to screen all people with mental
health problems to prevent rare acts of serious violence. The danger is that those who are identified
as being at risk of violence, rather than being given priority access to treatment and becoming eligi-
ble for intensive services, will instead be discriminated against, deprived of their liberty and subject to
social control, whether through arrest and incarceration or involuntary inpatient or outpatient com-
mitment. In addition, when only people with mental illnesses are profiled, many others who might
commit violence are missed. Nonetheless, improving behavioral health treatment access, quality and
patient engagement will likely prevent some violent episodes and, therefore, these strategies emerge
as important public health interventions.

While there has been substantial research and a body of evidence for violence risk assessment and pre-
diction, current methods still have significant limitations. Nevertheless, research in this important area
continues, and existing methods of threat assessment and management are valuable and have become
an important part of efforts to help prevent incidents of mass violence.

Threat Assessment and Management
Threat assessment, a term that originated in law enforcement, is a strategy to prevent violence targeted at
public figures and other people who are threatened by someone. The term “behavioral threat assessment”
is sometimes used to distinguish this approach from a more general security assessment. Over time, the
meaning of the term has evolved. Most important, threat assessment is no longer considered a single
assessment, but rather an ongoing assessment process with interventions designed to prevent violence.

A threat assessment team within a business or school is a multidisciplinary group that includes rep-
resentatives from security and law enforcement, behavioral health care, human resources, legal and
management, among others (see more about threat assessment teams in the section “Mass Violence
in Schools,” which follows). The threat assessment model recognizes that violence is a multi-deter-
mined phenomenon, arising from the interaction of three sets of variables: static and dynamic individual

18

MASS VIOLENCE IN AMERICA

IDENTIFYING HIGH-RISK PERSONSIDENTIFYING HIGH-RISK PERSONS

factors, static and dynamic environmental factors and situational factors or triggers (Fein, Vossekuil, &
Holden, 1995).

In many threat assessment situations, those assessing risk do not meet the person being assessed or do
a clinical, face-to-face evaluation. They look at social media, written documents, oral communications,
direct reports/observations from individuals other than the assumed perpetrator and other documen-
tation of behavior. Then they must determine what to do with that information. Threat assessment and
management is often effective in preventing violence but is a longer process and takes more resources
than the ineffective single-point-in-time clinical risk assessment.

Instead of focusing on static traits and features of individuals, threat assessment teams focus on tra-
jectories or pathways of individuals across key dimensions (e.g., motive and intent, ability and means,
intensity of fixation, suicidal intent or indifference to personal outcome) (Fein et al., 2004). Trajectories
or pathways can also be driven, shaped or disrupted by social and situational factors.

Factors can contribute to risk (e.g., identification with ideological, religious or deviant social subcultures
that provide reasons for mass violence) or diminish risk (e.g., observations or incidents that prompt
assessment and/or interventions). Approaches that use operational threat assessment methods to
assess the trajectory (pathway) of a potential attacker toward or away from executing an attack also
lend themselves to evidence-based (or potentially evidence-based) prevention and interdiction strate-
gies within a public health model (Meloy, Hoffmann, Guldimann, & James, 2012).

Calhoun & Weston (2003) conceptualized one pathway to violence related to workplace violence that
can be applied in other settings. Two key takeaways: First, all targeted or intended violence begins
with a grievance and escalates when the person cannot deal with their urgent emotional distress. And
second, there are many points in which the situation can be defused. That is part of what a threat
assessment team does.

The Pathway to Violence
Pathway to Workplace Targeted or Intended Violence

The “Grievance”

Violent Ideation

Research & Planning the Attack

Pre-attack Preparation

Probing and Breaches

Attack

decisio
n

Escalation

De-Escalation

final acts

Adapted with permission from F.S. Calhoun and S.W. Weston (2003). Contemporary threat management:
A prectical guide for identifying, assessing and managing individuals of violent intent.

© 2003 F.S. Calhoun and S.W. Weston. All rights reserved.

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IDENTIFYING HIGH-RISK PERSONS

Threat assessment examines behaviors, rather than diagnoses. It examines a set of specific individual
factors that do not change over time and that are not affected by intervention or interdiction. These
include criminal background, drug and weapons history, history of child abuse or other victimization,
individual and family violence, bullying, suicide attempts, etc. Dynamic individual factors that change
over time and are amenable to intervention or interdiction include current drug use, weapons posses-
sion, untreated psychotic symptoms, personal capacity for resilience, etc.

A common dynamic individual factor is a perception of injustice — the idea that the person has been
treated unfairly and no one cares. The grievance or sense of injustice is often associated with a sense
of hopelessness and grandiosity, revenge or fanatical beliefs and an adverse response to authority and
identification with violent perpetrators. Unemployment, lack of social support, emotional disconnection,
suicidal and homicidal ideation and mental illness, especially substance use disorder, can all play a role
in precipitating mass violence.

Environmental factors include the presence of available victims, lack of family and community supports,
access to weapons, a culture of violence, a high-conflict situation and an absence of constraints.

Situational factors include acute and chronic stressors. In their study of 63 active shooters, Silver, Simons,
& Craun (2018) found that in the year preceding the attack, active shooters typically experienced an
average of 3.6 stressors; those whose primary stressors were related to mental health accounted for
62 percent. This indicates that the active shooter appeared to be struggling with (most commonly)
depression, anxiety, paranoia, etc., in daily life in the year before the attack. Although these stresses were
present, it was unclear if these symptoms were sufficient to warrant a formal diagnosis of mental illness.
Other stressors included finances, jobs and interpersonal relationships, abuse of drugs and alcohol, care-
giving responsibilities, conflicts at school and with family members and sexual stress or frustration.

TABLE 1: Stressors

STRESSORS NUMBER %

Mental health 39 62

Financial strain 31 49

Job related 22 35

Conflicts with friends/peers 18 29

Marital problems 17 27

Abuse of illicit drugs/alcohol 14 22

Other (e.g., caregiving responsibilities) 14 22

Conflict at school 14 22

Physical injury 13 21

Conflict with parents 11 18

Conflict with other family members 10 16

Sexual stress/frustration 8 13

Criminal problems 7 11

Civil problems 6 10

Death of friend/relative 4 6

None 1 2

20

MASS VIOLENCE IN AMERICA

METHODS OF MASS VIOLENCEIDENTIFYING HIGH-RISK PERSONS

Schouten (2003) developed the mnemonic FINAL to describe the situational factors that may drive a
person to the edge of violence:

• Financial

• Intoxication

• Narcissistic injury

• Acute or chronic illness

• Losses

Factors that inhibit the risk for violence include the availability of mental health treatment and receptiv-
ity to its use, family and other social supports and spiritual beliefs, among other influences.

While being in a high-risk group increases the probability of mass violence, the positive predictive value
is still limited to “if” and “when.” There are certain process variables that must be examined. These
include the following (Association of Threat Assessment Professionals, 2006):

• Approach behavior (e.g., does the person go near the target; do they attempt to contact the target?).

• Evidence of escalation.

• Fantasy rehearsal.

• Actively violent state of mind.

• Command hallucinations to harm specific individuals.

• Diminishing inhibitions.

• Inability to pursue other options.

• Obsession.

• Diminished protective inhibitions.

• Sense of inevitability (apocalyptic vision).

• Pre-attack or ritual preparation (e.g., suicide note).

• Recent acquisition or preparation with firearms.

• Subject’s response to assessment and inquiries.

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METHODS OF MASS VIOLENCE

METHODS OF MASS VIOLENCE
Individuals committing mass violence, regardless of their motivation, can employ a variety of means:
knives, hammers, motor vehicles, poisons, arson, bombs and firearms. Although, individuals in the
United States are less likely to be assaulted than those in other countries, when individuals in the United
States become violent, the violence is often more lethal than in other countries because it more often
involves firearms (Wintemute, 2015).

Percent of Population Assaulted Annually by Nation

Death Rates from Suicide and Homicide by Nation

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22

MASS VIOLENCE IN AMERICA

METHODS OF MASS VIOLENCEMETHODS OF MASS VIOLENCE

U.S. homicide rates are seven times higher than in other high-income countries, driven by a gun homi-
cide rate that is 25 times higher (Grinshteyn & Hemenway, 2016). An adult in the United States is seven
times more likely to commit suicide with a firearm than an adult in another country. The U.S. homicide
rate by firearm is greater than the rate in the next seven countries combined.

These statistics clearly reflect the greater access to firearms in the United States. Estimates of the num-
ber of guns in the United States vary from slightly more than 300 million (Azrael, Hepburn, Hemenway,
& Miller, 2017) to more than 600 million (Owens, 2016), but even using a middle-of-the-road estimate of
just fewer than 400 million, the United States has more total guns than the next 24 countries combined
(Karp, 2018).

393,000,000
civilian-owned firearms in USA

(Small Arms Survey, 2018)

2. India 10. Turkey 18. Iran

3. China 11. France 19. Saudi Arabia

4. Pakistan 12. Canada 20. South Africa

5. Russian Federation 13. Thailand 21. Colombia

6. Brazil 14. Italy 22. Ukraine

7. Mexico 15. Iraq 23. Afghanistan

8. Germany 16. Nigeria 24. Egypt

9. Yemen 17. Venezuela 25. Philippines

The rights of individuals in the United States to own guns, protected by the Second Amendment to the
U.S. Constitution, has been upheld in two recent U.S. Supreme Court decisions. District of Columbia v.

Heller, 554 U.S. 570 (2008), held that the Second Amendment guarantees an individual’s right to pos-
sess a firearm unconnected with service in a militia and to use that arm for traditionally lawful purposes,
such as self-defense within the home. McDonald v. Chicago, 561 U.S. 742 (2010), extended Heller to
states and municipalities.

Heller made clear that Second Amendment rights are not unlimited (e.g., prohibitions on possession of
guns by those charged with a felony are still valid); it held that permitted firearms are those “in common
use at the time.” Some observers believe this would still protect the use of assault-style weapons and
high-capacity magazines [common use test discussed in Heller at 128 S. Ct. 2815 (2008)]. As of 2017,
eight U.S. states had laws banning high-capacity magazines, limiting the number of rounds to 10 or 15.
California passed Proposition 63 in 2016, banning the possession of high-capacity magazines holding
more than 10 rounds. On appeal, the federal courts stayed the new law as the state failed to show how
this law did not violate the Second Amendment or the property rights of owners of previously legal
goods. Shooters in mass violence events obtain their guns legally and illegally, suggesting that no single
restriction will prohibit all forms of gun violence.

Currently, the Brady Bill, P.L. 103–159 (1993), passed in the wake of the attempted assassination of Pres-
ident Ronald Reagan, forbids anyone who is “adjudicated a mental defective,” or has been involuntarily
committed, from owning or possessing a firearm. As noted, because the vast majority of people with
mental illnesses are not violent, this provision and the language used to characterize the population has
generated pushback, including from the mental health advocacy community. In addition, it is common
for mass violence perpetrators to obtain their firearms from family members who would not be covered
by this restriction.

23

MASS VIOLENCE IN AMERICA

METHODS OF MASS VIOLENCE

Frequently, in the wake of mass shootings, a spate of new legislation is introduced, both to regulate
guns and to protect gun rights. To date, legislation enacted at the state level has surpassed that at the
national level. Since the Sandy Hook Elementary School shootings of 20 children and six staff in New-
town, Connecticut, of all the gun control and guns rights legislation introduced in Congress, the only
one to pass was a limited measure called the Federal Law Enforcement Self-Defense and Protection Act
of 2015, which declares that a federal law enforcement official is allowed to carry federally issued fire-
arms during a furlough (Britzky, Canipe, & Witherspoon, 2018).

Gun Access Bills Introduced in Congress since 2013

Often, in the wake of a mass shooting, calls are made to reinstate the federal assault weapons ban. Fox
and DeLateur (2014) studied the impact of the federal assault weapons ban, which was in effect from
1994 to 2004, and found that assault rifles were used in fewer than 25 percent of shootings and that the
initial rate of mass shootings continued to increase at the same rate both while the ban was in place and
after it ended. While their findings indicate that banning assault rifles alone is unlikely to significantly
change the rate of mass shootings, a reduction in fatalities from mass shooting may be a more action-
able goal.

(Axios, interpreting ProPublica data, 2/19/18)

TYPE OF BILL

Gun Control (259) Gun Rights (102) Other (7) Became law (1)

2013

2014

2015

2016

2017

2018

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Navy Yard

Charleston

San Bernadino

Las Vegas
Pulse

Parkland

Tex. First Baptist

24

MASS VIOLENCE IN AMERICA

METHODS OF MASS VIOLENCEMETHODS OF MASS VIOLENCE

TABLE 2: Mass Shootings and the Federal Assault Weapon Ban (1994–2004)

INCIDENTS VICTIMS

TIME PERIOD TOTAL AVERAGE TOTAL AVERAGE
1976–1994 335 17.6 1,536 80.8

1995–2004 193 19.3 876 87.6

2005–2011 144 20.6 699 99.9

Source: Supplementary Homicide Reports, 1976–2011.

TABLE 3: Weapons Used in Mass Shootings

TYPE OF FIREARM n %

Assault weapons 35 24.6

Semiautomatic handguns 68 47.9

Revolvers 20 14.1

Shotguns 19 13.4

Total 142 100.0

Source: Mother Jones database of mass shootings 1982–2012.

Fox DeLauter, HS 2014

Furthermore, although the use of assault weapons in mass shootings was lower during the assault
weapons ban (DiMaggio et al., 2019), there is differing data about the relative danger of assault rifles
versus other weapons used in mass shootings. Some observers believe there is more lethality with
assault weapons (de Jager et al., 2018), while others believe this is not the case (Sarani et al., 2018).

Part of the problem in studying gun violence is the dearth of good information. The Centers for Disease
Control and Prevention (CDC) and the FBI’s UCR program have no highly reliable, standardized and
centralized data set for tracking firearms crime, shootings, injuries and deaths. The National Institutes of
Health awarded only three major grants to study gun violence between 1973 and 2012 (Masters, 2016).
Stark and Shah (2017) found that federal funding for firearms injuries research was about one percent
compared to that expected for other causes of morbidity and mortality. In addition to funding limita-
tions, the small amount of funded research on gun violence is due to bureaucratic impediments and
political factors.

Because there is no single solution to mass violence, studies of the impact of putative solutions can be
misleading. The RAND Corporation’s 2018 systematic review and meta-analysis of gun policy in the United
States found “little persuasive evidence for the effects of most policies on most outcomes” (RAND Corp.,
n.d.). Researchers reviewed 9,382 studies, 72 of which addressed mass shootings. There were inconclusive
findings on background checks, assault-style weapons and high-capacity magazine bans, license/permit
requirements, child access laws, minimum purchase age, concealed-carry laws and waiting periods. There
was no useful research on stand-your-ground laws, lost/stolen gun reporting, gun sales reporting/record-
ing, gun surrenders by prohibited possessors, gun-free zones or prohibitions for mental illness.

However, there are studies of these individual interventions in combination that show the impact on
mass violence involving guns. Fleeger et al. (2013) used an overall legislative strength-of-gun-control
law summary score for each of the 50 states that, when compared to each state’s homicide rate overall,
showed lower homicide rates associated with a higher score of legislative strength of gun control laws.


25

MASS VIOLENCE IN AMERICA

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Rates of Firearm Deaths Compared to Firearm Restrictions by State

In a similar vein, Reeping et al. (under review) examined the restrictiveness or permissiveness of state
gun laws and compared them to mass shooting events between 1998 and 2017. Restrictiveness refers
to such things as restrictions for open carry in government buildings and banning loaded gun permits
in schools, while permissiveness includes such items as recognizing out-of-state permits, the use of
lifetime permits and permitless carry. The restrictiveness score was created using ratings from “The
Traveler’s Guide to State Laws” published annually from 1998 to 2007.

The researchers used mass shootings as defined in the FBI’s UCR database and those recorded by
Mother Jones and reached two key conclusions. First, they found that state laws regarding gun own-
ership have become much more permissive over time. Second, they found that those states with more
permissive gun laws tended to have more mass shootings (Branas & Rozel, 2018).

5

0

10

15

20

5 6 7 8 90 1 2 3 4 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

Legislative Strength
Score, Median

Fleegler EW, Lee LK, Monuteaux MC, Hemenway D,
Mannix R. Firearm Legislation and Firearm-

Related Fatalities in the United States. 
JAMA Intern Med. 2013;173(9):732–740.

doi:10.1001/jamainternmed.2013.1286

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FL

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SC

ID

KS
TX

INUT

CO
OR

OH

ND
VT WI

ME

NE

SD
NH

MN

IA

WA
DE

VA

NC

PA
MI

IL

MD

RI

HI

NY

CT

CA

NJ

MA

26

MASS VIOLENCE IN AMERICA

METHODS OF MASS VIOLENCEMETHODS OF MASS VIOLENCE

Number of Shootings in FBI UCR (1998–2015) and Mother Jones (1998–2017) Data
and State Restrictiveness-Permissiveness Score

On average, for every 10-unit increase in firearms permissiveness, there was an 11 to 13 percent increase
in the rate of mass shootings. The researchers caution that their study measured correlation and not
causation. It is unclear what came first — the restrictive/permissive gun laws or mass shootings. And if
the laws do have an impact, more research is needed about which laws and what the specific impact
might be. Comparing this score to the rate of mass shootings for each state showed stricter state fire-
arms laws are associated with fewer mass shootings after adjusting for multiple population factors.

That is not to say there is no agreement on certain measures aimed at addressing gun injuries and
deaths in America. Barry et al. (2018) found a series of evidence-based measures that have wide sup-
port, including among 75 percent of gun owners. They include the following:

1. Conducting universal background checks before purchase of a firearm.

2. Allowing the Bureau of Alcohol, Tobacco, Firearms and Explosives to suspend a dealer’s license if
more than 20 guns are unaccounted for on audit.

3. Implementing permitting and competence testing for concealed carry.

4. Requiring states to report people to the NICS when they are involuntarily committed.

5. Removing firearms from a person subject to a domestic violence temporary restraining order.

6. Allowing families to petition for the temporary removal of firearms.

For any gun measures to succeed, they must have broad popular support. They should be supported by
empirical evidence and be designed to adequately balance public safety with individual rights. A perti-
nent example is the federal law allowing for temporary gun removal court orders in cases of domestic
violence. This was broadly accepted at least in part because it involves due process and the gun
removal is temporary with a clear process for return.

10

5

0

20

25

30

35

15

68

66

64

70

72

74

76

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19
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20
00

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01

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06

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07

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08

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09

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10

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12

20
13

20
14

20
15

20
16

20
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UCR-All UCR-Strangers Mother Jones Restrictiveness-Permissiveness Score

27

MASS VIOLENCE IN AMERICA

METHODS OF MASS VIOLENCE

Fourteen states have passed risk-based firearms removal laws (Frizzell & Chien, 2019) that are known
by different names, including a risk warrant law, gun violence restraining order, extreme-risk protection
order, lethal violence protective order, security temporary order of protection or red flag law. However,
they all share common elements, including:

1. Civil court order for gun removal (non-criminalizing).

2. Targeting individuals who possess firearms and are known to pose a high risk of harming others or
themselves in the near future.

3. Criteria for gun removal that do not require that the person have a diagnosis of mental illness or
any gun-disqualifying record.

4. Authorizing police to search for and remove firearms

a. Initial warrant based on probable cause of imminent harm

b. Subsequent court hearing (e.g., within two weeks) requires state to show clear and convincing
evidence of ongoing risk.

5. Limiting the duration of gun removal, typically 12 months.

For example, the Marjorie Stoneman Douglas High School Public Safety Act, F.S. 790.401, was passed
just over one month after the Parkland, Florida, shooting. It provides that law enforcement can peti-
tion the court to temporarily remove and prohibit the purchase of firearms when an individual poses
“significant danger to themselves or others, when they may not be legally prohibited from purchasing
or possessing a firearm.” The statute sets forth the filing process as well as factors for the circuit court
to consider.

28

MASS VIOLENCE IN AMERICA

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Descriptive information on the implementation of Connecticut’s risk warrant gun removal law, GS §
29-38c (1999–2013), found the following (Swanson et al., 2017):

Characteristics of gun removal cases: (N=762)

• Average number of guns removed per case: 7 guns

• Gender: 92 percent male

• Age: mean 47 years

• Mental health or substance use treatment record: 46 percent

• Arrest leading to conviction in year before or after: 12 percent

• Risk of harm to self: 61 percent

• Calls to police come from family/acquaintance: 49 percent of cases

• Transported to Emergency department/hospital: 55 percent

Every 10 to 20 gun-removal actions is equal to one life saved, often from self-harm (Swanson et al.,
2017). Although the risk-based gun removal laws in Connecticut and Indiana were both enacted in the
aftermath of highly publicized mass shootings, data indicate that they are most often used in response
to concerns about suicide risk, not violence toward others.

Gun removal measures should be temporary, for temporary risk, and not based on any single criteria like
mental illness. Gun removal measures must meet all constitutional requirements of due process. Effec-
tive gun measures should promote positive behavior, not simply sanction negative behavior (Kapoor et
al., 2018).

29

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VENUES OF MASS VIOLENCE
Mass violence is perpetrated in numerous venues. These include office buildings and other workplace
settings, vehicles of mass transportation, shopping malls, public streets, concert arenas, cinemas,
restaurants, college campuses and grade schools. All are vulnerable venues that lend themselves to
such mayhem and can only be hardened (further protected) at the risk of restricting personal freedoms;
installing expensive and intrusive security systems (e.g., metal detectors, surveillance cameras, barri-
cades); or eliminating access to weapons to specific risk groups.

The question of security best practices is beyond the scope of our expertise and we believe ultimately
is best addressed by identifying and alleviating the root causes of violence among perpetrators. (In
the case of people with mental illness, this would entail providing effective, comprehensive treatment.)
However, schools have been a particularly vulnerable and painful venue for violence because of their
defenselessness, the youth of potential victims and the large numbers gathered in educational settings.
Consequently, the remainder of this section will focus on schools.

Though schools are much safer than the public might believe, school shootings grab national headlines,
leading to some ill-considered policy decisions that are addressed below. Creating safe and supportive
environments and conducting threat assessment and management can help make schools even safer.

Mass Violence in Schools
Media attention to school shootings has generated a misperception that schools are dangerous places.
On the contrary, shootings are much more prevalent outside of schools in places such as restaurants,
stores and residences. A study by Nekvasil, Cornell, & Huang (2015) at the University of Virginia using
FBI homicide data examined the locations of homicides in 37 states over six years and found that
schools, including colleges, are one of the safest places in the United States, compared to other loca-
tions. A person is 10 times more likely to be murdered in a restaurant than in a school. This applies to
shootings and mass shootings, as well as homicides in general.

Despite their statistical rarity, school shootings shock the nation. They cause widespread trauma for
victims and their families, perpetrators’ families, first responders and whole communities. The fear of
school shootings has led to an overemphasis on expensive school security measures; at the same time,
schools have shortages of mental health professionals whose services have the potential to prevent vio-
lence both in schools and in the broader community by helping troubled youth.

Policy Mistakes

One example of mistaken policy that has created detrimental downstream consequences is the use
of zero-tolerance policies for threats in school (American Psychological Association Zero Tolerance
Task Force, 2008). There was an increase in zero-tolerance policies in the wake of the 1999 Columbine
shooting, expanding from a no-guns policy to include such things as no nail clippers, plastic utensils,
finger-pointing, jokes, drawings or rubber band shooting. The result is that students are suspended for
all sorts of minor misbehavior. Often these youth have to present back to school with a doctor’s note or
some type of safety medical clearance. This can result in youth being sent to an emergency room, with
emergency room providers needing to sort out a complex situation and attesting to the fact that the
youth is safe to discharge and return to school.

30

MASS VIOLENCE IN AMERICA

VENUES OF MASS VIOLENCEVENUES OF MASS VIOLENCE

Many studies have found negative outcomes to suspension (Fabelo et al., 2011; Morgan, Salomen, Plot-
kin, & Cohen, 2014; Noltemeyer, Ward, & Mcloughlin, 2015). Students who are suspended often fall
behind in their classes, even if their work is sent home. They may return to school feeling alienated and
rejected, and rather than improve their behavior, they are more likely to misbehave and be suspended
again. They are at increased risk of dropping out of school. These conclusions have prompted a national
movement away from the use of school suspension.

In addition, school suspension has a disproportionate impact on minority students, who are often sus-
pended at higher rates than white students (Fabelo et al., 2011; Losen & Martinez, 2013). Racial disparities
in suspensions are seen across the country. Minority students are generally suspended for less serious,
more subjective offenses, like disorderly conduct or disrespect, rather than more serious offenses such as
drug possession or weapons possession, which were the original basis for zero tolerance.

A burgeoning industry of school security leads to what some consider to be excessive security mea-
sures, including bulletproof building entrances, electronic door locks, metal detectors and panic rooms
with video monitors and ventilation systems. All are expensive, and, when money is tight, student sup-
port services and preventive interventions suffer.

A final practice that has grown in the wake of school shootings is the use of school-shooter drills.
Although fire drills are conducted in a calm and low-key manner, shooting drills have become increas-
ingly dramatic. Some involve student roleplaying, with students made up to look like they have been
shot. Students are taught to attack armed shooters with anything they have at hand. In some cases,
drills are not announced in advance and there are situations where deception is used so that students,
and sometimes staff, are led to believe that an active shooting is occurring, rather than a drill. Though
some safety drills are warranted, those that evoke fear and create trauma do more harm than good
(Schonfeld, Rossen, & Woodard, 2017; Rich & Cox, 2018).

The goal is to prevent shootings and not simply prepare for them. To that end, many school systems
around the country are focused on creating a safe and supportive school environment and establishing
threat assessment and management teams. Both are lynchpins in violence prevention initiatives.

A Safe, Supportive School Environment

A safe, supportive school environment is one in which students forge connections with adults and cre-
ate positive ties with their peers. Key elements include:

• Respect and emotional support within educational institutions.

• Positive adult (teachers, advisors) role models.

• Constructive communication between adults and students.

• Equivalent attention to emotional needs as to academic needs.

• Bullying prevention.

Breaking the code of silence is critical. Students should feel safe reporting their concerns about their
fellow classmates, which assumes the school has procedures in place to handle these concerns (see
discussion of threat assessment in the next section). They must be willing to seek help for themselves
or others. Every student must feel that he or she has a trusting relationship with at least one adult in a
position of responsibility at their school. Research reveals that these kinds of trusting relationships can
be formed but usually are not (Williams, Horgan, & Evans, 2016; The Federal Commission on School
Safety, 2018; Pollack, Modzeleski, & Rooney, 2008).

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Students who feel that they are in a safe school and have an adult they can go to are more likely to
report a potentially threatening situation (Pollack, Modzeleski, & Rooney, 2008). They will become an
upstander rather than standing by. This requires that staff be trained to properly respond to students
who provide them with information about a threatening or disturbing situation, as well as to deal with
actual threats. Research in Virginia schools found that students are the most frequent reporters of a
student’s threat to harm someone (Cornell et al., 2016).

Threat Assessment and Management in Schools

Threat assessment is a strategy to prevent violence by identifying and assisting troubled individuals
about their potential for violence. The FBI, Secret Service and U.S. Department of Education recom-
mended a threat assessment approach nearly 20 years ago (O’Toole, 2000; Vossekuil, Fein, Reddy,
Borum, & Modzeleski, 2004). Threat assessment must be adapted for schools, recognizing developmen-
tal issues in young people and the social context of the school. Unlike threat assessment for protecting
public figures, school threat assessment must recognize the overarching goal of helping all students to
be successful in their education and development.

In school settings, threat assessment is a problem-solving approach to violence prevention that involves
assessment and intervention with students who have threatened or pose a threat of violence in some
way (Cornell et al., 2018b). The threat assessment team identifies threats made by students, as well as
indicators that a student poses a threat in the absence of an explicit threat; evaluates the seriousness of
the threat and the danger it poses to others, recognizing that all threats are not the same; intervenes to
reduce the risk of violence; and follows up to assess the intervention results. In the most serious cases,
protective action is taken.

• Clear and consistent discipline
• Positive behavior support system
• School security program
• Programs for bullying and teasing
• Character development and curriculum
• Conflict resolution for peer disputes

• Ongoing counseling
• Intensive monitoring and supervision

• Community-based treatment
• Alternative school placement
• Special education evalution and services

• Social skills groups
• Short-term counseling
• Mentoring and after-school programs
• Tutoring and other academic support
• Special education evaluation and services

Schoolwide Prevention
All students

At-Risk Students
Students with some
problem behaviors

Intensive
Intervention

Students with
very serious

behavior problems

Dewey Cornell, Ph.D., Curry School of Education, University of Virginia www.youthviolence.edschool.virginia.edu

Threat assessment is part of a comprehensive appproach

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The goal of school-based teams is to identify needs for services and either offer them in house or
make referrals to outside providers when indicated. Students who make a threat are waving a red flag
to indicate that they have encountered a problem they do not know how to solve. Threat assessment
teams are problem solvers. The problems they encounter might involve mental health concerns or they
might involve special or general education needs. Often, a student is experiencing conflicts in social
competence and conflict resolution. So, school counselors, school psychologists and social workers are
often involved. In the most serious cases, the school resource officer plays an essential role in the threat
assessment and management process. As with adults, the goal of threat assessment and management
with students is prevention and, where appropriate, getting people the help they need.

The composition of a school threat assessment team will vary depending on school staffing patterns. A
typical school threat assessment team draws upon school administration (principal or assistant prin-
cipal), mental health (school counselor, psychologist, social worker) and law enforcement or security
(Cornell, 2018b). Teachers, school nurses and other professional staff may be included. Each school
should have a threat assessment team, although a districtwide team can be a valuable resource in the
most complex or challenging cases. A school-based team will have firsthand knowledge of the students,
be able to respond quickly and can carry out preventive actions and monitor their effectiveness. Collab-
oration with law enforcement is critical so that authorities can avoid overreaction to cases that do not
rise to the level of a criminal offense and can be resolved with counseling and school discipline, and, yet,
react appropriately to more serious cases that merit law enforcement intervention.

Based on work done by the U.S. Secret Service National Threat Assessment Center on enhancing school
safety, threat assessment is predicated on a set of key principles (Fein et al., 2004):

1. Targeted violence is the end result of an understandable, and often discernible, process of thinking
and behavior.

2. Targeted violence stems from an interaction among the individual, the situation, the setting and the
target.

3. An investigative, skeptical, inquisitive mindset is critical to successful threat assessment.

4. Effective threat assessment is based upon facts, rather than on characteristics or traits.

5. An integrated systems approach should guide threat assessment inquiries and investigations.

6. A central question in a threat assessment inquiry or investigation is whether a student poses a

threat, not whether the student has made a threat [emphasis original].

A threat assessment model specifically designed for schools was developed at the University of Vir-
ginia in 2001 (Cornell et al., 2004). This model uses a decision tree to guide school-based teams in an
assessment of student threats that emphasizes the distinction between transient threats that are not
serious and can be easily resolved as student misbehavior and a smaller number of substantive threats
that merit protective action and require a more extended safety plan (Burnette, Datta, & Cornell, 2017).
Five controlled studies compared schools using this model with control group schools (either using a
different model of threat assessment or not using threat assessment). In brief, these studies found that
schools using the Virginia Student Threat Assessment Guidelines had lower rates of school suspension,
less bullying and student aggression and more positive perceptions of school environment and safety,
as reported by teachers and students (Cornell, 2018b).

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A randomized controlled trial found that schools using threat assessment (compared to a waitlist con-
trol group of schools not using threat assessment) were less likely to suspend students or transfer them
to another school and more likely to use counseling services and parent involvement in resolving stu-
dent threats (Cornell, Allen, & Fan, 2012). However, there were too few incidents of threats being carried
out to compare the two groups of schools. (Studies of threat assessment in Virginia schools have been
unable to examine the impact on school homicides or serious injuries because no such incidents have
occurred during any of the study time periods.)

Following the Sandy Hook shooting, Virginia schools mandated that all K–12 public schools use a threat
assessment approach. A statewide assessment (Cornell et al., 2018) found that, across 1,865 threat cases
from 785 schools, 97.7 percent of threats were not attempted and less than 1 percent were carried out,
with no serious injuries. Also, 84 percent of the students who made the threats continued in their orig-
inal school. Notably, there were no statistically significant differences in suspension rates for white and
minority students (Cornell, Maeng, Huang, Shukla, & Konold, 2018).

School administrators, employers and others may feel caught between a rock and a hard place: at risk
of litigation for failing to respond to potential threat and prevent harm, but also for violating the rights
of students and employees. Mass violence has given rise to personal injury lawsuits seeking damages for
wrongful death, nonfatal injuries and the economic and emotional harms flowing from them. Lawsuits
resulting from these tragedies are rooted in fundamental legal principles of duty to take reasonable
care to guard against known or reasonably foreseeable hazards. Defendants in such suits have included
employers, school districts and officials, law enforcement, mental health professionals and even the
parents of perpetrators. In these cases, plaintiffs allege that the defendants had an obligation to act to
prevent the harm from occurring and negligently failed to do so.

While the potential for such suits causes justifiable concern, many school officials and others also
worry that they may be sued for disability discrimination, or violation of federal or state statutes, such
as the Health Insurance Portability and Accountability Act (HIPAA) and the Family Educational Rights
and Privacy Act (FERPA) (see text box, Clarifications on HIPAA and FERPA). These concerns are
often exaggerated, as both HIPAA and FERPA provide multiple exceptions for the disclosure of other-
wise-protected information to protect the person of concern or others.

With that in mind, the safest course is to behave in a reasonable fashion that responds to known or fore-
seeable harm and adheres to legal requirements. This can include:

1. Developing policies and procedures that address the risks of potential harm and managing them.

2. Training employees on these policies and procedures, including periodic retraining.

3. Applying the policy and procedures and following up.

4. Establishing multidisciplinary threat assessment and management teams.

5. Practicing the application of the policies and procedures.

6. Educating team members and others in the organization as to the actual requirements of statutes
such as HIPAA and FERPA.

7. Keeping track of cases for future reference and reviewing how they were handled for quality
improvement purposes.

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It is important to note that merely having policy and procedures in place is not sufficient to protect
against liability. Indeed, unless staff are trained on the policy and procedures, and they are actually
applied, their existence may be used to show that the defendant knew of the risks but was negligent in
failing to follow its own rules.

Recognizing and Responding to Trauma in the Wake of a School Shooting

Multiple reactions follow school shootings, including shock, outrage and grief when deaths occur. Such
a crisis is often followed by a cascade of unexpected secondary losses and stressors. For example, after
a school shooting, there may be a drop in school enrollment when students who have experienced
trauma transfer out or even students who were not traumatized seek a school that is less impacted by
the recovery from the event and more focused on academic pursuits. Prospective students and fami-
lies often opt to go to a different school. Budgets are based on the number of students attending the
school and if the budget drops after enrollment drops, schools may feel the need to cut support ser-
vices to save money, just at a time when students need this help. Tax bases may drop, too, as property
values diminish due to the violence occurring within the neighborhood.

Crisis events uncover prior trauma or loss, even if it is unrelated to the event. Research reveals that
trauma and loss are common, but provider training addressing these issues is often not sufficient to
meet the need. One out of 20 young people experiences the death of a parent and nine out of 10
experience the death of a close relative by the time they complete high school. However, fewer than 10
percent of educators receive any training on how to support grieving children and youth, which is the
main factor limiting their ability and willingness to provide support (Schonfeld & Demaria, 2016).

In a study on the effects of the September 11, 2001, terrorist attacks on New York City schoolchildren
(Hoven et al., 2005), one in four students surveyed six months later met the criteria for one or more
probable psychiatric disorders, including posttraumatic stress disorder, major depressive disorder,
separation anxiety and general anxiety disorders, panic attacks and agoraphobia. Based on a survey of
8,000 students, 87 percent had at least one trauma symptom that was continuing six months later. More
important, the vast majority who self-reported their symptoms also reported they had neither sought
nor received mental health treatment, even though there was free mental health counseling available in
the school.

This means that individual treatment services in isolation are not enough to address the broad range of
needs for supportive and therapeutic services after a traumatic event like a school shooting. A school
response should not be limited to only providing individual services outside of the classroom. Teachers,
school administrators and staff can have a profound impact by providing compassionate support in
their daily interactions with students, in addition to identifying those who may benefit from additional
mental health services. This more comprehensive and trauma-informed approach requires both training
and adequate resources.

Training in providing compassionate support after a trauma has not been a priority in teacher prepara-
tion coursework nor in professional development. Such training is often sought in the wake of a school
shooting, but so-called “just-in-time-training” is far from ideal, since school staff will also be deeply
impacted personally by these events and therefore often overwhelmed themselves and less able to
focus on learning new skills (Sandy Hook Advisory Commission, 2015). Prior to any major event, they
need to learn about the impact of trauma and bereavement on young people and their learning, prac-
tical strategies for providing Psychological First Aid and brief supportive services and indications for
referral for mental health services. Given that these skills can be used to support young people who
are struggling with personal and family crisis events, they are critical for educators and will be valuable
even in the absence of a school shooting.

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Preparedness involves not just preparing to respond but also preparing to recover. Too little attention
is paid to the time needed to recover, which may take years and the timeframe for federal funding is
not aligned with this need. In addition, the amount of funding is often less than the scope of the need.
Recovery funding mechanisms should, therefore, be harmonized with the duration and extent of need
(Sandy Hook Advisory Commission, 2015).

Ultimately, schools can help prevent violence by ensuring that students are successful academically and
in their interpersonal relationships. Investing in universal social and emotional curriculum may be one
way to support prosocial behavior and emotional well-being. However, this investment can be challeng-
ing in schools without adequate staff-to-student ratios and an emphasis on high academic standards
and behavioral expectations in lieu of social and emotional learning.

Helping Families Heal
Family members of those who are victims of mass violence experience a wide range of emotions that
run the gamut of loss and grief to trauma. They are grieving the loss of someone to whom they didn’t
say goodbye and traumatized by the way in which they died. They are likely dazed and confused and
initially may want to withdraw rather than talk to providers. They may have little recall for what is dis-
cussed in bereavement counseling, so written materials can be helpful.

It is also important for providers to remember that those who have experienced this kind of loss likely
have an altered perception of the world and their safety and are often hypervigilant. This means they
may have difficulties establishing trusting relationships with treatment providers. Some will want to
work out their grief by speaking to the media, but others will need to be protected from the constant
glare. As future tragedies strike, even years after an event, their trauma may be retriggered, as seen in
the recent suicides of two students who were survivors of the Parkland shooting and the suicide of a
father of a Sandy Hook victim.

Families of perpetrators go through the same reactions, but they bear an additional layer of scrutiny.
They may be barraged by the press; blamed by the media, public officials and other families; and have
legal concerns to address. But they may also be grieving the loss of a loved one and left to wonder
what, if anything, they could have done. Often, their concerns are brushed aside.

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“Something Was Broken”

Sue Klebold remembers her son Dylan, one of the two Columbine High School shooters, as “the
young cherub with the golden curls and the blue eyes.” He could read “Stuart Little” at the age of
four and was a loving brother. Three days before the April 20, 1999, shooting that left 12 students
and one teacher dead and another 24 individuals injured, the 17-year-old senior attended his high
school prom. He had been accepted at four colleges. Three days later he would be dead of a self-
inflicted gunshot wound.

To this day, Sue is not sure what prompted Dylan and his friend, Eric Harris, to plan to kill everyone in
the school. Fourteen months before his death, Dylan and Eric got in trouble for stealing something
from a parked van, but they were released early from a diversion program. At 17, he was sometimes
moody and Sue found out after his death that he drank alcohol, but she’s not aware that he used
drugs (none were reported in the toxicology report). He did not have a diagnosed mental illness.

Years after his death and long after the police report came out, Sue discovered that Dylan had writ-
ten in his journal when he was 15 that he was in agony and wanted to die. He wrote that he wanted
to get a gun and that he was cutting himself. “I never saw signs of those, but we found it in his writ-
ings,” Sue says.

Sue now says she believes, “Something was broken. Something was not right in Dylan’s thinking. He
had lost access to whatever tools he had of self-governance and reason, logic and concern.”

Everyone from the public to the media to the governor blamed the shooting on poor parenting and
Sue says she has had trouble forgiving herself. “I believe now that I could have done things differ-
ently,” she says. “I could have listened differently. I could have asked different questions. And I really
believe that his participation, at least, could have been prevented.” She noted that neither his teach-
ers nor his friends suspected he was capable of this level of violence.

For Sue, the concept of “life indifference” or suicidality on the part of active shooters rings true. She
has become a vocal suicide prevention advocate who believes that every citizen should have some
type of suicide prevention training and that everyone should be trained in Mental Health First Aid.
Because mass violence is a rare event, she notes, the goal is not to prevent a shooting but to help
people who are suffering.

She also believes, “We can’t back away from the conversation of how mental ‘unwellness’ intersects with
violence. I don’t think we should be afraid of having that conversation,” Sue says, while acknowledging
the need to put some boundaries around the discussion so as not to unfairly characterize all mental
illness as linked to violence, which would increase stigma for those with mental health problems.

Ultimately, Sue believes we must get quiet and listen to one another. “I think we have lost our ability
to do that,” she says. The goal, as community members, family members and adults in our youth’s
lives is not to make them feel better, but simply to help them feel — to identify their feelings and
learn how to respond. “We might save their lives,” Sue says.

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A PUBLIC HEALTH MODEL OF PREVENTION
Mass violence, to the limited extent that it is due to mental illness, may best be prevented by providing
competent and comprehensive mental health care to the American population (a situation that doesn’t
currently exist) and, in this context, adopting a public health model of prevention:

• Universal: A public education campaign to help identify people of concern (e.g., “see something, say
something”).

• Selective: Measures to assess and intervene with people with specific identified warning signs —
but no history of past significant violence, communication of threat or evidence of planning — and
access to weapons capable of inflicting mass casualties.

• Indicated: Measures to contain, assess and intervene with people with past histories of threatened or
actual significant violence, specific warning signs that include communications of threat and evi-
dence of planning/practice and access to weapons capable of inflicting mass casualties.

It is important to note that most of the people who pose a risk of violence are not hidden from view. In the
right kind of organizational setting — whether community, workplace, health care or educational venues —
people exhibit signs with what they say, do and how they behave that reveal their distress or propensities.
Some of them overtly threaten violence, recruit accomplices, talk about their violent acts and clearly need
help. But there’s a broader pool of people who are in urgent emotional distress. They might have a mental
illness, but their distress may be circumstantial, caused by a domestic dispute, a setback or disappoint-
ment in their job, financial duress or a combination of events. In such conditions there are interventions
that can defuse the situation and move people off the pathway to violence well before they show up with
a gun (Rozel, 2018). And while it may not be possible to precisely determine if and when their suspected
untoward behavior might emerge, creating within an organization a place where a person who sees
something can say something and know that their concerns will be acted on is a powerful public health
intervention. It also becomes an important basis for getting information about who might cause harm.

The goal is to minimize exposure to traumatic events and maximize protective factors. This involves
teaching resilience and helping young people learn how to regulate their emotions and consider-
ing investments in home visiting programs, parental supports, maternal leave policies and access to
high-quality preschools. It means helping strengthen a young person’s coping skills, teaching parents to
model nonviolent behavior and educating their children on positive ways to deal with stressful events. It
means creating healthy communities in places that too often are racked by poverty, violence and sub-
stance use. Incorporating the pediatric medical home, which can serve as a hub for so-called “medical
neighborhoods,” can address social determinants of health and promote affiliative childhood/family/
community experiences over adverse ones. Several evidence- based social and emotional learning cur-
ricula exist that can aid schools and ultimately communities in this vital endeavor (Macklem, 2014).

Opportunities for Prevention
Despite the gravity of the problem and increasing public concern, there is little research available
regarding the efficacy of violence prevention interventions. This is in part due to the relatively rare
occurrence of mass violent events, but more so the result of limitations in research funding. The
increased public demand for stemming this growing and disturbing problem should move govern-
ment to action but has yet to do so. In the absence of coordinated policy-driven action, individuals and
communities have pursued opportunities for prevention and, in doing so, helped promote resilience and
relieve emotional distress. Several examples of such prevention efforts follow.

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“See something, say something.”

The concept of “see something, say something” is predicated on the belief that often individuals
demonstrate red flags in their behavior and the individuals most trained to recognize and address those
flags are not the individuals most likely to see them. The so-called “bystander problem” was discussed
in Williams, Horgan, & Evans (2016), who examined a program in Bethesda, Md., that was designed to
encourage students to report concerning behavior. When they surveyed the young people who par-
ticipated in the program, none indicated that they would report a friend who said they were about to
engage in a violent act. The bystanders said there were afraid they’d be wrong, they didn’t want to get
their friend in trouble, or they didn’t want to be a target of their friend’s anger. Other studies have found
greater bystander willingness to report and have found that school environment is associated with
student willingness to seek help for threats of violence (Millspaugh, Cornell, Huang, & Datta, 2015; Eliot,
Cornell, Gregory, & Fan, 2010).

Silver, Simons, & Craun (2018) found similar results. Even though the active shooters they studied
showed four to five concerning behaviors that bystanders observed, only 41 percent reported their
concerns to law enforcement. Eighty-three percent of bystanders communicated their concerns directly
to the active shooter, who would try to allay the bystander’s concerns. Each subject of concern had
more than one contact whose behavior (talked to the subject, reported to police, etc.) was noted. The
researchers concluded that more needs to be done to help bystanders understand that their concerns
will elicit a caretaking rather than a punitive approach (Pollack, Modzeleski, & Rooney, 2008; The Fed-
eral Commission on School Safety, 2018). School shootings have been averted because a student or
someone else reported the threat (Daniels et al., 2007; Madfis, 2014; Daniels & Bradley, 2011; Daniels et
al., 2010; Esserman, n.d.).

Community Intervention Programs

Programs like Community Connect at Boston Children’s Hospital bring together a broad segment of
the community — including local police departments, public schools, mental health professionals and
members of the faith community — to provide resources for families at risk (Ellis & Abdi, 2017). Pro-
gram members refer cases of children, adolescents and young adults who are at risk of involvement in
the criminal justice system, for whatever reason, and an effort is made to first identify the needs of the
individual and family and then coordinate how those needs can be met. The goal of all participants,
including those from law enforcement, is to help avoid involvement in the criminal justice system.

In 2015, President Obama issued task forces on Countering Violent Extremism that examined three
cities. Part of what was developed was an organized approach through the Department of Homeland
Security, but also, many communities came to understand that open dialogue and conversation, as well
as the building of safety networks, would help families and friends know where to turn if concerns about
behavior arose (The White House, 2015).

Mental Health First Aid is an eight-hour training that prepares the average person to identify someone
in distress from mental illness, provide them with reassurance and get them assistance. Early identifica-
tion and treatment of mental illness reduces the risk for violence.

A Role for Treatment Providers
Behavioral health treatment providers have key roles to play in preventing and responding to incidents of mass
violence. Engaging clinicians in these activities requires sensitivity to their concerns in a number of key areas.

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Prevention

Behavioral health clinicians working with patients who may be at risk for violence may have concerns
that need to be addressed. First and foremost, they are potential victims of violence, an occupational
hazard. In this context violence prevention becomes a workplace safety goal. In addition, they may also
be worried about damaging the therapeutic alliance with patients if they report their concerns, and,
conversely, they may fear repercussions if they don’t.

Clinicians may also wrongly believe they can’t act on their concerns because of HIPAA, which protects
patient privacy. But, in fact, providers can pass along information to law enforcement, family members
of the patient or others when they feel such action is warranted to protect personal safety (see the
text box, Clarifications on HIPAA and FERPA). The FERPA protects students’ educational records (their
health records are covered by HIPAA) and federal restrictions on disclosure of information related to
alcohol and drug abuse treatment records are governed by 42 CFR Part 2. Clinicians and school officials
need to be educated about their rights and responsibilities under these regulations.

Clarifications On Federal Regulations Related to Confidentiality

For HIPAA, when a provider believes in good faith that a warning to law enforcement, family mem-
bers of the patient or others is necessary to prevent or lessen a serious and imminent threat to the
health or safety of the patient or others, the privacy rule allows the provider, consistent with appli-
cable law and standards of ethical conduct, to alert those people whom the provider believes are
reasonably able to prevent or lessen the threat (45 CFR Sec. 164.512(j)). They may notify the family
to watch for symptoms, even if harm is not imminent (45 CFR 164.510(b)(2)).

Under 42 CFR Part 2 § 2.63 confidential communications may be disclosed pursuant to “(a) A court
order under the regulations in this part may authorize disclosure of confidential communications
made by a patient to a part 2 program in the course of diagnosis, treatment, or referral for treat-
ment only if: (1) The disclosure is necessary to protect against an existing threat to life or of serious
bodily injury, including circumstances which constitute suspected child abuse and neglect and ver-
bal threats against third parties.”

The FERPA (20 U.S.C. § 1232g; 34 CFR Part 99) is a federal law that protects the privacy of student
education records. The law applies to all schools receiving funds under an applicable program of
the U.S. Department of Education. FERPA gives families certain rights with respect to their child’s
education records. However, there are areas in which a school has the right to disclose information
to specified officials for evaluation purposes (e.g., concerns of violence risk). After the Virginia Tech
shooting, the U.S. Department of Education issued brochures with clarifications on FERPA that
explicitly recognized that school authorities can disclose names and other identifying information to
protect the health or safety of others (https://www2.ed.gov/policy/gen/guid/fpco/ferpa/safe
schools/index.html). The clarification also acknowledged that school authorities may have personal
knowledge of a student that is not part of the educational record and therefore can be disclosed
at the authority’s discretion. This is important because there is a widespread misperception that
FERPA prevents school authorities from sharing information about a threatening student.

In some situations, clinicians are required to breach confidentiality.

A PUBLIC HEALTH MODEL OF PREVENTION

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Tarasoff Duty to Protect

“When a therapist determines, or pursuant to the standards of his profession, should determine, that
his patient presents a serious danger of violence to another, he incurs an obligation to use reason-
able care to protect the intended victim against such danger.” “[T]he judgment of the therapist
in diagnosing emotional disorders and in predicting whether a patient presents a serious danger
of violence is comparable to the judgment which doctors and professionals must regularly render
under accepted rules of responsibility.”

This rule, which has spread to many states and has been modified or rejected in others, originated
in the California Supreme Court’s decision in Tarasoff v. Regents of the University of California (17
Cal.3d 425 [1976]). In Tarasoff, a patient told his psychotherapist that he intended to kill an unnamed
but readily identifiable woman. Subsequently, the patient killed the woman. Her parents then sued
the psychotherapist for failing to warn them or their daughter about the danger. The therapist noti-
fied the police, who contacted the patient and also notified his supervisor, who reprimanded the
therapist for violating confidentiality and threatened to fire him for any further violation of confi-
dentiality. The California Supreme Court rejected the psychotherapist’s claim that he owed no duty
to the woman because she was not his patient, holding that if a therapist determines or reasonably
should have determined “that a patient poses a serious danger of violence to others, he bears a
duty to exercise reasonable care to protect the foreseeable victim of that danger.”

Under the Anglo-American legal system, individuals who cause harm to others may be held liable
and required to pay damages if the injury caused was reasonably foreseeable (i.e., a reasonable
person in similar circumstances would understand that the behavior in question was likely to cause
injury). A fundamental tenet of personal injury law in this system is that Person A cannot be held
responsible for harm caused by another person (the actor, Person B) unless a special relationship
exists between A and B. Tarasoff and its progeny reconfirmed this principle but limited foreseeabil-
ity to situations in which there is an actual threat of violence to a specific person or a reasonably
identified person. The primary significance of this line of cases is the requirement that under such
circumstances, therapists may be obligated to breach confidentiality.

The Tarasoff duty to protect others only applies to specifically identified or readily identifiable
individuals. The Tarasoff case does not contemplate duties that may arise toward groups of people.
Duties to third parties vary highly across states and even across time as new cases are decided and
statutes enacted; because subsequent cases in other states have broadened or narrowed the duty
or specify how it can be met, the reader is advised to discuss the legal duty in their state with their
legal advisor.

Finally, ideological and philosophical beliefs about an individual’s rights and personal autonomy versus
the safety and best interests of society may influence providers’ actions regarding violence surveillance
and prevention.

Mental health advanced directives, including Ulysses contracts, can aid in preventing mass violence
during times of exacerbation of mental illness. In a Ulysses contract, a person documents their agree-
ment to have their guns temporarily removed if their clinicians decide their risk of using them to harm
themselves or others has become significant. Research shows that 46 percent of psychiatric patients
would willingly agree to a seven-day delay or judicial review limit on firearms access (Vars, McCullum,
Smith, Shelton, & Cropsey, 2017). The psychiatric advance directive, which offers instruction for men-

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tal health treatment and authorizes someone as a health care proxy, might be especially important for
young adults transitioning into college, a time when mental illnesses often are exacerbated.

Response

Community mental health treatment providers play a vital role in the wake of a mass violence incident.
They provide support to victims and their families, to first responders and to the community at large.
Sometimes they are called on to define the role that mental health may have played in the incident.
Those seeking to provide a leadership role or consulting role to schools and school systems after major
events should have training and experience in systems-level consultation in the aftermath of such events
and experience in working with and in school settings. Otherwise, to be of optimal assistance, they
should seek consultation from individuals or groups that have this experience. It is critical that providers
understand their role in a communitywide response. Lessons learned from past events shed some light
on how best to prepare.

• Establish relationships in the community early on to foster trust and support in the aftermath of a
tragic event. Attempting to establish relationships in the aftermath of an event can be challenging.

• Be responsive, but not intrusive. It is easy to get overinvolved and to want to be everything to
everyone. Go with invitation as a guest of the institution that owns the incident. Support, but don’t
take over.

• Have identified sources of funding in place so providers can spend their time responding and not
fundraising.

• Have a plan to coordinate volunteers; they may come from all over the country and will need to be
managed effectively.

• Have a plan to coordinate and credential clinicians. Ensuring community mental health centers have
certified clinicians on staff and a process to disseminate information/support to others is essential to
meet the needs of the community.

• Understand your place in the critical incident command structure. Leverage key relationships to
remain involved when and where you are needed.

• Remember that disaster response is a marathon, not a sprint. Don’t underestimate the level of need
or the duration of these events.

• Prioritize. Start with the people who need your help the most. Be aware that those who need your
help may not be the ones who seek it, so be prepared to identify them and reach out. Go to them,
rather than waiting for them to come to you.

• Be flexible. Whatever is anticipated about the way the community response will look will undoubt-
edly change. Things are quite fluid on the ground. One phrase that was helpful to hear, for instance,
in the response by psychiatrists in the early days of the Sandy Hook tragedy was that they would
benefit by providing “therapy by walking around,” as people gathered in the town in large groups.

• Understand that those in the community who have experienced previous trauma (e.g., veterans) may
be triggered by a mass violence incident. Be prepared for an increase in need across the behavioral
health care system.

• Support staff early and often. Be aware of vicarious trauma and compassion fatigue and have plans
to address them.

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• Address gaps in care by reaching out to organizations that are not typically at the table. Include
business leaders, the faith community, youth, mental health consumers and law enforcement. Collab-
orate with local crisis providers.

• Consider providing Mental Health First Aid training to all staff, including receptionists, human
resources personnel and security staff and to members of the community the agency serves.

• Remember that health center staff can themselves be a target of violence and prepare them for how
to respond.

• Be prepared for an onslaught of media. Know who in your organization or broader mental health
system is authorized to speak with the press. If you are tasked with this role, have talking points
about mental illness and violence, your state’s commitment laws and your state’s gun laws at the
ready. A resource such as “Responding to a High-Profile Tragic Incident Involving a Person with a
Serious Mental Illness” (NASMHPD and CSG Justice Center, 2010) can help. See more in “Recom-
mendations for Working with the Media,” later in this paper.

Community mental health providers have a role to play both in violence risk assessments of individual
clients and as part of multidisciplinary threat assessment teams. Violence risk assessment differs from
threat assessment and management. The most fundamental difference is that the latter focuses on
whether a given individual poses a risk of harm to a specific target, whereas the former focuses on the
likelihood of violence, in general. Other ways in which they differ include those listed in the following
table (Meloy & Hoffman, 2014):

THREAT ASSESSMENT AND MANAGEMENT VIOLENCE RISK ASSESSMENT

Investigative approach Clinical assessment approach

Ongoing process Single point-in-time assessment

Includes non-clinicians — police, lawyers, etc. Clinicians only

More resource intense Less resource intense

Includes interventions Does not include interventions

Unfortunately, many clinicians are not adequately trained in violence risk assessment and very few are
trained in threat assessment and management. Clinicians must have access to responsive threat assess-
ment and management for persons who are experiencing intense emotional crisis but who do not meet
criteria for involuntary hospitalization or treatment.

Liability fears may prevent providers from being involved in broader threat assessment approaches. But
the time has long since passed when providers can deny their role in assessing risk for violence. The
goal is not for community providers to play the only role in identifying and addressing risk for violence
but to be a critical part of integrated, comprehensive community-based care for individuals at elevated
risk for committing a violent act (Rozel, Jain, Mulvey, & Roth, 2017).

The behavioral health system needs to be able to respond quickly to struggling or distressed youth
and adults who could be experiencing mental health problems. However, access to care and treatment
can be challenging. Although 76 percent of Americans think mental health is just as important as phys-
ical health, we are experiencing a crisis in access to care. One in four Americans have had to choose
between getting mental health treatment and paying for daily necessities and 96 million have had to
wait more than a week for mental health services.

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But inroads to increasing such access have been expanding, such as services that help consult primary
care providers around behavioral health issues. Private practitioners who are not part of a mental health
system may need further training and outreach to address these complex areas of concern. Specialized
services include programs designed to work with youth who are experiencing a first episode of psycho-
sis and their families.

The federal Interdepartmental Serious Mental Illness Coordinating Committee recognized the need to
increase access to care when it released its initial report (Interdepartmental Serious Mental Illness Coor-
dinating Committee, 2017). Among its recommendations were the following:

• Define and implement a national standard for crisis care.

• Prioritize early identification and intervention for children, youth and young adults.

• Maximize the capacity of the behavioral health workforce.

• Expect serious mental illness and serious emotional disturbance screening to occur in all primary
care settings.

• Make screening and early intervention among children, youth, transition-age youth and young adults
a national expectation.

• Make trauma-informed, whole-person health care the expectation in all our systems of care for peo-
ple with serious mental illnesses and serious emotional disturbances.

Finally, any efforts at prevention and early intervention must include activities that help reduce stigma.
Many people can benefit from mental health services in times of urgent emotional distress without being
diagnosed as having a mental illness. It must be understood that mental illness is treatable in the same
way that acute and chronic medical conditions are treatable and, likewise, that recovery is possible.

A Role for Primary Care Providers
The belief among primary care clinicians (in family medicine, internal medicine, pediatrics and obstet-
rics and gynecology) is that 40 percent of the problems they encounter in their practice are behavioral
health and psychiatric in nature. This is important in all age groups but particularly among young
people. Half of all lifetime cases of mental illness begin by age 14 and three-quarters begin by age 24
(Kessler et al., 2005). The average delay between onset of symptoms and their diagnosis and treatment
is eight to 10 years (NAMI, n.d.) and, yet, there is a nationwide shortage of child and adolescent psychi-
atrists and other mental health professionals. Primary care providers are often the first to detect mental
illness and offer a potential opportunity to diagnose, refer and treat underlying mental disorders (e.g.,
conduct disorder, depression, psychosis). However, primary care clinicians are ill prepared to fulfill this
opportunity. In addition, there are numerous barriers to enhancing mental health care in the primary
care setting.

Chief among these is a lack of adequate training in behavioral health and a resulting ambivalence and
discomfort in dealing with mental disorders. In addition, time constraints and poor payment models
discourage treatment of mental health problems in the primary care setting. Primary care providers may
also lack access to mental health specialty resources — two-thirds of primary care clinicians reported
difficulty accessing psychiatric services, more than double the percentage that report difficulty referring
to any other specialty (National Council Medical Director Institute, 2017). Further, young people and
their families may be reluctant to seek care from the specialty sector. Administrative barriers and limited

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information exchange between primary care and mental health specialty providers also act as con-
straints on serving young people with behavioral health needs in the primary care sector.

In response, primary care and behavioral health teams have developed innovative ways of working
together to support young people and their families (Coffey, Vanderlip, & Sarvet, 2017). These range
from developing formal consultation and collaboration protocols to locating staff in the same facility
with access to the same health records. One such example is Project ECHO, a telehealth model that
bridges the gap in health care for rural and underserved communities. Project ECHO is a collaborative
model of both education and consultation aimed at providing specialty care to primary care physicians
serving patients with mental illnesses. In another model, several states have developed consultative
services for primary care and pediatric practices where a child psychiatrist can be consulted directly
using telehealth services (e.g., Massachusetts MCPAP and Michigan’s MC3). These innovative ways of
care delivery can be effective in meeting the mental health needs of children and adolescents; however,
funding mechanisms — alternative to fee for service — are needed to sustain this level of support.

To facilitate the integration of behavioral and mental health care into primary care, the model of “collab-
orative care,” in which mental health providers are embedded in primary care settings, was developed
by Katon and Unützer (Katon, Unützer, Wells, & Jones L, 2010). The medical community has strongly
advocated for these important approaches. Health care organizations and individual clinicians are
encouraged to advocate on both state and national levels for policies that promote social and emotional
health and increased access to mental health care.

Courts and Law Enforcement Working with Youth
Although not all perpetrators of mass violence had behavioral challenges as youth, sometimes there
is an overlap. Community partnerships connecting law enforcement with mental health are a potential
avenue for therapeutic intervention and possible prevention of mass violence by at-risk youth. Some
programs work directly with children and adolescents to help prevent violence and head off youth from
becoming involved in the juvenile justice system. For instance, the Child Development-Community Polic-
ing (CD-CP) program in New Haven, Connecticut, began as a partnership between the Yale Child Study
Center and the New Haven Department of Police Service in 1991. The program, whose goal is to respond
to young people and families exposed to violence, serves as a model for law enforcement/mental health
partnerships around the country.

In CD-CP communities, mental health professionals respond 24 hours a day, seven days a week to police
calls involving child victims or witnesses to violence. Police, mental health professionals, child protec-
tive services and other providers work together to help reestablish safety, security and well-being in the
immediate wake of violent events. In the CD-CP model, clinicians and officers interrupt a trajectory that
frequently leads to increased risk of psychiatric problems, academic failure, encounters with the crim-
inal justice system and perpetuation of violence. They set young people and their families on a path to
recovery.

In Cambridge, Mass., the mission of Safety Net is to “foster positive youth development, promote men-
tal health, support safe school and community environments and limit youth involvement in the juvenile
justice system through coordinated prevention, intervention and diversion services for Cambridge
youth and families.” The program is a collaboration among the Cambridge Police and County District
Attorney’s Office, the Cambridge Police Department Youth and Family Services Unit, Cambridge Health
Alliance, Department of Human Services and Cambridge Public Schools.

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Together, the partners conduct outreach to families to develop an action plan that is tailored to meet
the unique needs of the child. Services include connections to mental health services, home visits,
juvenile diversion programs and help navigating the legal system. In addition, since 2007, all Cam-
bridge public schools and city youth programs have had an assigned Youth Resource Officer who
helps reduce juvenile delinquency through prevention, early intervention and diversion programs
(Haas & Barrett, 2014).

North Carolina’s School Justice Partnership (SJP) program began as a local effort but is now being
rolled out statewide. Chief district court judges convene stakeholders from schools, law enforcement,
the court system and the community to establish policies and procedures through a memorandum of
understanding to address student misconduct within the school system and community rather than
by automatic referral to the justice system. The goal is to help reduce in-school arrests, out-of-school
suspensions and expulsions, which can set youth on a path into the school-to-prison pipeline. A single
suspension can triple the likelihood that a student will enter the juvenile justice system and confinement
in a juvenile facility increases the risk that a youth will be rearrested as an adult (School Justice Partner-
ship North Carolina, n.d.).

SJP programs use evidence-based discipline strategies for minor, nonviolent offenses that keep kids in
school and improve academic achievement. In North Carolina, Texas and Connecticut, SJP programs
show an overall decrease in referrals to juvenile court, a decrease in referrals of youth of color to juve-
nile court and an increase in graduation rates (School Justice Partnership North Carolina, n.d.). However,
there is no evidence that these programs reduce mass violence.

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IMPACT ON COURTS AND LAW ENFORCEMENTIMPACT ON COURTS AND LAW ENFORCEMENT

IMPACT ON COURTS AND LAW ENFORCEMENT
Problem-solving courts (e.g., drug courts, mental health courts) and law enforcement have become an
extension of and, in some cases, an entrée into, the mental health system. These efforts are described in
this section.

Therapeutic Jurisprudence in Problem-solving Courts
According to the Bureau of Justice Statistics, “problem-solving courts were created to address
underlying problems that result in criminal behavior” (Strong, Rantala, & Kyckelhahn, 2016). These
interdisciplinary and collaborative courts help fill gaps in psychosocial services, provide early identifica-
tion and intervention with individuals who may be at risk for violence and extend the reach of an often
under-resourced and overworked behavioral health treatment system.

Since the first drug treatment court was founded in Miami-Dade County, Florida, in 1989, the concept
of “therapeutic jurisprudence” has taken hold in problem-solving courts around the country. Therapeu-
tic jurisprudence is “a multidisciplinary examination of how law and mental health interact.” And, more
significantly, it is the explicit recognition that what happens in a courtroom, including the behavior and
decision of the judge, can have significant positive effects on a defendant’s mental health and can work
to decrease the risk of recidivism. It was developed in the 1980s by Professors David Wexler and Bruce
Winick as an academic approach to mental health law (Winick & Wexler, 2003).

Today, the range of problem-solving courts includes not only drug and mental health courts, but also
domestic violence courts (misdemeanor and felony), veterans’ courts, DWI courts, homeless courts,
girls’ courts, community reentry courts and truancy courts, among others. The civil legal system has its
own array of collaborative problem-solving courts that include juvenile dependency/child welfare courts
and safe babies’ courts. There are now more than 3,000 problem-solving courts around the country.
For example, Michigan currently has 185 problem-solving courts and legislation recently passed to fund
juvenile mental health courts statewide (Cook, 2018). In addition, courts of general jurisdiction have
become more interested in using alternative sentencing models and diversion.

Number of Drug Courts by Year in the United States, 1989–2014

Source of data: National Drug Court Institute,, “Painting the Current Picture:
A National Report on Drug Courts and Other Problem-Solving Courts in the United States.” (2016),

Table 3 (http://www.nadcp.prg/sites/default/files/2014/Painting%20the%20Current%20Picture%202016.pdf)

1,000

500

0

2,000

2,500

3,000

3,500

1,500

19
90

19
91

19
92

19
93

19
94

19
95

19
96

19
97

19
98

19
99

20
03

20
04

20
05

20
06

20
07

20
08

20
09

20
10

20
11

20
12

20
13

20
14

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IMPACT ON COURTS AND LAW ENFORCEMENT

Problem-solving courts evolved from the realization that many criminal courts had become revolving
doors for individuals with mental and substance use disorders and trauma histories who might be bet-
ter served in treatment. Along the way, judges that serve in problem-solving courts have become first
responders and crisis interveners. The courts themselves help fill gaps in services for individuals who
need mental and substance use disorder treatment, serving, in essence, as an offramp to the criminal
justice system.

TABLE 4: Point of entry into problem-solving courts, by type of court, 2012

TYPE OF COURT
PRE-PLEA OR AT

CASE FILING
POST-
PLEA

POST-
SENTENCE OR

POST-RELEASEa
JUDICIAL
ORDER OTHERb

All courts 35.5% 66.1% 35.7% 8.5% 2.4%

Drug 27.1 73.9 44.5 2.1 0.9

Mental health 44.1 73.1 41.1 3.7 0.7

Family 43.3 16.1 12.1 60.7 10.7

Youth specialty 49.5 54.3 11.7 3.2 6.4

Hybrid DWI/drugc 24.0 85.4 40.1 1.6 0.5

DWI 14.7 68.4 41.2 2.3 1.1

Domestic violence 72.8 39.1 14.6 15.9 2.0

Veterans 46.3 81.0 27.3 2.5 3.3

Tribal wellness 29.2 83.3 54.2 16.7 0.0

Otherd 49.2 45.8 36.7 7.5 4.2

Note: detail may be more than 100% because multiple responses were allowed. Percentages based on 96.6% response rate.
aIncludes entry after violation or revocation of parole.
bIncludes acceptance on a case-by-case basis, post-referral from outside agency, entry after child adjudicated dependent,
and after admitting to impaired ability to care for a child.
cHandles alcohol- or drug-dependent offenders also charged with a driving offense.
dIncludes other courts not shown

Source: Bureau of Justice Statistics, Census of Problem-Solving Courts, 2012.

Problem-solving courts share common goals and objectives, which include being led by a judicial officer
who applies the social science of therapeutic jurisprudence. Unlike traditional courts of general juris-
diction, this model includes a specialized docket. Although court models may differ, common fidelities
include individual clinical assessments, treatment planning and court oversight, typically from a diver-
sionary approach.

Using the best evidence-based practices, problem-solving courts are trauma-informed and culturally
sensitive. Judges act as conveners for a broad group of community stakeholders, including those from
the behavioral health care system, who come together to develop treatment plans that are person-cen-
tered, trauma-informed and strengths-based. Most courts use an incentive/sanction approach, with the
goals of improving public safety, increasing positive health outcomes and reducing recidivism.

Through a collaboration of trained stakeholders and court staff, the impact of childhood trauma,
adverse childhood experiences and/or identification of emotional disorders for youth and/or adults are
typically reviewed to evaluate not only treatment needs, but also matters of risk and accountability. The
legal system across the spectrum — from family/juvenile courts to domestic violence, truancy, veterans’

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mental health and DWI courts — may be viewed as early interveners in the identification of potential
dangerousness (Shauhin, 2007).

The legal system across the spectrum — from family/juvenile courts to

domestic violence, truancy, veterans’ mental health and DWI courts — may

be viewed as early interveners in the identification of potential dangerousness

(Shauhin, 2007).

Law Enforcement Training and Co-responder Models
In many parts of the country, local, state and federal law enforcement officials are being trained in how
to respond to calls that involve people with serious mental illnesses. They are trained in how to identify
mental health problems, respond appropriately and de-escalate a situation that may lead to violence.
Programs include Mental Health First Aid, Crisis Intervention Team (CIT) training and motivational
interviewing. There are currently nearly 3,000 Mental Health First Aid instructors with the public safety
designation. They have trained 200,000 officers to date (including patrol, intake, corrections, warrant,
court staff, etc.) in about 500 departments nationwide.

The goal is for officers to work collaboratively with an individual and with their partners in mental health
to defuse a situation and find help for a person who may not belong in the criminal justice system. For
example, in Pittsburgh, law enforcement officers have access to a mobile app that links them with men-
tal health crisis resources and also walks them through an appropriate response to a person who may
be experiencing a mental health crisis.

More formal collaborations include the Community Mental Health Liaison program in Missouri, in which
master’s-level clinicians with community mental health centers work directly with law enforcement. In
this co-responder model, every law enforcement officer in Missouri has access to these clinicians, who
can help an officer assess a person and refer them to appropriate treatment. This moves the interven-
tion upstream and helps the person avoid coming into contact with the criminal justice system.

Mobile crisis teams in many communities and states develop a liaison with law enforcement. Less for-
mally, mental health center staff may ride along with local law enforcement. This makes them available
should police encounter a mental health crisis situation.

In Massachusetts, a specialized law enforcement training at the academy level fostered numerous mul-
tiagency collaborations to help police be better equipped to manage crises, all while co-responder, CIT
and innovative diversion strategies were being developed across the state.

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Involuntary Commitment
Civil commitment is a legal mechanism to treat patients regarded as mentally ill and potentially danger-
ous, even over their objection. This is most commonly done by admitting patients to mental hospitals
or the psychiatric units of general hospitals. In addition, many states have statutes providing for invol-
untary outpatient commitment, which may be an option for someone who has severe mental illness
and is thought to be at serious risk for violence or harm to themselves but does not require hospital-
ization. Swartz et al. (2010), a study of New York State’s Kendra’s Law, found that with the appropriate
resources devoted to community treatment, involuntary outpatient commitment for a narrowly defined
population can reduce hospitalization and length of stay, increase receipt of psychotropic medication
and intensive case management services and promote greater engagement in outpatient services. Yet,
court-ordered treatment is not a total solution — some individuals at risk for violence will not meet the
mental health criteria and court-ordered care does not mean full adherence. Moreover, the cumbersome
legal process that is warranted and the time constraints on mental health providers have resulted in this
mechanism being underused.

Others argue that voluntary treatment is always preferred (Beauchamp & Childress, 2013; Saks, 2017).
Involuntary inpatient commitment may not be the panacea some would hope for if the person cannot
be held beyond the initial several days that a court order allows. Civil commitment, whether inpatient
or outpatient, is a complicated intervention and it is not clear that it could be an approach to a mass
shooter, or even firearms violence in general, though it could be helpful where mental illness is present
and there is a clear risk of harm to self or others (Pinals, 2016).

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MEDIA AND MASS VIOLENCEMEDIA AND MASS VIOLENCE

MEDIA AND MASS VIOLENCE
Since the first highly publicized American mass violence event in the 1960s — the Texas Clock Tower
shootings in 1966 — the media has played a critical and sometimes controversial role in how these
events are viewed and filtered and the social and policy mandates proposed to prevent them. The fol-
lowing section is based on information provided to the Expert Panel on Mass Violence by Stephen Fried,
author, investigative journalist and adjunct faculty at the Columbia University School of Journalism.

Media coverage may be problematic for several reasons:

• Media portrayals of the role of mental illness as a cause of violence are exaggerated (McGinty, Web-
ster, Jarlenski, & Barry, 2014).

• Media portrayals of the violence/mental illness intersection drive stigma.

• Overstating the role that mental illnesses play in mass shootings further increases harmful stigma
(Clement et al., 2015; Silton, Flannelly, Milstein, & Vaaler, 2011).

• It has been suggested that media coverage of mass shootings can be correlated with tactical mim-
icry (imitating techniques) and temporal clustering (increased frequency after an index event)
(Jetter & Walker, 2018; Towers, Gomez-Lievano, Khan, Mubayi, & Castillo-Chavez, 2015).

As soon as expanded live coverage was added to traditional reported and edited stories in print, radio
and television, conversations began about how mental illness was portrayed and discussed by report-
ers and pundits, the experts who were consulted to comment on points (for which there is substantial
debate in the unfolding mental health literature) and how media coverage could lead to contagion.
These dynamics have become increasingly challenging with the proliferation of 24-hour cable news
and the internet — much of which goes out immediately live — and the reduction of some traditional
reporting staffs. While these changes affect all news coverage, they are especially challenging for the
coverage of mental illness, in general, and the coverage of emergencies that may or may not involve
mental illness, in particular. Before many facts can be gathered, real-time speculation of the role of men-
tal illness — by reporters, pundits and mental health professionals with little concrete information — can
create problems and lead to unjust characterizations of all people with mental illness, as well as unfair
speculation about the links between violence and mental illness.

In critiquing the media, however, it is important to differentiate between live interviews on television
and produced, edited pieces in print, online and for radio and television broadcast. It is also important
to note the irony that while there is more discussion than ever about mental illness in national and local
media during mass violence events (and suicides of well-known people), there is often a paucity of
coverage the rest of the time. The scant coverage is sometimes shaped by ideological bias about the
nature of mental illness and the fields that are charged with understanding and treating it. Rather than
an emphasis on a spectrum of mental well-being, often biased views support an “us vs. them” dichoto-
mous approach.

When a mass violence event unfolds, reporters look for credible sources. They might reach out to a local
mental health provider, a provider agency, the state mental health authority or an organization such as
the American Psychiatric Association or the American Psychological Association. Some of these organi-
zations provide media training to their staff and members so they know who should respond and what
they prefer their initial and ongoing response to be. Typically, after any event involving mass casualty,
the initial response is one of sympathy and shared solidarity.

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But subject matter experts may have an opportunity to help educate the media and the public about
mental illness. Even if the perpetrator does turn out to have mental illness, experts can use their airtime
to provide a framework for understanding these rare but disturbing events and offer some general infor-
mation about mental illness treatment and services and the problems caused by lack of access to them.
They can also attempt to dispel myths about how common it is for mental illness to lead to violence.
Further, experts can provide valuable information to the community about mental health resources that
may be available to help deal with resulting trauma in the aftermath of a significant violent incident.

Some organizations have prepared position statements on such hot-button topics as firearms and
mental illness (see Resources Appendix for examples) that allow them to speak with a clear and con-
sistent message.

Often, factual distinctions can impact decisions about whether and how to speak to the media. For
example, the perpetrator may be a person with no known mental health history, a person with a known
or newly revealed mental health history (treated privately or within the public system) or a person with
a vague mental health history. Clearly, providers have confidentiality limitations, including HIPAA and
42 CFR Part 2, if the perpetrator has been in their care. However, journalists are not bound by HIPAA,
patients and their families are allowed to break confidentiality in speaking to the press and the question
of whether or not a caregiver should have broken confidentiality in a case where a patient made violent
threats is a fair subject for coverage.

Clinicians also are bound by the ethics of their profession, which stipulate that they should not break the
confidentiality of their patients (without their informed permission). They also should not speculate on
diagnoses for people on the public stage about whom they have no direct knowledge (as detailed in the
“Goldwater Rule,” promulgated by the American Psychiatric Association after a public figure questioned
how a psychiatrist could opine on his diagnosis without having a formal professional role or examination
to do so). Even with these ethical standards, some mental health professionals will speak out. Although
these individuals might not be speaking on behalf of their profession, since they are credentialed and
have expertise, journalists and the public will likely interpret their personal opinions as an authoritative
position on certain mental health issues. This can lead to the dissemination of potentially biased or false
information and potentially add to the confusion around mental health stereotypes, patients with men-
tal illnesses and the mental health profession.

As news about a mass shooting event unfolds, response from the mental health community will change
over time. While the initial focus may be on the shooter and the victims, the ongoing response will
focus on the needs of the broader community. Here, mental health organizations can be a significant
resource. Many have amassed materials for dealing with the aftermath of a traumatic event. For exam-
ple, the American Academy of Child and Adolescent Psychiatry has prepared information for schools to
help young people who may be exposed to violent extremism. Other sources of information include the
Substance Abuse and Mental Health Administration’s Disaster Technical Assistance Center; the National
Child Traumatic Stress Network; the American Academy of Pediatrics, which has policies, recommenda-
tions and resources, including a coping and adjustment to disasters webpage; the Coalition to Support
Grieving Students; and the National Center for School Crisis and Bereavement. See the Appendices for
additional information.

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Working with Reporters
Studies of reporting on mass violence show that the biggest differences in how stories are covered
include whether or not the killer survived the incident, the ethnicity of the killer and the age and ethnic-
ity of the victims. In a recent study, Silva & Capellan (2019) found the following:

“The most common mass public shooting characteristics include perpetrators that are middle-
aged, white and nonideological, as well as incidents that have relativity low victim rates, occur
most commonly in the workplace and only involve handguns. Despite this, the media highlights
mass public shootings involving perpetrators that are younger, Middle Eastern and ideological,
as well as incidents involving higher victim rates, in non-workplace settings, with a combination
of weapons.”

There are few formal guidelines for media coverage of mass shooting events. The ones that do exist
(see https://www.reportingonmassshootings.org/, created by SAVE — Suicide Awareness Voices of
Education) are largely based on recommendations for reporting on suicide (a more common event than
a mass shooting) and they are voluntary and subject to wide interpretation. These guidelines emphasize
making sure the perpetrator(s) are not glamourized and advocating that the victims, police and other
first responders get the media’s attention. Following these guidelines is easier said than done, of course,
especially when the biggest open questions are: Who did the killing, how and why?

Just as in suicide situations, guidelines emphasize the need to not sensationalize the acts or perpetra-
tors. Suicide reporting guidelines sometimes insist the means of suicide not be reported at all for fear
of contagion; mass shooting guidelines sometimes suggest the perpetrator not even be named, or his
or her photo printed or broadcast. More important, guidelines suggest making sure that emergency
contact information for an organization that can render assistance is included in any stories about the
subject that might be considered triggering. Some organizations now offer “trigger warnings” at the
beginning of a story or broadcast.

While recognizing the risk of contagion from stories concerning suicides or mass violence, it would be
difficult to actually restrict media coverage the way some of these guidelines suggest. And, given the
proliferation of information on social media — sometimes before journalists even get it — one could
wonder if asking a reporter not to report something will really keep it from the public.

Implicit in any guidelines — and any teaching of journalists about covering such stories — is that the
journalist does everything possible to get the mental health reporting right, which is trickier than it
seems. Getting actual information about a perpetrator or victim, what treatment they may or may not
have been getting, how compliant they were, whether or not they had family support for treatment,
what their treating professional thinks, etc., is very difficult even when reporters have the luxury of time.
Some journalists believe that if untreated or improperly treated mental illness is part of the story, it
needs to be communicated to reporters and they must cover it fairly and compassionately. On the other
hand, mental health professionals and advocates, and even personal acquaintances, might object to this
level of detail in reporting as invasion of privacy.

While mental health professionals may debate whether or not they are able to help a journalist get
detailed information (which could mean nothing more than suggesting the family request treatment
records), there is no debate that more and better information is the key to accurate stories. Journalists
who want to do evidence-based reporting on mental health care are encouraged to ask individuals or
family members if they are willing to ask for their own or their family member’s medical records, rather

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than use the memories of primary and secondary sources to detail facts about care. Sometimes it is
only possible for journalists to offer true perspective once some time has passed and sources who ini-
tially would not agree to be interviewed change their minds. One of the best examples of this would be
the profile of Adam Lanza’s father (Solomon, 2014).

Journalists always try to do fair and balanced stories; when it comes to mass shootings, there are many
definitions of fair and balanced that are based on the mental health politics of the sources (psychiatrist
sources often focus on medical treatment issues and failures; psychologist and social worker sources
often focus on social issues). Often these ideas are being injected into coverage — especially the instant
broadcast coverage — to fill time until more facts emerge.

Finally, recognition must be paid to the fact that covering these events can be traumatizing for the jour-
nalists themselves, just as it is for the first responders and the community as a whole. Journalists, like
many others in our community not directly impacted by the event, are often close to the periphery of
these traumatic experiences and may be considered secondary victims.

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CONCLUSIONS

CONCLUSIONS
The following conclusions and recommendations were derived from the members of our workgroup,
relevant literature and discussions among workgroup members and editors. They should not be con-
strued as the position of any association represented by individual experts and may not reflect the
personal or professional views of all individuals in the expert panel.

1. Mass violence is not a major cause of death or injury in statistical terms, even though such incidents
are increasing in number and frequency in the United States. Nevertheless, they receive extensive
media attention, elicit strong emotional reactions in the population and are powerful motivators
for government officials. Consequently, this disturbing phenomenon constitutes a major social and
public health problem for our country.

2. Mass violence occurs in many, if not all, countries but is more common, inflicts more casualties and
more often involves firearms in the United States.

3. While people with mental illness account for a small proportion of the violent crime in the United
States, they perpetrate a somewhat larger portion of mass violence crimes.

4. Having a mental illness like schizophrenia, bipolar disorder or severe depression does not automati-
cally make a person a high risk for perpetrating mass violence. At the same time, the nature of their
symptoms, whether they are effectively treated, and other factors in their lives (drug use, family or
workplace conflict, access to weapons) can increase their potential for such behaviors.

5. Perpetrators of mass violence may be motivated by mental distress from life events and circum-
stances or by the symptoms of mental illness. These are not the same and thus require different
modes of detection and prevention. At present, our current health care delivery system is not
designed to address the causes or detect and provide interventions for people at risk for mass vio-
lence behavior.

6. Mass violence is a societal phenomenon that is amenable to actions that could reduce its fre-
quency; this requires cooperation among multiple national systems and institutions, including the
health care, law enforcement, judicial, correctional and school systems, as well as government and
community leaders and officials.

7. Legislation that restricts firearms, which has been enacted in some states (as discussed on pages
21–27), is associated with moderately reduced mass violence.

8. Profile-based screening, even when coupled with individual clinical evaluation, cannot precisely
predict who and when specific people will perpetrate mass violence, but research to improve meth-
ods of prediction and intervention are ongoing and progressing.

9. Additional resources for research and interventions are needed in communities, in general, and for
the educational and health care systems, in particular, to identify and provide assistance to people
who are experiencing extreme emotional distress and/or experiencing symptoms of mental illness
that may increase their violence risk and who have ready access to firearms.

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RECOMMENDATIONS

RECOMMENDATIONS
Based on the review, discussion and analysis of published information by the National Council Expert
Panel on Mass Violence, the following recommendations were made. These recommendations may not
reflect and should not be construed as representing, the views of each individual on the expert panel or
the organizations to which they belong. Rather, these recommendations are derived from the National
Council Expert Panel on Mass Violence process for the purposes of this paper.

General Recommendations
• Identify root causes of mass violence and develop strategies to alleviate them, instead of focusing

only on quick fixes downstream from the sources of the problem.

• Mental health providers and advocacy groups must acknowledge the role mental illness plays in
mass violence and support efforts to prevent the portion of mass violence perpetrated by people
with mental illness.

• Mass violence should be considered a public health emergency similar to an anticipated strain of
influenza or a contaminated food supply. Efforts to address this should include:

o Orient and align societal institutions and stakeholder organizations to the need to stem the fre-
quency of, and eliminate the causes of, mass violence as perpetrated by people who are mentally
ill and mentally distressed.

■ These institutions may include, but are not limited to, health care providers, law enforcement,
judicial and criminal justice personnel and educators.

■ These institutions can be better served by providing information and protocols for surveillance,
threat assessment, engagement and establishing means for referral to mental health care providers.

o Ensure access to quality mental health care for all people. This includes establishing:

■ An adequate mental health workforce.

■ Geographic distribution of facilities.

■ Reduction of stigma, lack of awareness and other barriers to seeking care.

o Ensure that mental health care benefits are included equitably in health insurance coverage (as
mandated by the Mental Health Parity and Addiction Equity Act).

o Implement proactive screening for mental illness and promote mental health.

Recommendations for Health Care Organizations
The National Council Expert Panel on Mass Violence made a number of recommendations for health
care organizations, including those that provide mental health care services to people who have mental
and substance use disorders and developmental disabilities. Many of these require funding that is not
currently available and will not be achievable without payment methodologies such as the Certified
Community Behavioral Health Clinic prospective payment system, which covers the actual costs of the
interventions, without compromising funding for traditional mental health and substance use services or
integrated health care models. Specific recommendations follow.

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RECOMMENDATIONS

• Provide training to mental health professionals in threat assessment (including suicide) and educate
them about the protocols to follow when patients exceed a threshold of risk. Help establish and
participate in community threat/risk assessment and management teams. These multidisciplinary
teams should include representatives from mental health, security, human resources, legal and law
enforcement.

o Implement ongoing quality improvement around the issues of violence risk assessment and threat
assessment and management.

o One-off trainings will not be successful, especially with turnover in behavioral health and health
care organizations.

o Ensure continuity of threat management across silos by promoting case conferencing and success-
ful handoffs from one agency to another for individuals who may be at risk for violence.

• Train staff in lethal means reduction. This is a rational strategy for lethal violence reduction and very
helpful in combating suicide.

• Add required professional development training as part of initial and continued professional licen-
sure and for accreditation of programs and facilities providing behavioral health care, so that these
professionals know how to talk to clients or patients and their families about firearms safety.

• Establish crisis intervention services staffed by personnel trained in threat assessment and manage-
ment of distressed, symptomatic and potentially dangerous patients including:

o Use crisis hotlines to help determine whether someone is at risk for self-violence and/or violence
toward others. Train the professionals and volunteers who staff these lines in behavioral/violence
risk assessment models using evidence-based research about risk factors for violence among
those who are in crisis. Train them on how to activate follow-up threat assessment and preven-
tive services.

o Provide mobile crisis services that make home visits in the community.

o Provide Crisis Intervention Team (CIT) training.

o Ensure that health care provider organizations have adequate mental health staff or access to or
means of referral to mental health providers. Implement the recommendations of “The Psychiatric
Shortage — Causes and Solutions” (National Council Medical Director Institute, 2017).

• Train mental health personnel in the use of legal mechanisms such as assisted outpatient treatment
and outpatient commitment. Train health care personnel and educate patients in the use of mental
health or psychiatric advanced directives, including Ulysses contracts, to aid in treatment decisions
during times of exacerbation of mental illness.

• Provide primary care support, e.g., community psychiatry access programs, such as the one in
Massachusetts and similar models in other states, with urgent psychiatric consultation available for
primary care clinicians on the frontlines of addressing mental health and potential risks in children
and adolescents (http://web.jhu.edu/pedmentalhealth/nncpap_members.html).

• Prepare staff for vicarious trauma and compassion fatigue. Provide resources for self-care rituals and
support for staff needs.

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RECOMMENDATIONS

• Educate health care providers in HIPAA policy, which allows sharing information when a person pres-
ents a risk of harming others. Keep HIPAA training brief and simple.

• Train personnel and establish programs in the use of mechanisms and services to enhance treatment
adherence, including:

o Increase the number, capacity and use of Assertive Community Treatment teams

o Train providers in medication adherence interventions as described in “Medication Matters: Causes
and Solutions to Medication Non-Adherence” (National Council Medical Director Institute, 2018).

Recommendations for Schools
While mass violence has and can occur in numerous venues, the National Council Expert Panel on Mass
Violence focused on the educational system and made recommendations about what schools should
and shouldn’t do to create an environment of safety and emphasize violence prevention. Many of these
recommendations, such as the need to conduct evidence-based shooter drills, are not unique to schools
but apply to other venues (e.g., workplaces), as well. Specific recommendations follow.

• Revise zero-tolerance policies to avoid suspensions and expulsions as they are ineffective and
harmful practices that may increase the student’s isolation, alienation, feelings of injustice and sense
of hopelessness, which increases risk. Replace zero tolerance with interventions that examine the
circumstances of concern and increase engagement. Teachers and students should make efforts to
include students who exhibit social shyness, awkwardness, unique ideas, mannerisms or interests. All
concerns should be taken seriously; this does not mean that a child should be automatically expelled
for behavior that is not considered dangerous (e.g., bringing a plastic knife to school) or that an
employee will be fired automatically for yelling at someone in the workplace.

• Schools should be resourced to provide in-school mental health and substance use evaluation and
treatment (or means for referral) for students and to promote better school environments.

• Avoid measures that create a correctional facility-like atmosphere such as bulletproof glass, armed
security guards and metal detectors. These are costly and, as physical reminders of potential danger,
can create a threatening atmosphere and an environment not conducive to education. Less heavy-
handed measures such as limited entry points into the school and surveillance cameras can be just
as effective and less intrusive.

• Emphasize and train staff in interpersonally based and emotionally supportive prevention measures,
such as Youth Mental Health First Aid, which have been shown to reduce violence and enhance posi-
tive educational school environments.

• Establish threat/risk assessment and management teams. These multidisciplinary teams should
include representatives from mental health, security, human resources, legal and law enforcement.

• There is no current evidence regarding the efficacy of arming teachers as a means to reduce
fatalities from mass violence and there are significant concerns about possible unintended and
unfortunate psychological and physical consequences of such policies.

• Schools should not emphasize high-stress security drills. Some security drills are fine and recom-
mended, but those in which students are not informed that they are participating in a drill, can
be traumatizing. Shooter drills should be no more stressful or realistic than fire drills. Trauma-in-
formed drill design and the availability of counselors for students and staff should be considered.

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RECOMMENDATIONSRECOMMENDATIONS

The National Association of School Psychologists (NASP) and the National Association of School
Resource Officers (NASRO) have published a set of “Best Practice Considerations for Schools in
Active Shooter and Other Armed Assailant Drills” (NASP & NASRO, 2017).

• Schools should endeavor to ensure an environment in which students feel comfortable coming
forward to a responsible adult with information regarding a threatening situation from any source.
Schools should create a positive school environment and should be required vis-à-vis a set of
national standards to assess their schools for physical and emotional safety.

• Schools should endeavor to implement universal social-emotional learning and add mental health to
the school health curriculum. A program such as Typical or Troubled (see the Appendices for more
information) is an example of curricula that can help schools be more prepared.

• Schools should endeavor to train staff in how to properly respond to students who provide them
with information about a threatening or disturbing situation and selected staff should be trained on
how to deal with actual threats.

• Schools should endeavor to train staff and other school personnel in how to address the impact of
trauma and bereavement on young people and their learning; likely reactions they may see; practical
strategies for providing psychological first aid, bereavement support and academic accommoda-
tions; and indications for referral for mental health services.

• We recognize that many of these recommendations add additional functions to the traditional
educational mandate and scope of services of schools and represent mission creep. Therefore, we
endorse the following recommendation from the National Commission on Children and Disasters
Teacher Training and other groups, including the Sandy Hook Advisory Commission:

Congress and the U.S. Department of Education should award funding to states to teach educators

basic skills in providing support to grieving students and students in crisis and establish statewide

requirements related to teacher certification and recertification.

Recommendations for Communities
The National Council Expert Panel on Mass Violence considered the special needs of those who might
be at enhanced risk of perpetrating violence and made the following recommendations.

• Create and support broad community partnerships that include behavioral health, law enforcement,
schools, the faith and medical communities, etc., to strengthen the connections among those sys-
tems that interact with individuals who have mental illnesses and addictions and may be at risk for
committing violence.

• Do not focus solely on people with a prior diagnosis of schizophrenia, bipolar disorder or other seri-
ous mental illness. Communities should involve clinicians in prioritizing people with narcissistic and/
or paranoid personality traits who are fixated on thoughts and feelings of injustice and who have few
social relationships and recent stresses, as this is the higher-risk group.

• Establish a workplace culture of responsibility and safety in commercial establishments and service
organizations so that employees feel comfortable reporting their concerns about a colleague. Edu-
cate employees about warning signs and risky behaviors. Ensure that they understand the response
will be one of caring and not punishment, even if the individual has to be removed from the work-
place temporarily, for example, to seek appropriate mental health treatment.

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RECOMMENDATIONS

• Institute a mandatory employee assistance program evaluation for employees threatening others.

• Establish community threat/risk assessment and management teams. These multidisciplinary
teams should include representatives from mental health, security, human resources, legal and
law enforcement.

• Ensure close collaboration between domestic violence services and behavioral health providers. Pri-
oritize people with a prior history of domestic violence for threat assessment and management.

• Encourage education on the role of substance use in violence, rather than emphasizing mental illness
as the single most relevant cause of violence. Provide information about co-existing issues that can
trigger violence but may not be causal, given the complexity of violence in society.

• Promote health and wellness, including social-emotional learning, resiliency and skill building in
community-based settings (including schools, employment, religious, primary health care) as popu-
lation-wide goals.

• Expand early childcare and home visiting programs that are known to reduce abuse and promote
school readiness.

• Ensure that communities have adequate, accessible, quality, comprehensive mental health services
and that people are encouraged to seek assistance when they or their family members are in need.

• Provide training in Mental Health First Aid, which teaches the skills to respond to the signs of mental
and substance use disorders. This can be modeled on similar public health programs to educate the
public in lifesaving and health promoting procedures, including cardiopulmonary resuscitation and
the Heimlich maneuver.

Recommendations for Judicial, Correctional and Law Enforcement
Institutions
The National Council Expert Panel on Mass Violence considered the special needs of judicial, correc-
tional and law enforcement institutions and made the following recommendations.

• Help law enforcement and other first responders be better equipped to manage people who are
mentally disturbed and other threatening individuals, including better training of law enforcement
and more involvement of mental health professionals in threat assessments conducted by law
enforcement and implementation of red flag laws.

• Help correctional system officers and employees be better equipped to manage people who are
mentally disturbed and other threatening individuals, including better training in the recognition
and management of mental illness and more on-site involvement of mental health professionals and
referral options or access to telepsychiatry consultations.

• Develop a basic educational toolkit for judges on the nuances of risk assessment, the role of trauma
and the need for additional supports for individuals who may pose risks — particularly in juvenile
courts, veterans’ courts, mental health and drug courts, domestic violence courts and family courts
— but also for traditional (non-problem-solving) courts, such as through the Judicial Psychiatry
Leadership Initiative. Help judges understand such issues as prevalence of mental illness, cautions
about over-assuming risk of violence for people with mental illness and consideration of other risk
factors that may be relevant and the usefulness of programs that allow for reporting their concerns

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RECOMMENDATIONSRECOMMENDATIONS

(“if you see something, say something”), as well as the importance of long-term monitoring and fol-
low-up for people at elevated risk.

Recommendations for Legislation and Government Agencies
The National Council Expert Panel on Mass Violence made the following recommendations for legisla-
tive and government agencies.

• Pass legislation to increase the availability of threat assessment training at the local, state, tribal and
national levels. Many, but not all, panel members endorsed passing and funding H.R. 838/S. 265, the
Threat Assessment, Prevention, and Safety Act, introduced in the 116th Congress.

• Where threat assessment is established, a payment methodology or direct funding for threat assess-
ment and management should be provided. Such payment methodology should not compromise
funding that exists for other critical ventures and should not be construed as solely related to mental
health and taken out of mental health budgets. Consider raising this issue to the Interdepartmen-
tal Serious Mental Illness Coordinating Committee for funding by the U.S. Department of Justice,
extension of the Joint Terrorism Task Forces and fusion centers, Centers for Medicare and Medicaid
Services and the Substance Abuse and Mental Health Services Administration.

• Promote expansion of the Certified Community Behavioral Health Clinic (CCBHC) model because
these clinics are required to provide extensive crisis response capability and the CCBHC prospective
payment model can support the development and operation of a multidisciplinary threat assessment
team. Amend CCBHC to allow for developing and participating on local community threat assess-
ment and management teams, where appropriate.

• Award funding to states to teach educators basic skills in providing support to grieving students
and students in crisis and establish statewide requirements related to teacher certification and
recertification.

• Require training in the evidence-based assessment of potentially lethal violence toward self and/or
others and credentialing in relevant behavioral health disciplines.

• Enact state red flag or gun violence prevention laws that will permit police, family or anyone with a
relationship to a person (e.g., clergy, educator, employer, coach, colleague, neighbor or other person
in a position to be aware of the gun owner’s statements and actions) to petition a state court, judge
or magistrate to order the temporary removal of firearms from an individual for whom there is suffi-
cient evidence that he or she poses a danger to themselves or others.

o The determination to issue the order should be based on statements and actions of the firearms
owner, rather than labels or classes of individuals.

o The removal should be time-limited, subject to renewal after rehearing and with a clear process
and criteria for restoration. This process should be independent from any other civil actions that
may or may not be temporally related. It should not be discriminatory in its application or pro-
cesses and not dependent on an individual’s health status.

o Recommend that all officers executing these extreme-risk protection orders receive CIT or other
de-escalation skills training, with knowledge of resources available for the individual.

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RECOMMENDATIONS

• Fully implement the existing federal background check requirement. Expand and create more rig-
orous background checks for firearms purchases, including closing loopholes where background
checks are not required, such as private sales or inheritance of firearms, while protecting emergency
transfers from people at imminent risk of suicide or violence to trusted friends or family members.

• Remove statutory complexities and budget restrictions that restrict firearms violence research and
the extension of its funding through public agencies.

o Publicly and widely clarify that federal funding is permitted to research firearms injury and preven-
tion, especially as it relates to mass violence.

o Provide adequate funding for research and best practices on firearms safety, access and preven-
tion for such agencies as the National Institutes of Health and the CDC.

o Remove the Dickey Amendment limits on firearms injuries research and earmarking federal funds
specifically for this purpose.

• Enact and enforce criminal and/or civil sanctions for people who knowingly provide firearms to peo-
ple already lawfully barred from possession of a firearm.

• Enact mental health Good Samaritan laws to protect from civil or criminal liability individuals making
good-faith reports to law enforcement or others about people whose conduct and/or statements
raise concerns about risk to self and/or others.

• Require federal, military and state and local agencies to report circumstances that disqualify an
individual from legal gun ownership to state and national (NICS) databases and clarify and broadly
disseminate these disqualifying circumstances.

• Evaluate the effectiveness of state statutes that prevent those who have misdemeanor violent crime
convictions from owning firearms.

• Consider adding a question about homicidal ideation, as well as related questions about the com-
fort of telling an adult in the school about concerns of homicidal ideation in a peer, to the Youth
Risk Behavior Surveillance System (YRBSS). YRBSS is an annual survey conducted by the CDC that
monitors six categories of health-related behaviors that contribute to the leading causes of death
and disability among youth and adults, including behaviors that contribute to unintentional injuries
and violence. The survey currently asks about suicidal ideation.

• Amend 42 CFR Part 2 and FERPA to explicitly allow sharing information when a person presents a
risk of harming others and implement national training.

• Amend HIPAA and 42 CFR Part 2 to supersede state laws for the purpose of sharing information
when a person presents a risk of harming others. Currently, some states have stricter laws that may
prevent sharing information when a person presents a risk of harming others and create confusion
regarding what is permissible sharing.

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Recommendations for Research
The National Council Expert Panel on Mass Violence made a number of recommendations about the
need for additional research on such topics as firearms-related violence and risk. In many cases, the
goal is to use policy development as a laboratory for research. While there is a need for evidence-based
policy, there is also a need for policy-informed research. Specific recommendations follow.

• Support research on the nature and factors that contribute to mass violence, including neurobiologi-
cal, psychological and sociological factors.

• Support research on methods and instruments for identifying and predicting perpetrators of mass
violence.

• Support research on methods of intervention and prevention of mass violence.

• Support the development and dissemination of standardized assessment tools for violence risk.

• Support research into copycat and contagion phenomena.

• Create a standardized, mandatory investigation/analysis of each mass violence incident, conducted
by a multiagency team led by the Department of Justice. Individual case results should be aggre-
gated in a database that allows capturing and differential coding of inchoate and complete attacks,
high lethality and low lethality/high morbidity in a way that allows different hypotheses to be tested
against different data mining and definitional strategies. Provide funding for rigorous academic stud-
ies with the data created by these primary studies.

• Evaluate extreme-risk protection orders in states that have enacted them to assess both the process
of implementation and their effectiveness.

• Track and research individuals that have incomplete attacks or plans thereof and their motivations.
Obtain data on events averted and those individuals who are high risk but don’t act.

RECOMMENDATIONS

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RECOMMENDATIONS

Recommendations for Working with the Media
The National Council Expert Panel on Mass Violence considered the role and the impact of media in its
coverage of mass violence events and offered recommendations for mental health professionals work-
ing with reporters. Specific recommendations follow.

• Build close working relationships with media representatives ahead of any crisis situation.

• Train behavioral health staff who will be responsible for responding to the media. Develop a toolkit
and protocols about who should respond to what type of request and what they should say about
such topics as the role of mental illness, gun rights, involuntary outpatient commitment, etc. Develop
these messages well in advance of a tragic event. A resource such as “Responding to a High-Profile
Tragic Incident Involving a Person with a Serious Mental Illness” (NASMHPD and CSG Justice Center,
2010) can help. Also, many guilds, such as the American Psychiatric Association, offer media train-
ing. In many organizations, a crisis communications team will handle media requests during a mass
violence incident.

• Mental health professionals should use media opportunities even when provided by tragic events to
advocate for better mental health care services; greater access; and elimination of barriers, dispari-
ties and stigma.

• Choose and disseminate existing guidance, such as that offered at https://www.reportingonmass
shootings.org/, and encourage reporters to follow these guidelines.

• In addition to media guidelines, develop or use existing guidance for messaging through the media
to victims, family members and the broader community about coping with traumatic incidents and
mental health in general. Use materials such as those in Appendix II to help families understand how
to talk to their children about violence.

• Do not try to answer questions about why a mass shooting happened. Talk about the role of treat-
ment in helping people at risk of violence. Highlight the fact that most people with mental illnesses
will never become violent. Speak to untreated or undertreated mental illness, in combination with
other risk factors.

• Share information with law enforcement partners in real time so they can respond accurately and in
a timely manner to reporters’ inquiries.

• Work with the media to develop guidance for the general public on risk factors for violence. Help the
public understand the importance of “see something, say something.”

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SUMMATION
Mass violence is a pernicious social pathology that is increasing in the United States and becoming
more deadly largely because of the availability of firearms. The good news is that we have the means
to limit if not stop it. The bad news is that we have not taken the necessary steps to do so. We lack the
social and political will, not the knowledge, capacity or means.

While much remains to be learned about the root causes of mass violence biologically, psychologically
and socially, additional progress can be made through research. This report, composed by representa-
tives of key stakeholder organizations that directly interface with mass violence, provides a template
with which to address and alleviate this scourge on American society.

Now is the time to mobilize and this is the way to act.

SUMMATION

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Swanson, J. W., & Belden, C. M. (2018). The link
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EXPERT PANEL
Co-editors
Joe Parks, M.D.
Medical Director, National Council for Mental

Wellbeing

Donald Bechtold, M.D.
Vice President, Healthcare and Integration
and Medical Director, Jefferson Center for
Mental Health

Frank Shelp, M.D., M.P.H.
Medical Director, Envolve

Jeffery Lieberman, M.D.
Professor and Chair, Department of Psychiatry,
Columbia University and Director, New York State
Psychiatric Institute

Sara Coffey, D.O.
Assistant Clinical Professor, Department of
Psychiatry, Oklahoma State University-Center
for Health Sciences

Panel
Charles Branas, Ph.D.
Gelman Endowed Professor and Chair, Department
of Epidemiology, Columbia University, Mailman
School of Public Health

John Greenlee, J.D.
Chief District Court Judge, 27A/Gaston County,
North Carolina Judicial Branch

Craig Allen, M.D.
Medical Director, Rushford/Hartford Healthcare

David J. Schonfeld, M.D., FAAP
Director, National Center for School Crisis and
Bereavement and Professor of the Practice,
Suzanne Dworak-Peck School of Social Work and
Pediatrics, Children’s Hospital Los Angeles, Univer-
sity of Southern California

Debra A. Pinals, M.D.
Medical Director of Behavioral Health and Foren-
sic Programs, Michigan Department of Health and
Human Services; Clinical Professor, Department of
Psychiatry, University of Michigan Medicine

Dewey Cornell, Ph.D., M.A.
Professor of Education, Curry School of Education
at the University of Virginia

Heather Gates, M.B.A.
President and CEO, Community Health Resources

Jacqueline Feldman, M.D.
Professor Emerita, Department of Psychiatry and
Behavioral Neurobiology, University of Alabama at
Birmingham; Associate Medical Director, National
Alliance on Mental Illness

Jason Beaman, D.O., FAPA
Assistant Clinical Professor and Chair, Department
of Psychiatry and Behavioral Sciences, Oklahoma
State University-Center for Health Sciences

Jeffrey Swanson, Ph.D.
Professor and Associate Director, Division of Social
and Community Psychiatry, Department of Psy-
chiatry and Behavioral Sciences, Duke University
School of Medicine

Joe Pyle, M.A.
President, Scattergood Foundation

John Rozel, M.D.
Medical Director, resolve Crisis Network, Western
Psychiatric Institute and Clinic of UPMC; Associate
Professor of Psychiatry and Adjunct Professor of
Law, University of Pittsburgh

John Santopietro, M.D.
Physician-in-Chief, Hartford HealthCare Behavioral
Health Network; Senior Vice President for Hartford
HealthCare

Ginger Lerner-Wren, J.D.
Broward County Mental Health Court Judge, 17th
Judicial Circuit

EXPERT PANEL

74

MASS VIOLENCE IN AMERICA

Jeremy Romo
Lieutenant, St. Louis County Police Department

Patricia Coleman
Chair, BHR Worldwide; President and CEO,
Behavioral Health Response, Inc.

Robert Kinscherff, Ph.D., J.D.
Associate Vice President for Community Engage-
ment and Associate Professor, Doctoral Clinical
Psychology Program, William James College

Ronald Schouten, M.D., J.D.
Director, Law and Psychiatry Service, Massachu-
setts General Hospital; Associate Professor of
Psychiatry, Harvard Medical School

Stephen Fried
New York Times Bestselling Author, American
Investigative Journalist, Essayist and Adjunct
Professor, Columbia University Graduate School of
Journalism and the University of Pennsylvania

Sue Klebold
Author of New York Times Bestseller, “A Mother’s
Reckoning: Living in the Aftermath of Tragedy”/
Mother of Columbine Shooter

William Pollack, Ph.D.
Associate Professor, Department of Psychiatry,
Harvard Medical School; Founder and Director,
Centers for Men, Young Men and Boys; CEO, Real
Boys® Institute

Consultants
Andre Simons
Special Agent, FBI

David Young
Special Agent, FBI

Robert Ambrosini
Special Agent, FBI

National Council Staff
Brie Reimann, M.P.A.
Director, SAMHSA-HRSA Center for Integrated
Health Solutions, National Council for Mental

Wellbeing

Keila Barber, M.H.S.
Senior Project Coordinator, SAMHSA-HRSA
Center for Integrated Health Solutions, National

Council for Mental Wellbeing

Susan Milstrey Wells
Senior Writer, National Council for Mental

Wellbeing

EXPERT PANEL

75

MASS VIOLENCE IN AMERICA

ONLINE RESOURCES
Documents
Best Practice Considerations for Schools in Active Shooter and Other Armed Assailant Drills, The
National Association of School Psychologists, Original released December 10, 2014 (Updated April 2017)
https://www.nasponline.org/resources-and-publications/resources/school-safety-and-crisis/best-
practice-considerations-for-schools-in-active-shooter-and-other-armed-assailant-drills

Call for Action to Prevent Gun Violence in the United States of America, Interdisciplinary Group on Pre-
venting School and Community Violence (February 28, 2018)
https://curry.virginia.edu/prevent-gun-violence

Cops and No Counselors: How the Lack of School Mental Health Staff Is Harming Students, ACLU
(March 2019)
https://www.aclu.org/sites/default/files/field_document/030119-acluschooldisciplinereport.pdf

Guns, Public Health and Mental Illness: An Evidence-Based Approach for Federal Policy, Consortium for
Risk-Based Firearm Policy (December 11, 2013)
https://www.jhsph.edu/research/centers-and-institutes/johns-hopkins-center-for-gun-policy-and-
research/_archive-2019/_pdfs/final-federal-report.pdf

Guns, Public Health and Mental Illness: An Evidence-Based Approach for State Policy, Consortium for
Risk-Based Firearm Policy (December 22, 2013)
https://www.jhsph.edu/research/centers-and-institutes/johns-hopkins-center-for-gun-policy-and-
research/publications/GPHMI-State.pdf

Gun Violence: Prediction, Prevention, and Policy. APA Panel of Experts Report, American Psychological
Association. (2013)
https://www.apa.org/pubs/info/reports/gun-violence-report.pdf

Making Prevention a Reality: Identifying, Assessing, and Managing the Threat of Targeted Attacks,

Behavioral Analysis Unit, National Center for the Analysis of Violent Crime, FBI
https://www.fbi.gov/file-repository/making-prevention-a-reality.pdf/view

Preventing Gun Violence, American Public Health Association
https://www.apha.org/~/media/files/pdf/factsheets/160317_gunviolencefs.ashx

Recommendations for Reporting on Mass Shootings
https://www.reportingonmassshootings.org/

Resource Document on Access to Firearms by People with Mental Disorders, American Psychiatric Asso-
ciation (May 2014)
https://www.psychiatry.org/File%20Library/Psychiatrists/Directories/Library-and-Archive/resource_
documents/Resource-2014-Firearms-Mental-Illness.pdf

Resource Document on Risk-Based Gun Removal Laws, American Psychiatric Association (June 2018)
https://www.psychiatry.org/psychiatrists/search-directories-databases/library-and-archive/
resource-documents

ONLINE RESOURCES

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Responding to a High-Profile Tragic Incident Involving a Person with a Serious Mental Illness: A Toolkit

for State Mental Health Commissioners, National Association of State Mental Health Program Directors
and Council of State Governments Justice Center (2010)
https://csgjusticecenter.org/wp-content/uploads/2012/12/Responding_to_a_High-Profile_Tragic_
Incident_Involving_a_Person_with_a_Serious_Mental_Illness.pdf

School Resource Officers, School Law Enforcement Units, and the Family Educational Rights and Privacy

Act (FERPA), Privacy Technical Assistance Center, U.S. Department of Education (February 2019)
https://studentprivacy.ed.gov/sites/default/files/resource_document/file/SRO_FAQs_2-5-19_0.pdf

The Science of Gun Policy: A Critical Synthesis of Research Evidence on the Effects of Gun Policies in the

United States, RAND Corp. (2018)
https://www.rand.org/content/dam/rand/pubs/research_reports/RR2000/RR2088/RAND_RR2088.pdf

Resources
Coalition to Support Grieving Students
https://grievingstudents.org/

Helping Victims of Mass Violence and Terrorism: Planning, Response, Recovery, and Resources, Office of
Justice Programs, Office for Victims of Crime
https://www.ovc.gov/pubs/mvt-toolkit/

Judges and Psychiatrists Leadership Initiative Resources, American Psychiatric Foundation
https://apafdn.org/impact/justice/judges-and-psychiatrists-leadership-initiative/program-resources

Mental Health Professionals’ Duty to Warn, National Conference of State Legislatures (October 12, 2018)
http://www.ncsl.org/research/health/mental-health-professionals-duty-to-warn.aspx#1

National Academy of Pediatrics, Children & Disasters webpage
https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Children-and-Disasters/Pages/
default.aspx

National Center for School Crisis and Bereavement
https://www.schoolcrisiscenter.org/

National Child Traumatic Stress Network
https://www.nctsn.org/

National Mass Violence and Victimization Resource Center
http://www.nmvvrc.org/

Substance Abuse and Mental Health Administration, Disaster Technical Assistance Center
https://www.samhsa.gov/dtac

Threat Assessment Research
https://curry.virginia.edu/faculty-research/centers-labs-projects/research-labs/youth-violence-project/
threat-assessment

Typical or Troubled, American Psychiatric Foundation
https://apafdn.org/impact/schools/typical-or-troubled-%C2%AE

ONLINE RESOURCES

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Violence Prevention Initiative, Children’s Hospital of Philadelphia Research Institute, Center for Injury
Research and Prevention
https://injury.research.chop.edu/violence-prevention-initiative/types-violence-involving-youth#.XH_
f8ihKhPY

Organization Position Statements
American Association for Emergency Psychiatry: Evaluation of Persons of Concern in Relation to Vio-

lence, Mass Shootings and Mental Illness (April 2018)
https://www.emergencypsychiatry.org/position-statements

American Psychiatric Association, Position Statement on Firearm Access, Acts of Violence and the Rela-

tionship to Mental Illness and Mental Health Services (2018, 2014)
https://www.psychiatry.org/File%20Library/About-APA/Organization-Documents-Policies/Policies/
Position-Firearm-Access-Acts-of-Violence-and-the-Relationship-to-Mental-Health.pdf

American Public Health Association Gun Violence Prevention Policy Statements
https://www.apha.org/-/media/files/pdf/advocacy/letters/aphagunviolencepreventionpolicystatements.ashx

ONLINE RESOURCES

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RESOURCES
Offering Support Following Community Violence: How Health Plans
Can Help
Kimberly Purinton, LCSW, Clinical Training Manager, Centene Corporation

The Stoneman Douglas High School tragedy quickly inspired a spirit of helping and service toward sur-
vivors in the community. As many do in the aftermath of senseless trauma and loss, Sunshine Health, a
subsidiary of Centene Corporation, considered various ways it could best offer support while not intrud-
ing upon the sanctity of the grieving process for so many. Leadership immediately came together to
assess staff needs and to organize thoughtful implementation of select larger scale assistive measures
prudent for a health plan to offer. The Substance Abuse and Mental Health Services Administration
(SAMSHA) principles offered guidance in decision-making, detailing how survivors or witnesses of
mass violence may go through multiple phases, (acute, intermediate and long term), in which particular
emotions, behaviors, and other reactions are fairly typical (Alexander & Klein, 2005; Freedy & Simpson,
2007; Goldmann & Galea, 2014; U.S. Department of Health and Human Services [HHS], SAMHSA, Center
for Mental Health Services [CMHS], 2004; Yehuda & Hyman, 2005).

During the acute phase, information gathering and stabilization efforts for health plan staff was initi-
ated, as many employees were closely impacted by the event. This included establishing clear, open
and frequent communication across all organization levels within the company and offering flexibility
and coverage assistance as staff attended to personal needs. Additionally, employees were reminded
of various programs and services, including the Employee Assistance Program, which offered enhanced
support during this time. Other staff care measures included ongoing psycho-educational webinars and
in-person supportive training groups on secondary traumatic stress in anticipation of increased volume
of member assistance needs related to the tragedy.

Research emphasizes the critical nature of monitoring the well-being of the impacted community during
the acute phase, as well as the best practice of infusing behavioral health interventions into existing
community services, as it increases the likelihood of acceptability of an intervention into that popula-
tion (Goldmann & Galea, 2014; Grills-Taquechel, Littleton, & Axsom, 2011; Hobfoll et al., 2011; Sherrieb &
Norris, 2013). Sunshine Health’s community outreach response during this phase included instituting
a 24-hour crisis hotline and partnering with local behavioral health provider to financially support the
stationing of a licensed clinician at the community’s Family Resource Center. The clinician provided link-
ages to vital community resources and crisis support.

During the intermediate and long term phases, services that address basic needs were provided by serv-
ing lunch for staff upon their first return to campus, as well as refreshments for 3,000 parents, children
and school personnel at the parent meeting prior to classes resuming. Research indicated activities,
including mental health screenings, behavioral health support, and offering psycho-educational infor-
mation to affected survivor and responder groups and health care and social service providers in the
community (Alexander & Klein, 2005; HHS, SAMHSA, CMHS, 2004; DOJ, OJP, OVC & American Red
Cross, 2005), were provided either via the health plan or through existing community resources during
all phases. Sunshine Health continues to underwrite the cost of the licensed therapist at the Family
Resource Center to this day. Finally, in conjunction with its parent company, Sunshine Health continues
to sponsor and facilitate trauma informed evidenced based treatment trainings to support the needs of
its provider community as they continue to work with survivors and responders.

RESOURCES

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As a health plan, Sunshine Health’s response has been based in research and guided by and dissemi-
nated in large part by existing community services.

PHASE SUPPORT ACTIVITIES
Acute • provided support by offering enhanced Employee Assistance

Program services and work coverage options to affected health
plan staff

• established 24 hour state-wide crisis hotline available to our mem-
bers, staff and community

• disseminated psycho-educational information and tip sheets to staff,
providers and community partners, on responding to community
violence and trauma (NCTSN)

• utilized social media to maintain communication, offer community
support and promote available resources

Intermediate & Long Term • served lunch for school staff upon their first return to campus

• provided refreshments for 3,000 parents, children and school per-
sonnel at the parent meeting prior to classes resuming

• financially support the cost of a licensed clinician at the Family
Resource Center, providing linkages to community resources and
crisis support

• offer psycho-educational webinars and in-person supportive training
groups

• sponsor and facilitate trauma informed evidenced based treatment
trainings to support the needs of our provider community as they
continue to work with survivors and responders

Acronyms

CMHS= Center for Mental Health Services

DOJ= Department of Justice

HHS= Department of Health and Human Services

OJP= Office of Justice Programs

OVC= Office for Victims of Crime

SAMSHA= Substance Abuse and Mental Health Services Administration

RESOURCES

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References
Alexander, D. A., & Klein, S. (2005). The psychological aspects of terrorism: From denial to hyperbole.
Journal of the Royal Society of Medicine, 98(12), 557–562. doi: 10.1258/jrsm.98.12.557

Goldmann, E., & Galea, S. (2014). Mental health consequences of disasters. Annual Review of Public
Health, 35, 169–183. doi: 10.1146/annurev-publhealth-032013-182435

Grills-Taquechel, A. E., Littleton, H. L., & Axsom, D. (2011). Social support, world assumptions, and expo-
sure as predictors of anxiety and quality of life following a mass trauma. Journal of Anxiety Disorders,
25(4), 498–506. doi: 10.1016/j.janxdis.2010.12.003

Freedy, J. R., & Simpson, W. M., Jr. (2007). Disaster-related physical and mental health: A role for the
family physician. American Family Physician, 75(6), 841–846.

Hobfoll, S. E., Canetti, D., Hall, B. J., Brom, D., Palmieri, P. A., Johnson, R. J., . . . Galea, S. (2011). Are
community studies of psychological trauma’s impact accurate? A study among Jews and Palestinians.
Psychological Assessment, 23(3), 599–605. doi: 10.1037/a0022817

Johnson-Agbakwu, C. E., Allen, J., Nizigiyimana, J. F., Ramirez, G., & Hollifield, M. (2014). Mental health
screening among newly arrived refugees seeking routine obstetric and gynecologic care. Psychological
Services, 11(4), 470–476. doi: 10.1037/a0036400

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Admin-
istration, Center for Mental Health Services. (2004). Mental health response to mass violence and
terrorism: A training manual. Retrieved from https://store.samhsa.gov/product/Mental-Health-Response-
to-Mass-Violence-and-Terrorism-A-Training-Manual/sma04-3959

U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Admin-
istration, Center for Mental Health Services. (1994). Disaster response and recovery: A handbook for
mental health professionals. Rockville, MD.

U.S. Department of Justice, Office of Justice Programs, Office for Victims of Crime, & American Red
Cross. (2005). Responding to victims of terrorism and mass violence crimes: Coordination and collabo-
ration between American Red Cross workers and crime victim service providers. Retrieved from https://
www.ovc.gov/publications/infores/redcross/ncj209681.pdf

Sherrieb, K., & Norris, F. H. (2013). Public health consequences of terrorism on maternal-child health in
New York City and Madrid. Journal of Urban Health, 90(3), 369–387. doi: 10.1007/s11524-012-9769-4

Yehuda, R., & Hyman, S. E. (2005). The impact of terrorism on brain, and behavior: What we know and
what we need to know. Neuropsychopharmacology, 30(10), 1773–1780. doi: 10.1038/sj.npp.1300817

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RESOURCES

Published by
National Council for Mental Wellbeing

1400 K Street, NW, Suite 400
Washington, DC 20005

www.TheNationalCouncil.org

www.thelancet.com/public-health Vol 8 February 2023 e141

Review

Lancet Public Health 2023;
8: e141–54

Published Online
November 2, 2022
https://doi.org/10.1016/
S2468-2667(22)00252-3

Department of Primary Care,
Population Sciences and
Medical Education, University
of Southampton,
Southampton, UK
(L Johnson MBBS); Collaborative
Centre for Inclusion Health,
Department of Epidemiology
and Public Health (L Johnson,
M Bradbury BMBS, G Sumner BA,
L Wills MSc,
Prof A C Hayward MD,
A Story PhD, B Sultan FRCP,
S A Luchenski FFPH) and Centre
for Public Health Data Science,
Institute of Health Informatics
(Prof R W Aldridge PhD,
N Pathak MBBS), University
College London, London, UK;
Centre for Academic Primary
Care, Department of
Population Health Sciences,
Bristol Medical School,
University of Bristol, Bristol,
UK (L C Potter MBChB,
Prof G Feder MD); Oxford
University Hospitals NHS
Foundation Trust, Oxford, UK
(H Beeching MBBCh);
Department of Psychology,
The American University of
Paris, Paris, France
(B Matos PGDip); Find & Treat,
University College London
Hospital, London, UK
(A Story, B Sultan); Centre for
Primary Care and Public Health,
Queen Mary University,
London, UK (K Worthing MPH);
Guy’s and St Thomas’ NHS
Foundation Trust, London, UK
(N Pathak); Faculty of Public
Health and Policy, London
School of Hygiene & Tropical
Medicine, London, UK
(Prof L Platt PhD)

Correspondence to:
Dr Luke Johnson, Department of
Primary Care, Population
Sciences and Medical Education,
University of Southampton,
Southampton SO17 1BJ, UK
[email protected]

Interventions to improve health and the determinants of
health among sex workers in high-income countries:
a systematic review
Luke Johnson, Lucy C Potter, Harriet Beeching, Molly Bradbury, Bella Matos, Grace Sumner, Lorna Wills, Kitty Worthing, Robert W Aldridge,
Gene Feder, Andrew C Hayward, Neha Pathak, Lucy Platt, Al Story, Binta Sultan, Serena A Luchenski

Many sex worker populations face high morbidity and mortality, but data are scarce on interventions to improve their
health. We did a systematic review of health and social interventions to improve the health and wider determinants of
health among adult sex workers in high-income countries. We searched MEDLINE, Embase, PsycINFO, CINAHL,
the Cochrane Library, Web of Science, EthOS, OpenGrey, and Social Care Online, as well as the Global Network of Sex
Work Projects and the Sex Work Research Hub for studies published between Jan 1, 2005 and Dec 16, 2021
(PROSPERO CRD42019158674). Quantitative studies reporting disaggregated data for sex workers were included and
no comparators were specified. We assessed rigour using the Quality Assessment Tool for Quantitative Studies. We
summarised studies using vote counting and a narrative synthesis. 20 studies were included. Most reported findings
exclusively for female sex workers (n=17) and street-based sex workers (n=11). Intervention components were divided
into education and empowerment (n=14), drug treatment (n=4), sexual and reproductive health care (n=7), other
health care (n=5), and welfare (n=5). Interventions affected a range of mental health, physical health, and health
behaviour outcomes. Multicomponent interventions and interventions that were focused on education and
empowerment were of benefit. Interventions that used peer design and peer delivery were effective. An outreach or
drop-in component might be beneficial in some contexts. Sex workers who were new to working in an area faced
greater challenges accessing services. Data were scarce for male, transgender, and indoor-based sex workers.
Co-designed and co-delivered interventions that are either multicomponent or focus on education and empowerment
are likely to be effective. Policy makers and health-care providers should improve access to services for all genders of
sex workers and those new to an area. Future research should develop interventions for a greater diversity of sex
worker populations and for wider health and social needs.

Introduction
Sex work spans a wide range of activities, but is defined in
this Review as the provision of sexual services in exchange
for money or goods. Sex workers are a heterogeneous
population—there is extensive variability in the structural,
economic, social, and legal context in which they work
and in their health and social needs.1

Stigma and the hidden—often transient—nature of
sex work restrict the availability of accurate data.1 There
are an estimated 1 million sex workers in the USA and
70 000 in the UK.2,3 There are large research gaps in the
understanding of their health needs in different settings.
Street-based sex workers are highly marginalised
and face disproportionate health inequities and harms
related to alcohol and drug use, and sometimes HIV
and sexually transmitted infections (STIs), hepatitis B,
and hepatitis C.4–8 Sex workers can encounter high
rates of physical, verbal, and sexual violence from
intimate partners, perpetrators posing as clients, and the
police.7,9–13 They frequently have poor mental health, with
increased rates of anxiety, depression, loneliness, post-
traumatic stress disorder, self-harm, and suicide.5,7,14–16
There can be severe, complex social needs and structural
determinants underlying these health issues, including
homelessness or insecure housing, unemployment,
adverse childhood experiences, gender and racial
inequality, poverty, sex work criminalisation, and the
setting of sex work.5,7,10,14,15,17–21 However, many sex workers

do not face this severe marginalisation or these adverse
health outcomes and remain largely unrepre sented in
academic literature. The legal context in which sex
work occurs varies substantially between countries
and can either exaggerate or mitigate these harms,
with repressive policing practices and criminalisation
worsening health outcomes.22

Many sex workers face large barriers to accessing
health and social care.23 There are few specialist services
for this community,24 and mainstream services are
often unaware of sex working and not tailored to sex
workers’ needs.17,25 Sex workers are often unaware of
available services,26 and might fear legal implications
from being identified as a sex worker.5 Additionally,
past experiences of judgement and stigmatisation while
using services could deter them from seeking care
again.5,17

WHO guidelines state the importance of high-quality,
integrated services to meet the health needs of sex
workers.27 However, there is little published evidence on
effective health and social care interventions for sex
workers in high-income countries.28 There have been
three previous systematic reviews, which have focused on
psychological interventions for all sex workers,29 HIV and
STI behaviour change interventions for female sex
workers in the USA,10 and interventions for illicit drug use
in street-working female sex workers.30 A com prehensive
understanding of interventions tailored to sex workers is

e142 www.thelancet.com/public-health Vol 8 February 2023

Review

needed. This study aimed to systematically review the
evidence of interventions used to improve health and the
wider determinants of health for all sex worker populations
living in high-income countries.

Methods
We have adhered to the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses guidelines.31
Our review protocol was registered with PROSPERO in
November, 2019 (CRD42019158674). Our team included
authors with lived experience, and authors who had
worked with and continue to work with sex workers, to
ensure the Review’s relevance and contextual insight in
interpretation of the data.

Search strategy and selection criteria
We conducted a systematic literature search in six data-
bases (MEDLINE, Embase, PsycINFO, CINAHL, the
Cochrane Library, and Web of Science). We used a
combination of subject headings and keyword searching
related to sex work and health interventions (appendix
pp 2–3). Grey literature was also searched using EthOS,
OpenGrey, and Social Care Online, the Global Network
of Sex Work Projects, the Sex Work Research Hub, and
by contacting academic experts and people with lived
experience of sex working. Further studies were iden-
tified through searching reference lists and citations
of included studies. Studies were restricted to those
published in English between Jan 1, 2005 and
Dec 16, 2021.

Eligibility criteria
Eligibility was defined using population, intervention,
control, and outcomes criteria. The included population
were current sex workers, which we defined as people
who had exchanged sex for money, drugs, or other goods
within the past 12 months. Trafficking and indirect sex
work (in which there is no physical contact of any kind
with the client) were not included. We included studies
with sex workers aged 18 years and older in high-income
countries, as defined by The World Bank.32 Any
intervention with data specifically for sex workers was
included. Studies with populations that did not entirely
consist of sex workers, and for which—following contact
with the authors—disaggregated sex-worker-specific data
were not available, were excluded. If the majority of a
study population was older than 18 years, and the data
was specific to sex workers, the study was still included
even if disaggregated data was not available following
author contact. Any intervention that studied outcomes
related to health or the wider determinants of health
(eg, housing and welfare support) was included. Studies
of sex work laws were excluded as these were investigated
in a systematic review in 2018.22 Control groups were not
specified a priori.

The review included all quantitative study designs
to summarise study effectiveness: randomised con-
trolled trials, quasi-experimental studies (ie, uncontrolled
or controlled before-and-after studies), observational
studies (ie, cohort, case-control, time series, and cross-
sectional), and mixed-methods studies with a quantitative
component.

Data extraction and quality assessment
Titles and abstracts were single-screened for inclusion
by one of two reviewers (MB or BM). Remaining
articles were double screened at full-text review by
two independent reviewers (LCP and BM). Discrepancies
were resolved through discussion.

Data extraction was done by one of three reviewers (LJ,
LW, or HB) with accuracy checked by a second reviewer
(LJ, KW, LW, or HB). Discrepancies were resolved through
discussion or decided by a third reviewer (LCP) when they
could not be resolved. A spreadsheet was used to extract a
standard set of data on study and population characteristics,
design, intervention, control, outcome, and results.

Rigour was assessed using the Effective Public Health
Practice Project’s Quality Assessment Tool for Quantitative
Studies,33 chosen due to its comprehensive assessment
of both observational and experimental studies, and
showed reliability and validity.34 Criteria assessed include
selection bias, study design, confounders, blinding, data
collection methods, withdrawals, intervention integrity,
and analyses.

Data synthesis
Due to heterogeneity in method, interventions, and
outcomes, we used descriptive vote counting35 alongside

See Online for appendix

Figure 1: Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram

18 611 records identified through
database searching

8984 records after duplicates removed

9750 records screened

9550 records excluded on basis of title or abstract

200 full-text articles assessed for eligibility

20 studies included in narrative synthesis

123 additional records identified through
other sources

180 full-text articles excluded
66 no intervention described
31 reviews without primary data
21 outcomes not described quantitatively
16 population not primarily adult sex workers
28 low-income or middle-income country population
13 no published full text available

5 study focused on criminalisation

www.thelancet.com/public-health Vol 8 February 2023 e143

Review
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a
gr

ea
te

r r
ed

uc
tio

n
in

H
IV

ri
sk

b
eh

av
io

ur
(e

g,

cr
ac

k
co

ca
in

e u
se

, n
um

be
r o

f s
ex

ua
l p

ar
tn

er
s,

an
d

fre
qu

en
cy

o
f u

np
ro

te
ct

ed
v

ag
in

al
se

x)
in

bo

th
g

ro
up

s

W
ea

k

(T
ab

le
1

co
nt

in
ue

s o
n

ne
xt

p
ag

e)

e144 www.thelancet.com/public-health Vol 8 February 2023

Review

Co
un

tr
y

St
ud

ie
s (

n)
Se

x
w

or
ke

r
po

pu
la

ti
on

In
te

rv
en

ti
on

se
tt

in
g

or
c

on
te

xt
In

te
rv

en
ti

on
Co

m
pa

ris
on

o
r

co
nt

ro
l

O
ut

co
m

es
Q

ua
lit

y
as

se
ss

m
en

t*

(C
on

tin
ue

d
fro

m
p

re
vi

ou
s p

ag
e)

Co
ho

rt
a

na
ly

ti
ca

l s
tu

di
es

(t
w

o
gr

ou
ps

, p
re

-in
te

rv
en

ti
on

a
nd

p
os

t-
in

te
rv

en
ti

on
)†

Ki
m

e
t a

l
(2

01
5)

26

Ca
na

da
54

5
(d

isa
gg

re
ga

te
d

sa
m

pl
e

siz
e

af
te

r e
xc

lu
sio

n
of

p
eo

pl
e

ag
ed

14

–1
8

ye
ar

s)

St
re

et
-b

as
ed

fe
m

al
e

se
x w

or
ke

rs
a

ge
d

≥1
4

ye
ar

s (
in

clu
di

ng

tr
an

sg
en

de
r

w
om

en
)

W
IS

H
d

ro
p-

in
ce

nt
re

W
om

en
-o

nl
y,

se
x-

w
or

k-
sp

ec
ifi

c
dr

op
-in

se
rv

ice
fo

r s
tr

ee
t-

ba
se

d
se

x
w

or
ke

rs
, w

hi
ch

p
ro

vi
de

d
fo

od
a

nd

dr
in

k,
sh

ow
er

s,
clo

th
in

g,
re

po
rt

s o
f

re
ce

nt
cl

ie
nt

v
io

le
nc

e
(n

am
ed

b
ad

da

te
sh

ee
ts

),
H

IV
p

re
ve

nt
io

n
re

so
ur

ce
s (

eg
, c

on
do

m
s a

nd

sy
rin

ge
s)

, a
nd

re
fe

rra
ls

to
so

cia
l a

nd

he
al

th
se

rv
ice

s;
al

so
, p

ee
r e

du
ca

tio
n

an
d

su
pp

or
t p

ro
gr

am
m

es
,

an
d

ou
tr

ea
ch

n
ur

sin
g

ca
re

so

m
et

im
es

o
ffe

re
d

Fe
m

al
e

se
x w

or
ke

rs
w

ho
d

id
n

ot

us
e t

he
W

IS
H

d
ro

p-
in

se
rv

ice
Se

rv
ice

u
se

w
as

a
ss

oc
ia

te
d

w
ith

o
ld

er
a

ge
,

In
di

ge
no

us
P

eo
pl

es
a

nc
es

tr
y,

in
je

ct
in

g
dr

ug

us
e,

e
xc

ha
ng

e o
f s

ex
fo

r d
ru

gs
, a

nd
a

cc
es

sin
g

se
xu

al
a

nd
re

pr
od

uc
tiv

e
he

al
th

se
rv

ice
s;

60
%

v
isi

te
d

W
IS

H
d

ur
in

g
th

e
3

ye
ar

s o
f f

ol
lo

w

up
; t

he
se

rv
ice

s m
os

t f
re

qu
en

tly
a

cc
es

se
d

w
er

e
fo

od
, m

ak
e-

up
, c

lo
th

in
g,

a
nd

p
rim

ar
y

nu
rs

e
ca

re

W
ea

k

De
er

in
g

et
a

l
(2

01
1)

42

Ca
na

da
24

2
Ci

sg
en

de
r a

nd

tr
an

sg
en

de
r w

om
en

st

re
et

-b
as

ed
se

x
w

or
ke

rs
ag

ed

≥1
4

ye
ar

s w
ho

sm

ok
ed

(n
ot

in

clu
di

ng
m

ar
iju

an
a)

or

in
je

ct
ed

ill
ici

t
dr

ug
s i

n
th

e l
as

t
m

on
th

; a
ut

ho
rs

st

at
ed

o
nl

y a
sm

al
l

nu
m

be
r o

f
pa

rt
ici

pa
nt

s l
ik

el
y t

o
be

ag
ed

<
18

ye
ar

s

Pe
er

-le
d

m
ob

ile

ou
tr

ea
ch

p
ro

gr
am

m
e

(t
he

M
AP

, o
r t

he
M

AP

va
n)

A
ni

gh
tly

o
ut

re
ac

h
se

rv
ice

st
aff

ed

by
a

d
riv

er
, a

su
pp

or
t w

or
ke

r,
an

d
a

pe
er

-s
up

po
rt

w
or

ke
r;

it
pr

ov
id

es
a

sa

fe
sp

ac
e

fo
r w

om
en

to
re

st
, e

at
,

an
d

dr
in

k,
a

nd
o

ut
re

ac
h

st
aff

di

st
rib

ut
e

re
po

rt
s o

f r
ec

en
t c

lie
nt

vi

ol
en

ce
(n

am
ed

b
ad

d
at

e
re

po
rt

s)
;

H
IV

p
re

ve
nt

io
n

re
so

ur
ce

s
di

st
rib

ut
ed

(e
g,

co
nd

om
s,

lu
br

ica
nt

,
an

d
sy

rin
ge

s)
a

nd
re

fe
rra

ls
m

ad
e t

o
he

al
th

a
nd

so
cia

l s
up

po
rt

, a
nd

d
ru

g
tr

ea
tm

en
t s

er
vi

ce
s

W
om

en
w

ith
in

th
e

co
ho

rt
w

ho

di
d

no
t a

cc
es

s t
he

M
AP

v
an

du

rin
g

th
e

18
-m

on
th

fo
llo

w
-u

p

O
ve

r t
he

1
8-

m
on

th
st

ud
y

pe
rio

d,
4

2%
o

f
re

po
rt

s f
ro

m
se

x w
or

ke
rs

st
at

ed
u

se
o

f t
he

va

n;
th

os
e u

sin
g

th
e

va
n

w
er

e
m

or
e

lik
el

y t
o

be
w

or
ki

ng
w

ith
te

n
or

m
or

e
cli

en
ts

p
er

w
ee

k,

w
or

ki
ng

in
is

ol
at

ed
p

ub
lic

sp
ac

es
, a

nd
u

sin
g

th
e W

IS
H

d
ro

p-
in

ce
nt

re
se

rv
ice

(l
in

ke
d

to
th

e
va

n)
; t

ho
se

w
ho

u
se

d
th

e
pr

og
ra

m
m

e w
er

e
m

or
e

lik
el

y t
o

ha
ve

u
se

d
in

pa
tie

nt
a

dd
ict

io
n

tr
ea

tm
en

t s
er

vi
ce

s i
n

th
e

pa
st

6
m

on
th

s;
th

er
e w

as
n

o
sig

ni
fic

an
t r

el
at

io
ns

hi
p

be
tw

ee
n

us
e o

f t
he

v
an

a
nd

a
cc

es
sin

g
ou

tp
at

ie
nt

d
ru

g
tr

ea
tm

en
t;

yo
ut

h
ag

ed

24
ye

ar
s w

er
e

sig
ni

fic
an

tly
le

ss
li

ke
ly

to
a

cc
es

s t
he

v
an

W
ea

k

Bu
rn

et
te

et

a
l (

20
09

)14

US
A

53
3

W
om

en
e

xc
ha

ng
in

g
se

x
fo

r m
on

ey
o

r
dr

ug
s i

n
th

e
pa

st

12
m

on
th

s

O
ut

pa
tie

nt
o

r
re

sid
en

tia
l t

re
at

m
en

t
pr

og
ra

m
m

e

Va
rio

us
d

ru
g

tr
ea

tm
en

t
pr

og
ra

m
m

es
a

cr
os

s 7
1

fa
cil

iti
es

in

th
e U

SA
(m

et
ha

do
ne

a
nd

n
on


m

et
ha

do
ne

; r
es

id
en

tia
l a

nd

ou
tp

at
ie

nt
);

an
cil

la
ry

se
rv

ice
s a

lso

off
er

ed

m
ed

ica
l s

er
vi

ce
s,

m
en

ta
l

he
al

th
se

rv
ice

s,
an

d
ps

yc
ho

so
cia

l
se

rv
ice

s

W
om

en
n

ot
re

po
rt

in
g

ex
ch

an
gi

ng
se

x
fo

r m
on

ey
o

r
dr

ug
s a

t b
as

el
in

e

12
m

on
th

s a
ft

er
d

isc
ha

rg
e

fro
m

tr
ea

tm
en

t,
se

x w
or

ke
rs

h
ad

a
lo

w
er

li
ke

lih
oo

d
of

ab

st
in

en
ce

fr
om

d
ru

gs
a

nd
a

lco
ho

l t
ha

n
no

n-
se

x w
or

ke
rs

u
sin

g
th

e
se

rv
ice

; o
f a

ll w
om

en
in

th

e
pr

og
ra

m
m

e,
th

er
e w

as
a

re
du

ct
io

n
of

30

%
in

th
os

e
re

po
rt

in
g

se
x w

or
k,

a
nd

a

re
du

ct
io

n
of

se
x w

or
k t

ra
ns

ac
tio

ns
in

th
os

e
w

ho
co

nt
in

ue
d

se
x w

or
k;

w
om

en
w

ith
a

lo

ng
er

d
ur

at
io

n
of

tr
ea

tm
en

t a
nd

th
os

e w
ho

re

ce
iv

ed
m

or
e

m
en

ta
l h

ea
lth

a
nd

ps

yc
ho

lo
gi

ca
l s

er
vi

ce
s w

er
e

m
or

e
lik

el
y t

o
ha

ve
st

op
pe

d
se

x w
or

k;
ce

ss
at

io
n

of
se

x w
or

k
w

as
p

re
di

ct
iv

e o
f l

es
s f

re
qu

en
t d

ru
g

an
d

al
co

ho
l u

se
a

nd
fe

w
er

m
en

ta
l h

ea
lth

sy

m
pt

om
s a

t f
ol

lo
w

-u
p

W
ea

k

(T
ab

le
1

co
nt

in
ue

s o
n

ne
xt

p
ag

e)

www.thelancet.com/public-health Vol 8 February 2023 e145

Review
Co

un
tr

y
St

ud
ie

s (
n)

Se
x

w
or

ke
r

po
pu

la
ti

on
In

te
rv

en
ti

on
se

tt
in

g
or

c
on

te
xt

In
te

rv
en

ti
on

Co
m

pa
ris

on
o

r
co

nt
ro

l
O

ut
co

m
es

Q
ua

lit
y

as
se

ss
m

en
t*

(C
on

tin
ue

d
fro

m
p

re
vi

ou
s p

ag
e)

Co
ho

rt
st

ud
ie

s (
on

e
gr

ou
p,

p
re

-in
te

rv
en

ti
on

a
nd

p
os

t-
in

te
rv

en
ti

on
)†

Pa
rk

e
t a

l
(2

02
0)

43

US
A

10
3

Fe
m

al
e

se
x w

or
ke

rs

ag
ed


18

ye
ar

s w
ho

w

er
e u

sin
g

op
io

id
s

ob
ta

in
ed

il
le

ga
lly

(ie

, h
er

oi
n,

fe
nt

an
yl

,
pr

es
cr

ip
tio

n
op

io
id

pi

lls
p

ur
ch

as
ed

o
n

th
e

st
re

et
, o

r a
ll

th
re

e)

Va
rio

us
se

tt
in

gs
(e

g,

m
ob

ile
v

an
, s

tu
dy

offi

ce
, f

as
t f

oo
d

re
st

au
ra

nt
s,

an
d

ho
m

e
vi

sit
s)

Tr
ai

ni
ng

a
nd

p
ro

vi
sio

n
of

fi
ve

fe

nt
an

yl
te

st
st

rip
s t

o
te

st
d

ru
g

sa
m

pl
es

fo
r f

en
ta

ny
l a

nd
re

la
te

d
an

al
og

ue
s t

ha
t h

av
e

in
cr

ea
se

d
ris

k
of

o
ve

rd
os

e
an

d
de

at
h;

a
lso

pr

ov
id

ed
b

rie
f o

ve
rd

os
e

ris
k

as
se

ss
m

en
t,

ta
ilo

re
d

ha
rm

re

du
ct

io
n

ad
vi

ce
, a

nd
n

al
ox

on
e

N
A

1
m

on
th

la
te

r,
th

er
e w

er
e

sig
ni

fic
an

t
re

du
ct

io
ns

in
il

lic
it

op
io

id
u

se
, i

nj
ec

tio
n

dr
ug

us

e,
b

en
zo

di
az

ep
in

e u
se

, a
nd

so
lit

ar
y d

ru
g

us
e;

8
4%

o
f w

om
en

u
se

d
th

e
st

rip
s;

of
th

e
48

w
ho

h
ad

a
p

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iti

ve
te

st
re

su
lt,

6
3%

st
ill

us

ed
th

ei
r d

ru
g

as
o

rig
in

al
ly

in
te

nd
ed

; o
th

er
s

us
ed

a
ra

ng
e o

f h
ar

m
re

du
ct

io
n

be
ha

vi
ou

rs

af
te

r p
os

iti
ve

re
su

lts

W
ea

k

De
ck

er
e

t a
l

(2
01

7)
44

US
A

60
St

re
et

-b
as

ed
a

nd

ve
nu

e-
ba

se
d

fe
m

al
e

se
x w

or
ke

rs

M
ob

ile
v

an
th

at
w

en
t

to
b

ot
h

a
st

re
et

lo

ca
tio

n
an

d
a

ve
nu

e
kn

ow
n

to
h

av
e

a
lo

t o
f

se
x t

ra
de

a
ct

iv
ity

IN
SP

IR
E—

a
sin

gl
e

br
ie

f s
em

i-
st

ru
ct

ur
ed

d
isc

us
sio

n
w

ith
a

n
ou

tr
ea

ch
w

or
ke

r a
bo

ut
im

pr
ov

in
g

sa
fe

ty
a

nd
re

du
cin

g
H

IV
ri

sk
, a

s w
el

l
as

h
ow

to
a

cc
es

s v
io

le
nc

e
su

pp
or

t
se

rv
ice

s;
su

pp
le

m
en

te
d

w
ith

w
al

le
t-

siz
ed

ca
rd

su
m

m
ar

isi
ng

in

fo
rm

at
io

n;
d

ev
el

op
ed

in

co
lla

bo
ra

tio
n

w
ith

fe
m

al
e

se
x

w
or

ke
rs

N
A

12
w

ee
ks

a
ft

er
co

m
pl

et
in

g
th

e
in

te
rv

en
tio

n,

pa
rt

ici
pa

nt
s u

se
d

m
or

e
sa

fe
ty

b
eh

av
io

ur
s,

m
ad

e
m

or
e u

se
o

f s
ex

ua
l v

io
le

nc
e

an
d

tr
affi

ck
in

g
su

pp
or

t p
ro

gr
am

m
es

, a
nd

w
er

e
m

or
e

aw
ar

e o
f h

ow
to

re
po

rt
v

io
le

nc
e t

o
th

e
po

lic
e t

ha
n

th
ey

w
er

e
be

fo
re

; t
he

y w
er

e
m

or
e

lik
el

y t
o

en
ga

ge
in

co
nd

om
n

eg
ot

ia
tio

n
an

d
le

ss
li

ke
ly

to
h

av
e

se
x w

ith
cl

ie
nt

s w
hi

le
u

sin
g

al
co

ho
l o

r d
ru

gs
th

an
b

ef
or

e;
th

er
e w

as
n

o
ch

an
ge

in
P

TS
D

or
d

ep
re

ss
iv

e
sy

m
pt

om
s

W
ea

k

Li
tc

hfi
el

d
et

a
l (

20
10

)45

UK
34

Ad
ul

t f
em

al
e

se
x

w
or

ke
rs

u
sin

g
he

ro
in

Ge
ne

ra
l p

ra
ct

io
ne

r-l
ed

pr

im
ar

y
ca

re
d

ru
g

tr
ea

tm
en

t s
er

vi
ce

th
at

in

co
rp

or
at

ed
a

sp
ec

ifi
c

cli
ni

c t
ar

ge
te

d
at

fe

m
al

e
se

x w
or

ke
rs

Ta
rg

et
ed

d
ru

g
tr

ea
tm

en
t

pr
og

ra
m

m
e—

pr
es

cr
ib

ed
o

pi
oi

d
su

bs
tit

ut
io

n
(t

yp
ica

lly
m

et
ha

do
ne

);
se

xu
al

h
ea

lth
in

te
rv

en
tio

ns
a

nd

ad
vi

ce
, a

nd
k

ey
-w

or
ki

ng
a

nd

ps
yc

ho
so

cia
l s

up
po

rt
w

er
e

al
so

av

ai
la

bl
e

N
A

Af
te

r 1
ye

ar
, o

nl
y

33
%

o
f p

ar
tic

ip
an

ts
w

er
e

st
ill

se

x w
or

ke
rs

, q
ua

lit
y o

f l
ife

h
ad

im
pr

ov
ed

, a
nd

he

ro
in

u
se

h
ad

re
du

ce
d

(in
u

rin
e

sa
m

pl
es

,
87

%
p

os
iti

ve
fo

r h
er

oi
n

at
b

as
el

in
e,

7
2%

a
t

1 y
ea

r)

W
ea

k

W
ar

d
an

d
Ro

e-
Se

po
w

itz

(2
00

9)
9

US
A

29
o

ve
ra

ll:
1

1
in

re

sid
en

tia
l

pr
og

ra
m

m
e a

nd

18
in

p
ris

on

(in
ca

rc
er

at
ed

fo

r n
on

-s
ex

w

or
ki

ng
cr

im
es

)

Fe
m

al
e

se
x w

or
ke

rs
Tw

o
se

tt
in

gs

a
co

m

m
un

ity
-b

as
ed

re

sid
en

tia
l p

ro
gr

am
m

e
an

d
a

m
od

er
at

e-
se

cu
rit

y
pr

iso
n

Th
e

Es
ub

a
pr

og
ra

m
m

e—
a

ps
yc

ho

ed
uc

at
io

na
l t

he
ra

py
g

ro
up

de

sig
ne

d
to

in
cr

ea
se

a
w

ar
en

es
s o

f
ab

us
e

an
d

vi
ol

en
ce

w
hi

le
te

ac
hi

ng

an
ge

r m
an

ag
em

en
t a

nd

co
m

m
un

ica
tio

n
sk

ill
s,

an
d

de
ve

lo
pi

ng
so

cia
l s

up
po

rt
; o

ne

se
ss

io
n

pe
r w

ee
k

fo
r 1

2
w

ee
ks

, e
ac

h
la

st
in

g
2

h;
se

ss
io

ns
fa

cil
ita

te
d

by
a

do

ct
or

al
st

ud
en

t a
nd

cl
in

ica
l s

oc
ia

l
w

or
ke

r

N
A

Re
du

ct
io

n
in

tr
au

m
a

sc
or

es
in

b
ot

h
gr

ou
ps

,
w

ith
th

e
pr

iso
n

gr
ou

p
ha

vi
ng

g
re

at
er

ch
an

ge

(b
ut

th
ey

a
lso

h
ad

h
ig

he
r b

as
el

in
e t

ra
um

a
sc

or
es

th
an

th
e

re
sid

en
tia

l p
ro

gr
am

m
e)

W
ea

k

Bo
w

se
r e

t a
l

(2
00

8)
46

US
A

18
9

Fe
m

al
e

se
x w

or
ke

rs

w
ho

u
se

d
ru

gs
Pr

og
ra

m
m

e
ho

us
e

Da
y

pr
og

ra
m

m
e

la
st

in
g

12
m

on
th

s,
pr

ov
id

in
g

m
ea

ls,
H

IV
ri

sk
-r

ed
uc

tio
n

ed
uc

at
io

n,
a

nd
o

ne
-o

n-
on

e
ps

yc
ho

lo
gi

ca
l c

ou
ns

el
lin

g

N
A

By
th

e
en

d
of

th
e

in
te

rv
en

tio
n,

th
er

e w
as

a

sig
ni

fic
an

t r
ed

uc
tio

n
in

p
ol

yd
ru

g
us

e w
ith

al

co
ho

l;
al

so
si

gn
ifi

ca
nt

im
pr

ov
em

en
t i

n
ho

us
in

g
se

cu
rit

y
an

d
a

sig
ni

fic
an

t r
ed

uc
tio

n
in

th

e
nu

m
be

r o
f n

ig
ht

s p
er

m
on

th
sp

en
t i

n
ja

il;

no
si

gn
ifi

ca
nt

ch
an

ge
in

e
m

pl
oy

m
en

t

W
ea

k

Sh
er

m
an

et

a
l (

20
06

)47

US
A

50
Fe

m
al

e
se

x w
or

ke
rs

ag

ed
1

8–
45

ye
ar

s
w

ho
h

ad
u

se
d

he
ro

in
o

r c
oc

ai
ne

a
t

le
as

t o
nc

e w
ee

kl
y

in

th
e

pa
st

m
on

th

O
ffi

ce
in

th
e t

ar
ge

t
ne

ig
hb

ou
rh

oo
d

(in

Ba
lti

m
or

e,
M

D,
U

SA
;

ho
w

ev
er

, e
xa

ct

ne
ig

hb
ou

rh
oo

d
un

sp
ec

ifi
ed

)

Si
x

2-
h

se
ss

io
ns

th
at

ta
ug

ht
H

IV
ri

sk

re
du

ct
io

n
an

d
th

e
m

ak
in

g,

m
ar

ke
tin

g,
a

nd
se

lli
ng

o
f j

ew
el

le
ry

;
th

er
e w

er
e o

pp
or

tu
ni

tie
s t

o
se

ll
je

w
el

le
ry

th
at

w
as

m
ad

e
as

w
el

l;
se

ss
io

ns
to

ok
p

la
ce

tw
ice

p
er

w
ee

k
ov

er
a

3
-w

ee
k

pe
rio

d

N
A

3
m

on
th

s a
ft

er
co

m
pl

et
in

g
th

e
in

te
rv

en
tio

n,

th
er

e w
er

e
sig

ni
fic

an
t r

ed
uc

tio
ns

in
th

e
nu

m
be

r o
f t

ra
ns

ac
tio

na
l s

ex
p

ar
tn

er
s,

al
l s

ex

pa
rt

ne
rs

, a
nd

d
ai

ly
in

je
ct

io
n

an
d

no
n-

in
je

ct
io

n
dr

ug
u

se
; w

om
en

w
ho

e
ar

ne
d

m
or

e
m

on
ey

th
ro

ug
h

je
w

el
le

ry
sa

le
s h

ad
a

sig

ni
fic

an
tly

re
du

ce
d

nu
m

be
r o

f s
ex

tr
ad

e
pa

rt
ne

rs
a

t f
ol

lo
w

-u
p

W
ea

k

(T
ab

le
1

co
nt

in
ue

s o
n

ne
xt

p
ag

e)

e146 www.thelancet.com/public-health Vol 8 February 2023

Review

Co
un

tr
y

St
ud

ie
s (

n)
Se

x
w

or
ke

r
po

pu
la

ti
on

In
te

rv
en

ti
on

se
tt

in
g

or
c

on
te

xt
In

te
rv

en
ti

on
Co

m
pa

ris
on

o
r

co
nt

ro
l

O
ut

co
m

es
Q

ua
lit

y
as

se
ss

m
en

t*

(C
on

tin
ue

d
fro

m
p

re
vi

ou
s p

ag
e)

Cr
os

s-
se

ct
io

na
l s

tu
di

es

St
ew

ar
t e

t a
l

(2
02

0)
48

US
A

50
Fi

rs
t 5

0
w

om
en

at

te
nd

in
g

th
e

cli
ni

c;
31

(6
2%

) o
f

50
re

po
rt

ed

tr
an

sa
ct

io
na

l s
ex

fo
r

fo
od

, s
he

lte
r,

or
d

ru
gs

; h
ow

ev
er

,
au

th
or

s w
er

e
co

nt
ac

te
d

an
d

st
ro

ng
ly

su
sp

ec
t

th
at

a
ll

cli
en

ts

en
ga

ge
d

in

tr
an

sa
ct

io
na

l s
ex

O
ut

re
ac

h
cli

ni
c a

t a

dr
op

-in
ce

nt
re

fo
r

pe
op

le
e

xp
er

ie
nc

in
g

ho
m

el
es

sn
es

s

3-
h

w
ee

kl
y

cli
ni

c i
nv

ol
vi

ng
a

n
in

fe
ct

io
us

d
ise

as
e

ph
ys

ici
an

,
a

nu
rs

e,
a

nd
a

m
ed

ica
l s

oc
ia

l
w

or
ke

r;
th

e
fu

ll-
tim

e
m

ed
ica

l s
oc

ia
l

w
or

ke
r w

as
p

re
se

nt
o

n
sit

e d
ur

in
g

ea
ch

cl
in

ic
se

ss
io

n
an

d
on

n
on

-c
lin

ic
da

ys
fo

r c
ar

e
co

or
di

na
tio

n;
cl

in
ic

pr
ov

id
es

p
rim

ar
y

m
ed

ica
l c

ar
e

an
d

ha
rm

re
du

ct
io

n
in

te
rv

en
tio

ns
fo

r
dr

ug
tr

ea
tm

en
t,

in
clu

di
ng

bu

pr
en

or
ph

in
e–

na
lo

xo
ne

, f
am

ily

pl
an

ni
ng

, a
nd

tr
ea

tm
en

t o
f S

TI
,

Pr
EP

, a
nd

H
IV

ca
re

N
A

Pr
im

ar
y

re
as

on
s f

or
se

ek
in

g
ca

re
w

er
e

sk
in

an

d
so

ft
ti

ss
ue

in
fe

ct
io

n,
S

TI
a

nd
H

IV

sc
re

en
in

g,
a

nd
u

rin
ar

y t
ra

ct
in

fe
ct

io
n;

fo

ur
(1

0%
) o

f 3
9

te
st

ed
w

om
en

h
ad

un

pl
an

ne
d

pr
eg

na
nc

ie
s;

fo
ur

(1
0%

) o
f

42
w

er
e

po
sit

iv
e

fo
r H

IV
, o

f w
hi

ch
tw

o
w

er
e

ne
w

d
ia

gn
os

es
; o

pi
oi

d
de

te
ct

ed
in

u
rin

e o
f

31
w

om
en


ni

ne
in

iti
at

ed
b

up
re

no
rp

hi
ne


na

lo
xo

ne
a

nd
th

re
e

al
re

ad
y

co
nn

ec
te

d
to

a

tr
ea

tm
en

t p
ro

gr
am

m
e;

1
1

(4
8%

) o
f 2

3
te

st
ed

po

sit
iv

e
fo

r T
ric

ho
m

on
as

va
gi

na
lis

,
fiv

e
(1

8%
) o

f 2
8

fo
r g

on
or

rh
oe

a,
fi

ve
(1

8%
) o

f
28

fo
r c

hl
am

yd
ia

, n
on

e o
f 1

3
fo

r s
yp

hi
lis

,
an

d
15

(3
9%

) o
f 3

8
fo

r h
ep

at
iti

s C
; H

IV
P

rE
P

pr
es

cr
ib

ed
to

1
7

w
om

en

W
ea

k

Ba
ar

s e
t a

l
(2

00
9)

49

N
et

he
rla

nd
s

25
9

Fe
m

al
e

se
x w

or
ke

rs

in
b

ro
th

el
s,

clu
bs

,
er

ot
ic

m
as

sa
ge

sa

lo
ns

, e
ro

tic
b

ar
s,

w
in

do
w

se
x w

or
k,

an

d
se

x w
or

k
zo

ne
s

O
ut

re
ac

h
an

d
cli

ni
c

Fr
ee

, t
ar

ge
te

d
na

tio
na

l h
ep

at
iti

s B

va
cc

in
at

io
n

pr
og

ra
m

m
e

fo
r s

ex

w
or

ke
rs

(i
nc

lu
de

d
m

en
a

nd

w
om

en

bu
t t

he
st

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y o

nl
y

lo
ok

ed

at
w

om
en

a
nd

o
th

er
g

ro
up

s a
t h

ig
h

ris
k)

; a
lso

sc
re

en
ed

fo
r h

ep
at

iti
s B

a
t

tim
e o

f v
ac

cin
at

io
n;

co
m

m
un

ity

he
al

th
st

aff
p

er
io

di
ca

lly
v

isi
te

d
va

rio
us

se
x w

or
ke

r l
oc

at
io

ns
(e

g,

st
re

et
s a

nd
b

ro
th

el
s)

a
nd

o
ffe

re
d

va
cc

in
es

th
er

e

N
A

20
5

(7
9%

) p
ar

tic
ip

an
ts

w
er

e
aw

ar
e t

ha
t t

he
y

co
ul

d
ob

ta
in

fr
ee

h
ep

at
iti

s B
v

ac
cin

at
io

n;

va
cc

in
at

io
n

up
ta

ke

of
a

t l
ea

st
o

ne
d

os
e—

w
as

63

%
(8

2%
o

f w
ho

re
ce

iv
ed

it
th

ro
ug

h
th

is
pr

og
ra

m
m

e)
; t

ho
se

w
ho

re
ce

iv
ed

th
e

va
cc

in
at

io
n

ha
d

w
or

ke
d

in
a

n
ar

ea
fo

r l
on

ge
r

an
d

w
er

e
m

or
e

lik
el

y t
o

w
or

k
be

hi
nd

w
in

do
w

s
th

an
th

os
e w

ho
d

id
n

ot
re

ce
iv

e t
he

va

cc
in

at
io

n;
th

e
m

os
t i

m
po

rt
an

t r
ea

so
n

fo
r

no
n-

pa
rt

ici
pa

tio
n

w
as

la
ck

o
f t

im
e;

o
f t

ho
se

w

ho
st

ar
te

d
th

e
va

cc
in

e
co

ur
se

,
74

(7
9%

) o
f 9

4
pa

rt
ici

pa
nt

s r
ec

ei
ve

d
th

re
e o

r
m

or
e

va
cc

in
at

io
ns

, 1
5

(1
6%

) r
ec

ei
ve

d
tw

o
va

cc
in

at
io

ns
, a

nd
fi

ve
(5

%
) r

ec
ei

ve
d

on
e

va
cc

in
at

io
n;

re
as

on
s f

or
n

ot
fi

ni
sh

in
g

w
er

e
va

ca
tio

n,
ch

an
ge

d
w

or
k

lo
ca

tio
n,

fo
rg

et
tin

g,

la
zin

es
s,

an
d

di
d

no
t k

no
w

; 7
5%

re
ce

iv
ed

th
ei

r
fir

st
v

ac
cin

at
io

n
at

a
n

ou
tr

ea
ch

lo
ca

tio
n

W
ea

k

Ja
ns

se
n

et
a

l
(2

00
9)

50

Ca
na

da
10

0
St

re
et

-b
as

ed
fe

m
al

e
se

x w
or

ke
rs

a
ge

d
≥1

6
ye

ar
s;

au
th

or
s

st
at

ed
th

at
o

nl
y

a
sm

al
l n

um
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lt,

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ag

e)

www.thelancet.com/public-health Vol 8 February 2023 e147

Review

a narrative synthesis36 to summarise findings, following
guidance from the Cochrane Handbook for Systematic
Reviews of Interventions.35

For the narrative synthesis, categories of intervention
were developed based on the included papers, and
interventions with multiple components were allocated
to as many categories as relevant. Intervention com-
ponents identified were education and empower ment,
drug treatment, sexual and reproductive health care,
other health care (eg, vaccination, screening, and primary
care), and welfare. We summarised the papers in each
intervention category according to four main areas: the
nature of the interventions, outcomes reported, what was
effective, and what was ineffective. We report outcomes
as described in the studies but recognise that outcomes
relating to cessation or reduction of sex working might
not be wanted or important for many sex workers.

To quantitatively analyse results, we used vote counting,
which can be used when outcomes are measured hetero-
geneously between studies.35 Vote counting compares the
number of studies in which a particular outcome
improved with the number of studies in which that
outcome did not improve, based only on the direction of
effect and therefore with no measure of the magnitude
of effect. All studies that measured outcomes before
and after an intervention were included. For randomised
controlled trials, both the intervention and control groups
were included separately if enough information was
available. We did this as most controls were well designed
interventions that contributed important results to the
Review. Intervention categories mirrored the narrative
synthesis; the exception to this was that multicomponent
interventions were categorised separately both to prevent
double counting and because their effectiveness relies on
the entirety of the intervention. Outcomes were grouped
together into categories. Only outcome categories
measured in two or more different interventions were
included. If multiple outcomes were reported within one
category for a particular intervention, only the primary
outcome was used. If no primary outcome was identified
and the results were not all in a single direction, the
intervention was labelled as having mixed results for that
outcome. No intervention had an outcome (or group of
outcomes) that deteriorated within an outcome category.
We display these data within a harvest plot, which
provides a visual summary of the vote counting.35
Additionally, we produced a standard binary metric
(benefit or mixed results), which we used to calculate
a proportion, 95% CI (binomial exact calculation), and
p value (binomial probability test) to show the evidence
for each intervention category’s effectiveness across all
outcome measures.

Results
Overview
18 611 studies were identified through database searching
and 123 through additional methods. After de-duplication

Co
un

tr
y

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ud

ie
s (

n)
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x
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ris
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ua
lit

y
as

se
ss

m
en

t*

(C
on

tin
ue

d
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m
p

re
vi

ou
s p

ag
e)

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ur

ro
ck

et

a
l (

20
07

)51

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st

ra
lia

71
M

al
e

an
d

fe
m

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se
x

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in
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s

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at
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fo

r 4
w

ee
ks

, t
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ee
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r f
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r t
im

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p

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on

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51
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in
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to
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(6

2%
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f 6
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; s

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(1
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) o
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68
re

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p
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co

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on
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tio
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(9
6%

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f 7

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w

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(2

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x w

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p
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cl

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ic

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; 1
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(o

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nl

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),
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as

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ily

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=M
ob

ile
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cc
es

s P
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. N
A=

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ot

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. N

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=n

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at

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. P

rE
P=

pr
e-

ex
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ax
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po

st
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iso
rd

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ly

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itt

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IS

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=W

om
en

’s
In

fo
rm

at
io

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Sa

fe
H

av
en

. *
Su

bc
at

eg
or

ise
d

by
st

ud
y d

es
ig

n
hi

er
ar

ch
y. †S

tu
dy

ca
te

go
ris

at
io

ns
u

se
d

ar
e d

er
iv

ed
fr

om
th

e
Eff

ec
tiv

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bl
ic

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ea

lth
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ra
ct

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ro
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ct
’s

Q
ua

lit
y A

ss
es

sm
en

t T
oo

l f
or

Q

ua
nt

ita
tiv

e
St

ud
ie

s.33

Ta
bl

e 1
: S

um
m

ar
y

an
d

ch
ar

ac
te

ris
ti

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o

f i
nc

lu
de

d
st

ud
ie

s

e148 www.thelancet.com/public-health Vol 8 February 2023

Review

and initial screening, 200 were reviewed in full.
20 studies were included in the final review (figure 1).
Summary characteristics and categorisations of included
studies are presented in table 1 and table 2. The appendix
(p 4) shows a map detailing the number of studies
included in each intervention category by country.

Most studies were from North America. 11 (55%)
focused on street-based sex workers, and nearly all
exclusively studied female sex workers. Eight (40%) of
the inter ventions were multicomponent. 18 (90%) of the

inter ventions (90%) took place in a context where
sex work was fully or partly criminalised at the time
of study. Interventions were primarily based in static
locations, although seven (35%) studies included
outreach compo nents. The most common outcomes
measured related to drug use and drug harm reduction,
sexual risk behaviours, and mental health and wellbeing.
No harms associated with the interventions were
reported. All studies presented limitations in sampling
strategy. Most used convenience or snowball sampling.
A few used repeated time-space sampling of mapped
sex worker districts to improve systematicity.26,38,41,42,49
Four (20%) studies were randomised controlled trials,
but all had limitations including non-systematic recruit-
ment strategies,37,38,40,41 an absence of information on the
randomisation process,38,40 and no data on loss to
follow-up.40 Only one was reported using Consolidated
Standards of Reporting Trials guidelines.37

The harvest plot (figure 2) summarises evidence for
effectiveness within each intervention category across

Studies (n=20)

Country

USA9,14,38–41,43,44,46–48 11 (55%)

Canada26,42,50 3 (15%)

UK45,53 2 (10%)

Hong Kong37,52 2 (10%)

Australia51 1 (5%)

Netherlands49 1 (5%)

Sex work legal context in intervention setting at time of study*

Full criminalisation of sex working9,14,38–41,43,44,46–48 11 (55%)

Partial criminalisation of sex working26,37,42,45,50,52,53 7 (35%)

Criminalisation of the purchase of sex 0

Regulation of sex working49,51 2 (10%)

Full decriminalisation 0

Sex worker’s sex, gender, or both†

Female9,14,26,37–53 20 (100%)

Male51 1 (5%)

Transgender women26,42 2 (10%)

Location of sex work

Street based26,38,41–43,45–47,50,52,53 11 (55%)

Brothel or indoor based51 1 (5%)

Street based and indoor based44,49 2 (10%)

Unclear where sex work takes place9,14,37,39,40,48 6 (30%)

Study design‡

Randomised controlled trial37,38,40,41 4 (20%)

Cohort analytic (two groups, pre-intervention and
post-intervention)14,26,42

3 (15%)

Cohort (one group, pre-intervention and post-
intervention)9,39,43–47

7 (35%)

Cross-sectional study48–53 6 (30%)

Quality rating

Strong 0

Moderate37–39 3 (15%)

Weak9,14,26,40–53 17 (85%)

Intervention setting

Outreach locations40,42–44,49–51 7§ (35%)

Static site9,14,26,37–41,45–48,52,53 14§ (70%)

Single component interventions

Overall9,14,37–41,43,44,49,51,53 12 (60%)

Education and empowerment37–41,44 6

Drug treatment14,43 2

Sexual and reproductive health care51,53 2

Other health care9,49 2

(Table 2 continues in next column)

Studies (n=20)

(Continued from previous column)

Multicomponent interventions†

Overall26,42,45–48,50,52 8 (40%)

Education and empowerment26,42,45–48,50,52 7

Drug treatment45,48 2

Sexual and reproductive health care26,42,48,50,52 5

Other health care26,48,52 3

Welfare26,42,46,47,50 5

Peer involvement

Developed with peer workers44 1 (5%)

Developed and delivered with peer workers26,38,41,42,50 5 (25%)

No peer involvement reported9,14,37,39,40,43,45–49,51–53 14 (70%)

Outcomes measured†

Drug use and drug harm reduction38,41,43,45–47,50 7 (35%)

Sexual risk behaviours14,37,38,41,44,45,47 7 (35%)

Sex worker safety38,44,50 3 (15%)

Mental health and wellbeing9,37,40,44,45 5 (25%)

Criminal activity39,46 2 (10%)

Outcomes related to wider determinants46 1 (5%)

Awareness of health-care and support services44 1 (5%)

Use of other health-care and support services37,41,43 3 (15%)

Sexually transmitted infection treatment48,51,53 3 (15%)

Other health-care outcomes26,38,41,42,48–52 6 (30%)

Data are presented as n or n (%). *Legal context categorisations from Platt and
colleagues (2018).22 Full criminalisation prohibits all aspects of sex work and
selling and buying sex; partial criminalisation criminalises only some aspects;
in criminalisation of purchase of sex models, the sale of sex is legal but clients are
criminalised; and regulatory models allow the sale of sex in some settings or
conditions. Full decriminalisation removes all criminality of sex work while still
prohibiting violence and coercion of sex workers. †Can be in more than one
category. ‡Study categorisations used are derived from the Effective Public Health
Practice Project’s Quality Assessment Tool for Quantitative Studies.33 §One study
evaluated both outreach and static interventions.

Table 2: Characteristics of included studies by category

www.thelancet.com/public-health Vol 8 February 2023 e149

Review

different outcomes. A total of 15 interventions from
12 studies could be included within the harvest plot.
Nine (60%) of 15 included interventions were focused
on education and empowerment and many showed
improvements in one or more outcome. Multi-
component interventions showed potential benefit,
although only three (15%) interventions were included
and all were of low quality. Only a small amount of
evidence could be included for drug treatment and
other health-care interventions; however, drug treatment
was a central component of one of the multicomponent
interventions (Litchfield and colleagues [2010]).45 No
studies based on sexual and reproductive health care
could be included. With the exception of Decker and
colleagues (2017),44 which only included a peer-design
element, all other interventions involving peers included
both a design and delivery element and showed potential
benefit. Three outreach interventions were included, of
which one showed potential benefits across outcomes,40
and two showed mixed results.43,44

We analysed the number of positive outcomes
(potential benefit) to the number of total outcomes
reported per intervention category using the binomial
exact calculation and binomial probability test (table 3).
Education and empowerment and multicomponent
interventions showed a greater proportion of positive
outcomes than would have been expected by chance,
suggesting their potential effectiveness, whereas the little
evidence for drug treatment and other health-care
interventions precludes clear insight.

Education and empowerment
Seven interventions (six single component,37–41,44 and one
multi component47) focused on education and empower-
ment, and four multicomponent interventions had a small
educational component, but did not detail what was
provided.45,46,51,52 Of the seven, three focused on street-based
sex workers,38,41,47 one on street-based and indoor-based sex
workers,44 and in the other three the authors did not state
the sex worker population that the intervention was
targeting.37,39,40 Three were of moderate quality,37–39 and
four were of weak quality.40,41,44,47

A few studies used health behaviour models that
recognise structural and environmental vulnerabilities
contributing to HIV and sexual health risk.37,47 Structural
determinants were addressed through enhancing sex
worker self-efficacy and condom negotiation skills,37,47
as well as teaching strategies to minimise risk of
violence.38,44 Several used psychological therapies—
five were individually administered,37–39,41,44 and one used
family therapy between mothers who were sex workers
and their children.40 Two were developed and delivered
in collaboration with peer sex workers.38,41 Key study
outcomes for these interventions related to sexual risk
behaviours,37,38,41,47 drug use and drug harm reduction,38,41,47
mental health and wellbeing,37,40,44 use of other health-care
and support services,37,41 and criminal activity.39

All interventions showed a level of effectiveness,
but most only measured outcomes at 3 months after
intervention.37,44,47 A brief intervention that provided

Figure 2: Harvest plot of evidence for interventions to improve health and
wider determinants in sex workers by intervention category
The harvest plot is a supermatrix showing the direction of effect for outcome
categories across different categories of intervention. Each bar represents an
intervention and is labelled by a footnote, which can be identified below.
Taller bars represent interventions from studies with a moderate-quality
assessment; shorter bars are interventions from studies with a low-quality
assessment. Darker purple bars are static interventions. Lighter purple bars are
outreach. Striped bars are interventions that involved peer design, delivery, or
both. Solid bars had no peer involvement. *Murnan et al (2018)40—home
intervention. †Murnan et al (2018)40—office intervention. ‡Surratt and Inciardi
(2010)38—sex worker-focused intervention. §Surratt and Inciardi (2010)38—
National Institute on Drug Abuse intervention. ¶Surratt et al (2014)41—
professional–peer intervention. ||Decker et al (2017).44 **Wong et al
(2019)37—resilience programme. ††Burnette et al (2009).14 ‡‡Cigrang et al
(2020).39 §§Park et al (2020).43 ¶¶Ward and Roe-Sepowitz (2009)9—prison
group intervention. ||||Ward and Roe-Sepowitz (2009)9—community group
intervention. ***Litchfield et al (2010).45 †††Sherman et al (2006).47
‡‡‡Bowser et al (2008).46

Mixed
results

Potential
benefit

Substance
misuse

Sexual risk
behaviours

Sex worker
safety

Mental health
and wellbeing

Crime

Support
service use

Mixed
results

Potential
benefit

* † ‡ § ¶

§ ¶

§

||

||

|| **

**

** ††

‡‡

§§

§§

¶¶ ||||

***

***

***

†††

†††

‡‡‡

‡‡‡

A Education and empowerment B Drug treatment

C Other health care D Multicomponent
interventions

* †

Substance
misuse

Sexual risk
behaviours

Sex worker
safety

Mental health
and wellbeing

Crime

Support
service use

e150 www.thelancet.com/public-health Vol 8 February 2023

Review

information on strategies to improve sex worker safety
and reduce the risk of violence affected safety behaviours
and use of relevant support programmes 12 weeks later.44
A six-session resilience-promoting programme showed
improvements in resilience, self-esteem, and condom
use 3 months later.37 A 12-session family therapy
programme showed greater reductions in drug use and
depressive symptoms than a psychoeducational pro-
gramme with only sex workers.40 One programme helped
sex workers to develop negotiation skills with different
sexual partner types alongside teaching jewellery-making
skills.47 3 months post-intervention, there were reductions
in transactional and total sex partners, as well as injection
and non-injection drug use. In another intervention,
female sex workers in prison were provided two brief
motivational interviews to help identify and problem
solve their greatest concerns for post-release.39 This
intervention led to a reduction in the number of arrests
in the 12-month period after release.

Two studies including peer sex workers in the
development and delivery of an intervention showed
mixed results.38,41 Both were randomised controlled trials
with interventions showing similarly positive outcomes to
control groups, which were high quality. One found that a
strengths-based programme did not show additional
effectiveness when incorporating a peer facilitator over
a case manager alone.38 The other study showed that a
sex worker-focused HIV risk education programme,
developed and delivered in collaboration with sex workers,
led to a significantly greater reduction in unprotected oral
sex and episodes of sexual violence than the US National
Institute on Drug Abuse standard intervention at 6-month
follow-up. However, other HIV risk outcomes were
similar to the standard intervention.41

Drug treatment
Drug treatment was provided by four interventions
(two single component14,43 and two multicomponent45,48).
Three specifically targeted sex worker populations—a drug
treatment clinic for street-based female sex workers,45

a one-off harm reduction intervention for street-based
female sex workers,43 and a one day per week clinic
offering an array of primary care and harm reduction
services to an unspecified sex worker population.48 The
fourth study compared outcomes between sex workers
(no subpopulation identified) and non-sex workers using
US-Government-funded drug treatment programmes
across 71 facilities.14 Three interventions were at static
locations,14,45,48 and all studies were low quality.

The primary care clinic studied by Stewart and
colleagues48 found that 31 (62%) of 50 women seen had
opioids in their urine. Of these, nine (29%) of 31 started
opioid substitution therapy (OST) and three (10%) were
already in OST programmes. In the harm reduction
inter vention, women were given naloxone, harm
reduction advice, and self-administered tests for
detecting the presence of fentanyl in drugs.43 Fentanyl
has a higher risk of overdose and death compared with
heroin. 1 month after intervention, opioid and injection
drug use, as well as solitary drug use, had reduced.
However, fentanyl detection in drugs did not lead to
changes in harm reduction behaviours for most people.
The other two studies on drug treatment found a
significant decrease in drug use at the end of drug
programmes (one focused on heroin,45 the other included
various drugs14), and a reduction in the number of
women still engaging in sex work.14,45 Burnette and
colleagues14 found that those still involved in sex work
were doing significantly less sex work than they had
before. Both interventions provided physical and mental
health services alongside OST, which led to improvements
in mental health and wellbeing. Burnette and colleagues14
found higher use of mental health services was associated
with increased probability of cessation of sex work at
follow-up, which in turn was associated with lower drug
use, higher abstinence rates, and fewer mental health
symptoms.14

Sexual and reproductive health care
Two interventions provided STI screening, STI treat-
ment, and HIV pre-exposure prophylaxis through
sexual health outreach clinics in brothels,51 and a 1 day
per week, multicomponent primary care intervention
for an unspecified sex worker population.48 Two multi-
component welfare services for street-based sex workers
provided free condoms and lubricants.26,42,50 One study
described the management of a syphilis outbreak in
street-based sex workers in east London.53 Through
partnership with a charity providing outreach to sex
workers, women with suspected syphilis were invited
to the charity’s drop-in centre, from where they were
driven to a nearby genitourinary medicine clinic.
Reproductive health-care service components included
pregnancy testing,48 contraceptive prescriptions and
advice,45,52 and post-coital contraception.51 No details of
service provision, uptake, or acceptability were provided
and no study focused on reproductive health care.

Number of
potentially beneficial
outcomes of total
outcomes

95% CI of the
proportion of
beneficial outcomes

p value

Education and
empowerment

17 (80%) of 21 58·1–94·6 0·007

Drug treatment 0 (0%) of 2 0–84·2 0·50

Other health care 0 (0%) of 2 0–84·2 0·50

Multicomponent
interventions

7 (100%) of 7 59·0–100 0·016

For each intervention category, a p value was calculated using the binomial
probability test to determine the chance that the true proportion of potentially
beneficial outcomes of total outcomes was 0·50. Accompanying exact
95% binomial CIs are also displayed.

Table 3: Effectiveness of intervention categories across different
outcome measures

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Review

Studies were observational and low quality. Two pro-
vided information on STI treatment.51,53 Sturrock and
colleagues51 invited sex workers with positive results
back for treatment. 42 (62%) of 68 participants returned
for their results and seven (17%) of 42 returning sex
workers received treatment. In the syphilis outbreak,
epi demiological treatment (ie, treatment based on
probable exposure) was provided to all sex workers.53
Most individuals declined intramuscular penicillin—
the best available treatment—and many instead chose
oral antibiotics, which are a suboptimal alternative.
13 (93%) of 14 sex workers were followed up.

Other health care
Other health-care interventions included a trauma-based
psychoeducational therapy group for street-based sex
workers,9 a vaccination programme for multiple sex
worker populations,49 a multicomponent clinic focused
on women’s health for street-based female sex workers,52
and multicomponent primary care clinics in the
proximity of welfare drop-in centres.26,48 The vaccination
programme was a nationally run programme in the
Netherlands. The programme provided free hepatitis B
vaccinations to sex workers through local community
health services, working alongside existing sex worker
outreach services, and by community health-service staff
periodically visiting various sex work locations, including
brothels and streets over several years. All other
interventions were at static locations, with the therapy
group provided at both a community-based residential
centre and a moderate-security prison. All studies were
low quality. Several interventions offered referral to other
health or social services, but no study gave information
on the uptake of this offer.26,38,40,42,50,52

The psychotherapy group participants’ trauma scores
decreased significantly in six of ten parameters at the end
of the 12-week intervention.9 The decrease was more
profound in the prison group than in the residential
centre, possibly as their baseline trauma scores were
higher. Baars and colleagues49 provided evidence of the
effectiveness of the Netherlands’ hepatitis B vaccination
programme. Through a cross-sectional survey of 259 sex
workers working in various settings across three cities,
they found that 2 years after programme initiation,
205 (79%) of 259 were aware of the programme
and 163 (63%) of 257 had received at least
one dose—134 (82%) of 163 through the programme. Of
those who started the vaccine programme, 74 (79%) of
94 received all three vaccinations. Those who had been
vaccinated were more likely to have worked in an area for
longer and 75% reported receiving their first vaccination
at an outreach location. Wong evaluated a well-women
clinic’s cervical cancer screening intervention for street-
based female sex workers in Hong Kong.52 208 (88%) of
236 tested women returned for their smear results, and
13 (45%) of 29 women with atypical smear results were
uncontactable. Nine (31%) of the 29 with atypical results

were given referral letters to attend a gynaecologist, but it
is not known whether they were seen.

Welfare
All interventions that addressed welfare were multi-
component and focused on meeting basic needs through
providing food and drink, washing facilities, clothing, and
a safe space.26,42,46,50 The intervention by Sherman and
colleagues47 was the only exception which, alongside
teaching better condom negotiation skills, taught female
sex workers jewellery-making skills over six sessions.
These women then had the opportunity to sell their
handmade items at a stand within a hospital. The
intervention was designed to address structural deter-
minants preventing these women earning a sustainable,
alternative income. 3 months after com pletion, there were
significant reductions in transactional and total sex
partners, as well as injection and non-injection drug use.47
Women who earned more money through market sales
had a significantly decreased number of transactional sex
partners at follow-up. All welfare interventions were
oriented towards street-based sex workers and studies
were of low quality.

Three studies focused on two linked interventions in
Vancouver, BC, Canada.26,42,50 The inter ventions, both
designed for female sex workers, were the Women’s
Information Safe Haven (WISH) drop-in centre and a
peer-led, van-based outreach programme called the
Mobile Access Project (MAP). Those with greater
numbers of clients and working in isolated areas were
more likely to use the MAP van,42 reflecting the outreach
approach used. The studies showed that both services
were associated with accessing other health services—
inpatient addiction services for the MAP van,42 and sexual
and reproductive services for WISH.26 However, the
temporality of both relationships is unclear. Both the
MAP van and WISH were less likely to be used by
younger sex workers compared with older sex workers.
Of those who used the MAP van, 94% felt safer when the
van was present, 16% recalled a time it had prevented
physical assault, and 10% a time it had prevented sexual
assault.

Discussion
We identified 20 studies, with intervention components
divided into education and empowerment, drug treat-
ment, sexual and reproductive health care, other
health care, and welfare. 12 interventions were single
component and eight were multicomponent. Considering
the diversity of sex worker populations and their
corresponding needs, this was a very small number of
studies. There was promising evidence for interventions
that focused on education and empowerment and those
that were multicomponent. Sherman and colleagues’47
jewellery skills and sexual negotiation strategy workshops
were particularly innovative as a multicomponent inter-
vention combining empowerment and a focus on the

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Review

structural determinants of health. Evidence across studies
also showed that designing and delivering interventions
alongside sex workers was effective. Importantly, only
six interventions used co-design or co-delivery. The
harvest plot provided unclear results as to the effectiveness
of outreach. However, two interventions that involved
outreach, but could not be included in the plot because
they were cross-sectional studies and did not follow up
participants, showed evidence of possible benefit. Both
the Netherlands’ hepatitis B vaccination programme49 and
the management of a syphilis outbreak in east London53
relied on collaboration with existing outreach services
and showed good uptake and retention. Few interventions
incorporated reproductive health care,48 and there was
no evidence for interventions treating chronic diseases.
One intervention provided cervical cancer screening, but
many people with atypical results could not be contacted
and informed, and it is unclear whether those who were
contacted were followed up.52

Previous systematic reviews analysing health inter-
ventions for sex workers in high-income countries
underscored the need for flexible services which are non-
judgemental, built on respect and trust, trauma-
informed, and targeted at specific sex worker needs.10,29,30
Our Review also found outreach might be important in
ensuring high levels of engagement in some contexts.
However, outreach was not always enough to ensure
continuity of care. Similar to other systematic reviews,10,29
we found many studies highlighted low levels of
follow-up. Three studies were exceptions to this. One
involved OST,45 possibly showing the perceived value of
this intervention. The other two,49,53 as discussed earlier,
collaborated with established outreach services, which
might have improved trust and provided a channel by
which to follow up individuals.

To the best of our knowledge, this Review is the
first compre hensive overview of evidence on sex worker
interventions aiming to improve health and wider
determinants of health outcomes in high-income
countries. Academic databases and grey literature were
searched, and both academic experts and people with
lived experience of sex work were contacted to ensure we
identified all relevant literature. Importantly, we have
included authors with lived experience, and authors who
have worked with and continue to work with sex workers,
from the study’s inception—to develop the search strategy,
ensuring relevant grey literature channels were searched
and experts in the field contacted, and to ensure findings
were relevant, correctly interpreted, and presented with
appropriate language and without stigma.

This Review has some limitations. Where stated,
the majority of interventions were either primarily
or exclusively targeted at street-based sex
workers,26,38,41–43,45–47,50,52,53 probably because they are more
easily identified by service providers and researchers;
are more exposed to structural determinants such as
homelessness, poverty, and violence;18,54,55 and typically

have worse health outcomes.56 Therefore, general is-
ability of this Review’s findings to other sex worker
populations is limited. People engaged in street-based
sex work often have a range of different health and
social issues, including homelessness,4,18 drug use,10,14
and history of imprison ment,10 emphasising the
need for a wider inclusion health approach to service
provision and research that addresses multiple,
overlapping risk factors and vulnerabilities.28 We
reviewed English language studies since 2005 as a
pragmatic choice and because an initial scoping search
suggested most studies relevant to this Review met
these criteria. We did not include qualitative studies
that might provide insight into differences in results
between studies. Outcomes were highly heterogeneous,
often self-reported, and might not be the outcomes that
are important for all sex workers. The development of a
core outcome set in collaboration with sex workers
would help future researchers to ensure that outcomes
measured are relevant.57 Methods used by the included
studies also represent an important limitation, with
only three studies37–39 rated moderate in our quality
assessment, and all other studies rated weak (table 2).
One common reason for low quality was study design—
the most common design was a single group, pre-post
cohort study (often referred to as quasi-experimental
studies). Additionally, due to the nature of recruiting
marginalised populations, all studies presented limi-
tations in sampling strategy and most used either
convenience or snowball sampling. Finally, the com-
plexity and dynamic nature of the legal sex working
context in which the interventions took place could not
be accounted for in the Review’s findings and is likely
to be an explanatory factor for study heterogeneity.

There is scarce investment both in services and
research, particularly for sex workers who are not street
based. However, a range of interventions are likely to be
effective. Services should be developed and delivered in
collaboration with sex workers. Interventions that are
focused on education and empowerment or those that
are multicomponent are likely to be effective, and an
outreach or drop-in component could be of benefit in
some contexts.58 Future interventions should incorporate
components related to chronic diseases given they are
an important contributor to sex worker mortality.58
Within the identified studies, almost all interventions
were designed exclusively for female sex workers—the
only exceptions being two that included transgender
women sex workers,26,42 and one that included male sex
workers.51 Sex worker services and future research
should take a gender-sensitive and inclusive approach.
Several studies highlighted that sex workers who were
new to working in an area were less likely to access
services than those who had been working in an area for
longer.26,42,49 Effective information dissemination and
outreach could help ensure accessibility. Crucially,
repressive policing practices and the criminalisation of

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Review

sex work have already been shown to adversely affect
access to health and social services and sex worker health
outcomes.22 Therefore, the effectiveness of any service
will always be restricted in settings where sex work is
criminalised.
Contributors
LCP and SAL conceptualised the study. LCP, MB, BM, LJ, LW, KW,
and HB were involved in screening and data extraction. All authors
were involved in interpretation of the findings. LJ and SAL wrote the
first draft. All authors were involved in draft revisions and approving
the final draft for submission. All authors had full access to all
systematic review data and accept responsibility for the decision to
submit for publication.

Declaration of interests
SAL and LCP are Pathway Fellows. Pathway is a charity that provides
health care to homeless and inclusion health patients, including sex
workers. All other authors declare no competing interests.

Acknowledgments
We would like to thank Kelsey Johnson for her help with some figures.
Although there was no specific funding for this study, LJ, LCP, BS,
and SAL were supported by funding from the National Institute for
Health Research (NIHR). This study was also supported by the
Wellcome Trust through a Wellcome Clinical Research Career
Development Fellowship to RWA (206602).

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Copyright © 2022 The Author(s). Published by Elsevier Ltd. This is an
Open Access article under the CC BY 4.0 license.

  • Interventions to improve health and the determinants of health among sex workers in high-income countries: a systematic review
    • Introduction
    • Methods
      • Search strategy and selection criteria
      • Eligibility criteria
      • Data extraction and quality assessment
      • Data synthesis
    • Results
      • Overview
      • Education and empowerment
      • Drug treatment
      • Sexual and reproductive health care
      • Other health care
      • Welfare
    • Discussion
    • Acknowledgments
    • References

LIKE EVERYONE ELSE, SEX WORKERS DESERVE HEALTH
CARE

A clinic in Kenya provides sensitive sexual and reproductive health services to a variety of clients,
including sex workers. © UNFPA/Luis Tato

Sex workers are a diverse group of people. They are men, women, and transgender people. Some are parents, members of religious
groups, and members of our communities. Some sex workers enjoy their work and see it as a way to express their sexuality. Others
like the income and flexibility. Others view sex work as their best available option to earn an income. Yet, whoever sex workers are and
whatever they do, they deserve the same protections as everyone else. This includes the right to health care, to safety, and to their
wages. UNFPA works with sex workers and with sex worker-led organizations to meet the needs of this often stigmatized and
vulnerable population.

Stigma Against Sex Workers

Sex workers, like Lila, are highly vulnerable to gender-based violence, HIV, discrimination
and other harms. © Tomislav Georgiev/UNFPA MK

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Stigma against sex workers leads to extreme barriers to health care. For example, Lila in North Macedonia is transgender and a sex
worker. One night, three of her clients attacked and raped her. Even though she endured a horrendous crime, she was afraid to see a
doctor because she had witnessed discrimination from health-care workers first-hand. When her friend, also a sex worker, fell ill,
doctors refused to address her concerns. Instead, Lila says, “They called a gynecologist to determine if my friend had genital injuries,
and performed HIV and STI tests without her permission… To this day, I do not use public health services.”

Lila and her friend are not alone. A UNFPA report found that nearly 1 in 4 sex workers have been denied health care because of their
occupation. And, not surprisingly, more than 60% of sex workers fear and distrust health care workers so much that they have
someone accompany them to the doctor’s office. However, health care workers aren’t the only people who stigmatize and harm sex
workers.

Police officers around the world are known to harass, violate, and arrest sex workers. However, because police officers are part of the
justice system and because prostitution is criminalized in most countries, it can be difficult for sex workers to report crimes against
them, including assault or theft. Just like everyone else, sex workers deserve fair access to health and safety services without
judgment or punishment. 

Sex Workers are 30x more likely to be HIV+

Sithu, 21, did not know how to protect himself from HIV. © UNFPA/Yenny Gamming

The stigma around sex work and its criminalization places sex workers in vulnerable positions. It is because they are less able to
access services like health care that sex workers are 30 times more likely to be HIV+ than the general population. This likelihood is not
attributed to irresponsible behavior. Rather, sex workers face high rates of violence and, for example, can be exposed to HIV during a
sexual assault by a client. In Haiti, UNAIDS found that 36.6% of women who do sex work report physical violence and 27.1% report
sexual violence. It should also be noted that because sex workers are so marginalized, reporting on the sex workers can have a range
of accuracy. By destigmatizing this group, agencies like UNFPA are better able to assess and address the needs of sex workers.

In places where sex work is criminalized, police have used condoms as evidence of sex work. To avoid arrest, some sex workers have
engaged in unprotected sex with clients, increasing their risk of HIV infection. COVID-19 lockdowns and restrictions have made in-
person sex work more difficult or impossible. This has made sex workers more dependent on the clients they do have, decreasing sex
workers’ ability to set boundaries. One sex worker told UNFPA, “Female sex workers have not been able to negotiate terms for sex
because they are afraid of losing clients, but have engaged in sex without condoms just to have money.”  These are just some
factors that put sex workers at higher risk for HIV. 

Sex Workers Face Extreme Discrimination

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Advocates prepare to deliver essential supplies to LGBTQI people, like Alina, in need.
Image courtesy of Kyrgyz Indigo.

Sex workers also need food, shelter, and safety, just like everyone else. But stigma and lost income has left some sex workers
homeless, hungry, and vulnerable to violence. In Kyrgyzstan, Alina‘s family rejected her because she is a transgender woman. She
became a sex worker after jobs rejected her because her identity did not match her legal documents.

Now that Alina’s community is under lockdown, she and other sex workers have no income. She cannot get groceries, pay rent, or
afford health care, including testing for COVID-19. She is unable to isolate safely, which increases her risk of catching and spreading
COVID-19. UNFPA is working with Kyrgyz Indigo, an LGBTQI+ organization, to support Kyrgyzstan’s queer community. This includes
providing groceries and medicines, like antiretrovirals for those living with HIV and hormone therapy for transgender people. UNFPA is
also working to train health care staff on non-discrimination. Every person has a right to health care without fearing poor treatment
by those who have power over their health. 

The Impact of COVID-19 on Sex Workers

A health worker prepares a vial of blood for an HIV test. HIV
services are essential for key populations. © UNFPA Panama/Luis
García

The COVID-19 pandemic has been particularly difficult for people whose only income is sex work. Hamida in Nigeria was only 12 years
old when her family married her to a man in his 30s. Hamida endured unimaginable trauma from her child marriage as well as an
early pregnancy. As she said, “When we got married, he tried to sleep with me. It was so painful, I fainted. In the third year of our
marriage, I gave birth to a baby.” Hamida escaped her abusive husband and became a sex worker to support herself and her
daughter.

Now, she faces daily harassment and stigma, saying, “Sometimes I pray for death so that at least my children won’t be picked on
anymore.” The coronavirus pandemic has taken away Hamida’s only source of income. Now, she and her children are at even
greater risk for violence, sickness, homelessness, and hunger.

Hamida is not the only sex worker who has lost income because of coronavirus. Sex worker expert, Dr. Jill McCracken, says, “Covid-19
has taught us that people who are vulnerable are disproportionately affected by this disease… These challenges are only

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exacerbated for sex workers. Not only are they not able to make a living, but in most countries the governments do not acknowledge
their existence, their work, and their lack of access to resources–placing them in even more precarious circumstances. There have
been multiple calls internationally to try to provide sex workers with the resources they need to survive.” Available research suggests
that many sex workers are experiencing economic strain. Much more needs to be done to support these members of our
community.

What is Decriminalization of Sex Work?

Engaging sex workers and sex worker-led organizations is incredibly important for improving health outcomes for sex workers.
Unsplash/Vin Stratton

UNFPA works with a variety of stakeholders to meet the health needs of sex workers. These include health care workers, government
and community leaders, sex worker organizations, and sex workers themselves. By supporting communities as they create their own
solutions, UNFPA helps change attitudes and reach better health outcomes. For sex workers, this can mean greater access to food,
shelter, health care, and safety. It can also mean working toward the decriminalization of sex work. Dr. McCracken defines
decriminalization as the repeal of, “…all laws that criminalize adult consensual sex and related activities, including laws criminalizing
sex work; buying, soliciting, or procuring sex; brothel-keeping and management of sex work, loitering, and public nuisance that are
also used to target sex workers or clients. It does not repeal laws against trafficking, child sexual exploitation, or other forms of
violence.” 

This means that those who provide or access sexual services are not penalized or punished for their behavior. Instead, sex work is
treated like other work. In New Zealand, where sex work is decriminalized, sex workers are entitled to unemployment benefits when
situations like the COVID-19 pandemic arise. Dr. McCracken says that the biggest health issue that sex workers face are
criminalization and discrimination. She explains, “If prostitution were not criminalized, it would allow sex workers greater access to the
systems that provide safety and health care. Sex workers are more susceptible to violence because predators know their work is
illegal and target them. Criminalization increases impunity and the violence perpetuated against sex workers–most especially when
it occurs by people with power, like police officers. Sex workers have virtually no recourse and the criminal legal system, in addition to
criminalizing prostitution, is designed to stigmatize and further marginalize them.”

UNFPA’s Work

In 2019, UNFPA, UNAIDS, and UNDP wrote a memo to the Convention on the Elimination of all Forms of Discrimination Against Women
(CEDAW) on the trafficking of women and girls. The memo stated that decriminalization and engagement with sex worker
organizations has the ability to decrease new HIV infection by 33-46 % over the next decade. AIDS is the leading killer of women and
girls of reproductive age in the world and, according to the memo, the decriminalization of sex work is the largest single factor in HIV
reduction. Further, the memo notes that sex workers could be instrumental in the fight against trafficking, “if partnerships engaging
this community are developed and accepted.”

UNFPA provides lifesaving sexual and reproductive health care to every person, regardless of their occupation and circumstance. The
agency also works to increase sensitivity toward sex workers and engages sex worker organizations in their work.

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Dr. Jill McCracken is a Professor of English and Women’s and Gender Studies at the University of South Florida. She is also the Co-
Founder and Co-Director of Sex Workers Outreach Project (SWOP) Behind Bars, an organization that provides direct support for
incarcerated sex workers and victims of trafficking in US prisons and jails. She has been an invaluable resources in this article.

-Dana Kirkegaard

Dana Kirkegaard

YOUR SUPPORT HELPS UNFPA CARE FOR WOMEN AND GIRLS WHEN THEY NEED IT
MOST.

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Improving Laws and Policies
to Protect Sex Workers and
Promote Health and Wellbeing

From the Whitman-Walker Institute, the O’Neill Institute for National and Global Health Law, and HIPS

A REPORT ON CRIMINALIZATION OF SEX WORK
IN THE DISTRICT OF COLUMBIA

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | i

Table of Contents

Authors ii
Acknowledgments ii
Executive Summary iii
Introduction 1
Overlapping Crises 1
Background 3
A Source of Vulnerability 3
Theories of Criminalization 4
Current Legal Landscape 4
Timeline of DC’s Prostitution Policies 5
Research on Protecting Sex Workers and Promoting Health and Wellbeing 10
Research Methods 10
Results from Community Focus Groups 11
Motivations and Reasons for Engaging in Sex Work 11
Experiences of Engaging in Sex Work 15
Encounters with Police and the Criminal Justice System 18
Consequences of Arrest And Incarceration 25
Views on Reforming Sex Work Criminal Laws 28
Results from Institutional Stakeholder Interviews 32
Motivations for Individuals Engaging in Sex Work 32
The Police and Criminal Justice System 34
Health 41
Online-Based Sex Work 45
Policy and Legal Reform 45
Comparing Perspectives 48
Motivations of Sex Workers 48
Sex Work versus Trafficking 49
Need for Social Services 49
Laws Create Barriers 49
Support for Legal Reforms 49
Concerns about Legalization 50
Limitations of Vacatur and Diversion 50
Distrust of the MPD 50
Cultural Competency Training 50
Recommendations 51
Reforms That We Recommend 51
Reforms That We Do Not Recommend 51
Research Limitations 52
Appendix A: Community Participant Survey Data 54
Appendix B: Institutional Stakeholder Interview Participants 56
Appendix C: DC’s History of Sex Work Policing 57
Endnotes 59

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | ii

Authors

This report was authored by Sean Bland of the

O’Neill Institute of National and Global Health

Law and Benjamin Brooks of the Whitman-Walker

Institute. The research project was designed

by Sean Bland, with considerable input from

Jennafer Kwait at the Whitman-Walker Institute.

Acknowledgments

This report would not have been possible

without the generous contributions of time

made by our many community participants

and institutional stakeholders. A particular

note of thanks to Shareese Mone and the staff

of HIPS who facilitated focus groups and the

sex workers who participated in focus groups;

your vulnerability, and generosity made this

report happen. Special thanks to Alexander/a

Bradley and Tamika Spellmen of HIPS for their

contributions to this report.

We would like to thank the organizations and

individuals who were part of our institutional

stakeholders: Denise Hunter of Whitman-

Walker Health Legal Services, Brett Parson

and Kelly O’Meara from the Metropolitan Police

Department, Michael Kharfen from the DC

Department of Health, Nassim Moshiree of the

ACLU of Washington DC, David Grosso and

Darby Hickey of the Council of the District of

Columbia, Tina Frundt of Courtney’s House,

Yasmin Vafa of Rights for Girls, Michael Tobin

of the DC Government’s Office of Police

Complaints, and Yvette Butler and Stacie

Reimer of Amara Legal, and an anonymous

activist and educator.

Thanks to Jeffrey Crowley from the O’Neill

Institute. Thanks to staff across the Whitman-

Walker Health System for their contributions

of time and expertise. Particular thanks are

due to Jennafer Kwait and Guillaume Bagal who

conducted focus group interviews and assisted

with stakeholder interviews respectively; Daniel

Bruner who assisted with data analysis and

structuring this report, Blaine Smith who provided

support in analyzing the demographic data from

participants, and Bryan Blanchard who designed

and formatted this report for publication.

This work was supported by a generous grant

from the Elton John AIDS Foundation.

Sean Bland & Benjamin Brooks, Improving Laws and
Policies to Protect Sex Workers and Promote Health
and Wellbeing: A Report on Criminalization of Sex
Work in the District of Columbia, Whitman-Walker
institute, O’neill institute FOr natiOnal and GlObal
health laW, hips (2020), available at
bit.ly/DCSexWorkReforms.

Suggested Citation

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | iii

Executive Summary

The District of Columbia has made significant

investments in reducing violence and improving

community health. DC implemented violence

interruption programs and accountability

mechanisms, reformed policing and trained in

cultural competency, and increased access to

health insurance for vulnerable communities

of immigrants and homeless people. Despite

their continued prioritization, violence and

infectious disease continue to be major public

health challenges, especially for DC’s Black and

LGBTQ communities. There is considerable

evidence from public health researchers

that criminalization of sex work contributes

to community violence, propagates crime,

blocks access to public health resources, is an

ineffective deterrent to participation in sex work,

and is deeply harmful to sex workers.

Whitman-Walker Institute, the O’Neill Institute

for National and Global Health Law, and HIPS

collaborated on this research project and

report to examine the impact of laws and

policies on sex workers in DC and identify

recommendations for lawmakers and law

enforcement. Three focus groups with 27 sex

workers and individual interviews with 13 DC

institutional stakeholders were conducted in

2017. Focus group participants were almost all

Black transgender women and gay or bisexual

men. Community focus group participants and

individual institutional stakeholder interviewees

discussed the motivations and reasons people

have for engaging in sex work (including limited

options for housing and employment), priorities

for addressing the health needs of and violence

against sex workers, sex workers’ experiences

with police and the criminal justice system, the

consequences of arrest and incarceration in

connection with sex work, and needed legal and

policy reforms in DC.

This research found that

• Legal and policy reforms are needed to

improve the health and wellbeing for sex

workers.

• DC prostitution laws are not successful

at stopping sex work because people rely

on sex work for survival and for access to

money, housing, and other necessities.

• Harassment, violence, and coercion by

the police and others in the community

against sex workers are facilitated – indeed,

encouraged – because sex workers are

criminalized.

• Sex work is different from trafficking, but

criminalization of sex work allows exploiters

to use the threat of arrest to control and

traffic their victims.

• DC laws stigmatize sex workers, and

stigma creates barriers to accessing HIV

care and prevention, regular medical care,

community programs, and other services.

These barriers act to trap sex workers in

cycles of poverty and homelessness.

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | iv

The quotes below are illustrative of the data

captured from community focus groups and

institutional stakeholder interviews:
The findings point to four policy

actions that can yield significant

improvements in health and

wellbeing:

1. Reform the criminal code of the
District of Columbia to eliminate
criminal consensual commercial
sexual exchange between adults.

2. Increase access to affordable
housing.

3. Expand resources for job
training and employment
programs.

4. Strengthen efforts to address
discrimination against lesbian,
gay, bisexual, transgender, and
queer (LGBTQ) people.

“It’s a real challenge, I think,
for people in the sex trade to be
able to report any instances of
violence.”
– Yasmin Vafa, Executive Director, Rights4Girls

“The impact of arrests is
you lose everything…. Like
but when I came home I lost
everything—family, money,
whatever clothes I had. I had
to start all over.”

“It’s survival to me. That’s what
makes me want to do sex work
because I don’t like asking
people for money.”

QUOTES FROM COMMUNITY FOCUS GROUPS:

“You get caught in this cycle and
it prevents you from being able
to access health care. It prevents
you from being able to access
a job. And so, you are both
stigmatized but you are also left
in a position where you don’t
have the tools to get yourself
out”
– Nassim Moshiree, Policy Director, ACLU of DC

QUOTES FROM INSTITUTIONAL STAKEHOLDERS:

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 1

Introduction

This report was prompted by a need to

understand how Washington, DC’s laws and

policies governing prostitution and solicitation

impact the health of marginalized communities.1

This report is informed by the results of the

community-based research conducted by the

Alliance for a Safe and Diverse DC in 20082 and

the DC Trans Coalition in 2015.3 The earlier

work addressed the lack of research on the

impact of policing and criminalization of sex

work on sex workers and transgender women

stereotyped as sex workers.4 These community-

based research projects identified that the laws

on prostitution in DC create barriers to HIV

prevention and care for transgender women and

gay and bisexual men, and contribute to violence

and discrimination against sex workers and

those stereotyped as sex workers.

This report places significant focus on the laws,

policies, and practices in DC and is intended to

inform policy makers. The research explores

the mechanisms of criminal laws and police

enforcement practices identified by earlier work.

The DC Council and the Metropolitan Police

Department (MPD) are identified as active policy

makers, and our recommendations focus on

policy changes in DC and within MPD that can

improve the health and safety of sex workers.

The report identifies how the government

can actively promote better health outcomes,

in particular through reducing violence and

reducing HIV infection for Black transgender

women and gay and bisexual men who engage in

sex work.5

OVERLAPPING CRISES

The District of Columbia is home to vibrant

lesbian, gay, bisexual, transgender, and queer

(LGBTQ) and Black communities, containing

disproportionate numbers of each due to

the District’s history and reputation as a

haven of civil rights for marginalized people. 6

Unfortunately, LGBTQ and Black communities

in D.C. are experiencing twin crises of violence

and HIV, and Black LGBTQ people are most

impacted. Bias motivated crimes are on the rise

in DC, and most of these crimes are targeted

at LGBTQ and Black people (see table on this

page).7 Young, Black gay and bisexual men

accounted for 42% of new cases of HIV among

young gay and bisexual men in the United States

in 2018.8 A 2015 needs assessment conducted

by the DC Trans Coalition sheds light on the

impact of HIV and violence on the lives of

transgender women in DC. Compared to 2.5%

of the general population of DC residents, 20%

of transgender respondents reported living with

HIV, and 43% of transgender respondents who

had engaged in sex work reported living with

HIV.9 Rates of HIV acquisition are higher for

transgender women who engage in sex work

compared to those who do not. While nearly one

third of transgender women in DC report having

HIV, almost three quarters of transgender

Motivations and Numbers of Hate
Crimes in Washington, DC in 2018

Sexual Orientation 61

Race 39

Ethnicity 36

Gender Identity 33

Religion 25

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 2

LEADING WITH RACE

Improving laws and policies for sex workers is a matter of racial justice. Nearly all of the sex workers
who participated in this project identified as Black. Due to social and economic factors in addition to
discrimination in the criminal justice system and other areas, Black people are vastly overrepresented
in the sex work population and often face arrest and incarceration. While Black people account for 13%
of the population in the United States, nearly 40% of adults and 60% of youth arrested for prostitution
in 2015 were Black. Black women, especially Black transgender women, are more likely to engage in sex
work and to be arrested and incarcerated for sex work-related offenses. In the United States, 28% of
Black transgender people who responded to the 2015 U.S. Transgender Survey (USTS) participated in
sex work in their lifetimes, compared to 20% of all transgender people in the USTS sample, and Black
transgender women represented a disproportionately high percentage of those who participated in sex
work. In comparison, 1% of cisgender women in the United States report engaging in sex work. In the
District of Columbia, transgender people have even higher rates of sex work participation with greater
racial disparities. Over one third of respondents to the 2015 DC Trans Needs Assessment reported
engaging in sex work in the past, and transgender women and transgender people of color were more
likely to have a history of sex work than other transgender people. Notably, over half of Black and
Hispanic transgender people had a history of sex work, compared to 12% of White transgender people.

Policing and criminalization of sex work are ways in which Black people are subjected of racial profiling,
police violence, and mass incarceration. Black transgender women are particularly vulnerable. It is critical
that we address the root causes of vulnerability. To do so, we must listen to Black people and place the
experiences and needs of Black transgender women at the center of conversations about legal and
policy reforms for sex workers. This requires recognizing the importance of decriminalizing sex work
as well as acknowledging that any interaction with police is not desirable for most sex workers who are
Black given histories of mistreatment by law enforcement. Beyond criminal justice issues, access to
housing, employment, education, and health care are also important to Black people and other people of
color who engage in sex work. Policy action is needed to address various forms of structural racism and
oppression that sex workers experience.

Sources:
(1) Federal Bureau of Investigation, Arrests by Race and Ethnicity, CRIME IN THE UNITED STATES tbl. 43 (2015),
https://ucr.fbi.gov/crime-in-the-u.s/2015/crime-in-the-u.s.-2015/tables/table-43.
(2) Sandy E. James et.al., The Report of the 2015 U.S. Transgender Survey, NAT’L CTR. FOR TRANSGENDER
EQUAL. (Dec. 2016), https://www.transequality.org/sites/default/files/docs/USTS-Full-Report-FINAL.PDF.
(3) Elijah A. Edelman et al., Access Denied: Washington, DC Trans Needs Assessment Report, DC TRANS COAL.
(Nov. 2015), https://dctranscoalition.files.wordpress.com/2015/11/dctc-access-denied-final.pdf.
(4) Prostitutes’ Education Network, Prostitution in the United States – The Statistics (2007).

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 3

people with a history of sex work in DC report

having HIV.10 Meanwhile, nationwide, only about

3% of transgender people at high risk for HIV

infection are taking pre-exposure prophylaxis

(PrEP), a pill that, when taken as prescribed,

reduces transmission of HIV by more than 96%.11

While data collection and reporting on

transgender communities are incomplete,

conservative calculations from 2015 estimate

that the murder rate for transgender women is

4.3 times higher than the murder rate for women

in the general population.12 Recent research on

the impact of structural interventions on public

health indicates that decriminalization of sex

work has the potential to reduce violence and

significantly lower rates of HIV transmission. 13

Gay and bisexual men and transgender

people disproportionately engage in sex work

due to employment discrimination.14 To get

a measure of the extent of anti-trans bias

in hiring, the DC Office of Human Rights

conducted a resume study and found that,

48% of the time, DC employers prefer a less-

qualified cisgender applicant over a more-

qualified transgender applicant. 15

This research finds that the violence and

disease in DC’s Black and LGBTQ communities

are attributable to the vulnerability that arises

from stigma and bias. A review of the literature

finds that an international community of public

health researchers and practitioners believe

that efforts to combat violence and disease are

more effective when they address the underlying

structural forces that contribute to stigma and

bias, forces which disproportionately affect

people in marginalized communities.

Background

A SOURCE OF VULNERABILITY

The growing international consensus is that

the criminalization of sex work erects barriers

to health, limits access to legal systems,

stigmatizes, and exacerbates racial disparities.

The United Nations’ Human Rights Council16,

Amnesty International17, the Global Alliance

Against Trafficking in Women18, Freedom

Network19, and Human Rights Watch20 critique

the criminalization of sex work from a human

rights perspective. Sex workers are unable to

access the protective features of legal systems

because of their participation in criminalized

work. A human rights analysis reveals that

criminalization submits sex workers to a paradox

by creating violent social conditions and cutting

off access to resources to ameliorate that

violence.21

The World Health Organization22, UNAIDS23,

the UN Special Rapporteur on the Right to

Health24 identify that the criminalization of sex

work propagates stigmatizing messages about

sex work. Stigmatization of sex work, LGBTQ

people, and people living with HIV directly

contribute to elevated rates of HIV transmission

in priority populations.25

The Black Lives Matter26 movement, in addition

to the international organizations listed above,

critiques criminal laws around sex work as

discriminatory against marginalized groups.

Laws criminalizing sex work have resulted in

the disproportionate incarceration of Black and

Brown people, immigrants, and LGBTQ people.27

Arrest, incarceration, and criminal records are

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 4

additional burdens for members of communities

that already experience discrimination in

employment, housing, education, and health care.

This research focuses on the experiences

of community participants as sex workers,

but their identities and relationships are

multifaceted and complex. Sex workers are

parents, children, spouses, renters, friends,

and taxpayers. The human rights approach

critiques criminalization of sex work as isolating

sex workers by criminalizing the economic

transactions that go along with it, including

paying rent, a driver, a security guard, or a

babysitter. 28 The human rights community and

the public health literature recognize that an

approach to reform that allows sex workers

to organize and advocate collectively is more

effective. Research on collectivists projects

find that they are safer and healthier; reporting

increased condom usage and reductions in

client and third-party violence.29

THEORIES OF CRIMINALIZATION

Sex work is criminalized under a theory that the

criminal and social consequences of operating

in the sex trades will prevent and deter people

from engaging in sex work. Some policy makers

justify these laws with moral or religious beliefs

that condemn sex work as inherently immoral

or the belief that sex work is so exploitative of

women that no woman would freely choose

to engage in it.30 Other justifications are that

sex work is associated with organized crime,

gambling, and illicit drugs and is socially

undesirable in its own right or because it

“spreads” disease and crime.31 Some believe

that sex work must be criminalized because law

enforcement needs to arrest sex workers to stop

human trafficking, or that all sex work is coerced

and therefore sex work is indistinguishable from

sex trafficking.32

CURRENT LEGAL LANDSCAPE

States and cities have the power to legislate

around sex work. Sex work is criminalized

throughout much of the United States. Aside

from a few counties in Nevada, selling or

buying sexual services in the United States is

a criminal offense that results in fines and jail

time. Other states laws adopt “prostitution”

and “solicitation” prohibitions to limit exposure

to negative externalities of sex work like public

visibility of sex workers or their clients. 33

Local Laws and Advocacy Efforts

The District of Columbia currently criminalizes

engaging in or soliciting prostitution.

Washington, DC imposes penalties ranging from

a maximum fine of $500 and 1 to 90 days in jail

for a first offense, to a fine of $1,000 and 1 to 180

days of imprisonment for the third offense.34

Acts and behaviors that are criminalized under

the District’s prostitution laws are found in DC

Code §§ 22-2701 – 22-273. Criminalized acts

include the following:

• Prostitution, defined as performing a sexual

act or contact with another person in return

for giving or receiving anything of value;

• Soliciting for prostitution;

• Arranging for prostitution, pandering,

or procuring;

• Operating or keeping a “house of prostitution”

or a “disorderly or bawdy house”; and

• Coercive, non-consensual activities and

activities involving minors.

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 5

TIMELINE OF DC’S PROSTITUTION POLICIES

Note: See Appendix A for a narrative of this historical timeline with greater details

DC’s prostitution laws and policies have changed throughout the years, often following cultural

shifts and sustained advocacy.

Congress passed
legislation to define and

prohibit pandering in
the District.

Congress criminalized
solicitation for prostitution

in the District.

DC Council passed laws
restricting freedom of

movement and empowering
MPD to stop, search, and arrest
people suspected of sex work.

Street signs were installed
in the District to prohibit

right turns at certain
times and intersections
to prevent clients from

circling blocks where sex
workers gathered.

Congress passed legislation
to restrict “houses of

lewdness, assignation and
prostitution” in the District.

MPD forcibly removed sex
workers from downtown DC

to Virginia.

DC Council passed a 90-
day bill criminalizing people

for wearing revealing
clothing and for repeatedly
engaging in conversation

with passersby for the
purpose of prostitution.

1910 1935 1990s Late
1990s1914 1989 1998

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 6

Note: See Appendix A for a narrative of this historical timeline with greater details

Mayor Muriel Bowser convened a Working Group to explore
potential diversion programs for sex workers.

MPD data revealed significant racial disparities in policing
practices, specifically finding that MPD stopped Black

people in excess of their demographic make-up by 14%-39%,
depending on the outcome and type of police encounter

The Human Trafficking and
Narcotics Unit of MPD conducted

extensive enforcement operations,
resulting in over 200 arrests for

solicitation and prostitution.

DC Council passed legislation to suppress
sex work, including laws declaring indoor sex
work a nuisance, impounding vehicles used in
furtherance of a prostitution-related offense,

and empowering the police chief to create
“prostitution free zones” (PFZs).

Human Rights Watch
published a report on

MPD officers’ interactions
with sex workers, and in

response, MPD launched a
public education campaign

for its officers.

DC Council
repealed PFZs.Sex workers and

communities of transgender
people organized the

Alliance for a Safe and
Diverse DC. DC Council passed

the Neighborhood
Engagement Achieves

Results (NEAR) Act.
Alliance for a Safe and

Diverse DC organized to
challenge MPD policies

and secure support
from District officials

and organizations.

201920152006 2012 20142005 20162007-
2008

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 7

Neither sexual activities involving coercion nor

minors are the subject of this research.

Presently and in this report, MPD characterizes

its enforcement tactics as consisting of

two actions: responding to requests of

neighborhood residents complaining about the

presence of sex workers around the District35

and sporadic sting operations targeting

street and hotel-based sex workers. MPD

sting operations have come under scrutiny.

Investigative reports find that undercover

operations fail to arrest traffickers and subject

sex workers to sexual contact by officers,

tactics which are unnecessary to meet the

legal standard for arrest.36 There have been

reports of MPD officer misconduct and reports

of harassment, extortion, and assault of sex

workers by law enforcement officers in the

District and surrounding jurisdictions.37

Advocacy and education by the DecrimNow

DC campaign built around the efforts to

pass a decriminalization bill, the Reducing

Criminalization to Promote Public Safety and

Health Amendment Act of 2017 during the 22nd

legislative session and the Community Safety

and Health Amendment Act of 2019 during the

23rd legislative session. The 2019 bill would

decriminalize consensual commercial sexual

exchange involving adults, repeal portions of

the criminal code criminalizing places of sex

work, and heighten the standard for consent

for cooperation between sex workers.38 The

advocacy around this effort resulted in a 14-hour

Judiciary Committee hearing in October 2019.

HIPS and Whitman-Walker are supporters of this

campaign and testified in favor of the bill during

a 2019 committee hearing.

Source: Screen Capture, The Community Safety and Health Amendment Act of 2019: Hearing on Bill 23-0318,
Council of the District of Columbia (October 17. 2019) (Forefront from left: HIPS Staff members, T. Spellman,
A. Bradley, J. Martinez, testify in support of the bill and billionaire S. Hunt testifies against the bill while council
members and staff look on), http://dc.granicus.com/ViewPublisher.php?view_id=44.

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 8

Additional calls for reform came from the Black

Lives Matter protests sparked by the death

of George Floyd on May 25, 2020. Ongoing,

nationwide protests against police violence

reached a crescendo in the summer of 2020.

In DC, protests called for decreasing the MPD

budget, greater police accountability, and

greater investments in community supports.

In response to advocacy and activism in DC,

the DC Council introduced the Comprehensive

Policing and Justice Reform Amendment Act

of 2020 on July 31, 2020.39 The legislation

is primarily a series of reforms to increase

transparency and accountability around use of

force by police. The bill would introduce reforms

to MPD hiring and training practices, enhance

access to the vote for people in prisons and jails,

and repeal a DC law that criminalized an officer

for neglecting to make an arrest when a crime

is committed in their presence. It is unclear

whether these reforms will pass the Council

or how much or how quickly these reforms

would affect MPD practices and the material

conditions of DC’s sex worker and transgender

communities. While Chief of Police Peter

Newsham has characterized the MPD as being

engaged in reform for the past two decades,40

there appears to be resistance to the new

reforms from within the MPD. For example, on

August 10, 2020, the DC police union, which

represents the approximately 3,600 MPD

officers, filed a lawsuit seeking to block the

release of body-camera footage.41

Federal Laws

The federal government’s powers are restricted

by constitutional limits. The federal government

has passed laws targeting criminal enterprises

that cross state lines under the power of the

Commerce Clause.42 Recent federal laws include

the Trafficking Victims Protection Act of 2000,

which provides additional tools for investigating

and prosecuting human traffickers,43 and

the Fight Online Sex Trafficking Act and Stop

Enabling Sex Traffickers Act (FOSTA-SESTA),

which allows website owners to be held liable for

transactional sex facilitated on their websites.44

Even before FOSTA-SESTA was enacted, the

federal government took numerous actions

to shut down websites used by sex workers,

including MyRedbook.com in 2014, Rentboy.

com in 2015, and Backpage.com in 2018. Fear

of increased liability from FOSTA-SESTA and

federal enforcement caused Craigslist, Google,

and others to remove portions of their sites most

often used by sex workers.45 FOSTA-SESTA

is criticized for making sex work less safe by

curtailing the ability to negotiate and screen

clients beforehand.46

At the time of publication of this report,

Congress is considering another bill aimed

at regulating content on the internet, the

Eliminating Abusive and Rampant Neglect of

Interactive Technologies Act of 2020 (EARN

IT).47 Like FOSTA-SESTA, EARN IT proposes

to expand criminal and civil liabilities for

internet services based on user-generated

content.48 The bill has received criticism from

supporters of internet freedom for enlisting

private companies to proactively search and

censor their content, which restricts speech

without recourse or appeal.49 The EARN IT Act,

if passed, is likely to make it more for difficult

to sex workers to operate in online spaces,

exacerbating many of the harms of FOSTA-

SESTA (see Text Box).

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 9

FOSTA-SESTA HARMS SEX WORKERS

The Allow States and Victims to Fight Online Sex Trafficking Act (FOSTA) and the Stop Enabling Sex
Traffickers Act (SESTA), known together as FOSTA-SESTA, became federal law on April 11, 2018. While
FOSTA-SESTA ostensibly focuses on curbing sex trafficking on online platforms, there is little evidence
that the law has actually reduced sex trafficking, even as it has vastly expanded liability for all online
platforms, including those that host content related to consensual sex work. Not only does FOSTA-
SESTA allow law enforcement to pursue civil penalties against online platforms for “knowingly assisting,
facilitating, or supporting sex trafficking,” but it also penalizes online platforms that “promote or facilitate
prostitution.” As a result of this overbroad and unclearly written language, online platforms that host
advertisements for sex workers, such as CityVibe, shut down, and websites such as Google and Craigslist
eliminated large portions of their platforms that they feared could be in violation of the new law. In
consequence, sex workers who used those platforms have been negatively impacted.

A major effect of FOSTA-SESTA is its elimination of a safety mechanism that sex workers greatly relied
on, namely their ability to review and screen clients before in-person meetings. Research indicates
that online platforms that allow sex workers to advertise, vet, and choose clients create safer work
environments. Some online platforms even provided the opportunity for sex workers to screen clients
for safety via peer references or “bad-date lists,” but these lists were mostly deleted because they could
expose online platforms to civil liability under FOSTA-SESTA. With at least parts of online platforms
shuttering due to FOSTA-SESTA, sex workers have been forced to find clients on the street, where they
have fewer advance safety precautions in place and are more susceptible to violence. A study from Call
Off Your Old Tired Ethics (COYOTE) found that following the passage of FOSTA-SESTA, sex workers
reported a 28% drop in screening clients and reported taking more risks to access clients.

Additionally, FOSTA-SESTA has jeopardized the livelihood and financial security of sex workers. Online
platforms offered a sense of stability and predictability in terms of financial income, but after FOSTA-
SESTA was passed, respondents in one study of sex workers noted that their main source of income had
now become more unstable. Some respondents in that study stated that they are now “always barely
scraping by” or are now “…homeless and can’t pay the bills.”

Lastly, the implementation of FOSTA-SESTA has had a significant impact on the mental health and
wellbeing of sex workers, mainly because of the law’s disruption of the online community and ability to
connect with others. Online platforms are spaces to share resources and build community, but the new
law has prevented sex workers from accessing these spaces and has contributed to increased fear and
anxiety among sex workers.

Sources:
(1) Pub. L. No. 115-164, 132 Stat. 1253 (2018) (codified as amended at 18 U.S.C. §§ 1591, 1595, 2421A and 47 U.S.C. §
230).
(2) Aja Romano, A new law intended to curb sex trafficking threatens the future of the internet as we know it, VOX (July
2, 2018, 1:08 pm EDT), https://www.vox.com/culture/2018/4/13/17172762/fosta-sesta-backpage-230-internet-
freedom.
(3) Danielle Blunt, Ariel Wolf & Naomi Lauren, Erased: The Impact of FOSTA-SESTA, hackinG//hustlinG 1, 20, https://
hackinghustling.org/wp-content/uploads/2020/01/HackingHustling-Erased.pdf (last visited Oct. 11, 2020).
(4) Noah Berlatsky, Female homicide rate dropped after Craigslist launched its erotic services platform,
THINKPROGRESS, (Oct. 20, 2017, 1:19 pm EDT), https://thinkprogress.org/craigslist-erotic-services-platform-
3eab46092717/.
(5) COYOTE-RI Impact Survey Results 2018, SWOP-SEATTLE 1, 17, http://www.swop-seattle.org/wp-content/
uploads/2018/11/COYOTE-Survey-Results-2018.pdf (last visited Oct. 15, 2020).
(6) D Blunt & A Wolf, Erased: The impact of FOSTA-SESTA and the removal of Backpage on sex-workers,14 anti-
traFFickinG revieW 117, 118-19 (2020), https://doi.org/10.14197/atr.201220148.

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 10

Research on Protecting Sex
Workers and Promoting
Health and Wellbeing

RESEARCH METHODS

In December 2016, the O’Neill Institute,

Whitman-Walker, and HIPS received a grant

from the Elton John AIDS Foundation for

this research project. The research project

consisted of three focus groups with a total of

27 individuals, at least 18 years old, who had

engaged in commercial sex work (exchanged sex

for money or some other type of compensation)

within the past two years, and individual

interviews with 13 institutional stakeholders

– DC police officials, other DC public officials,

lawyers who represent sex workers in criminal

proceedings, immigration attorneys, social

service providers, and community activists

who work with sex workers and sex trafficking

victims. All research forms and protocols

were approved by Georgetown University’s

Institutional Review Board (IRB), and all

individuals involved in the facilitation of focus

groups, interviews of institutional stakeholders,

or review or analysis of data completed

Georgetown University’s human subjects

research training.

Focus Groups with Community
Participants
Two focus groups of individuals who disclosed

that they had engaged in commercial sex work

within the past two years were held at HIPS

offices in Northeast DC on September 11 and

September 25, 2017. Focus group participants

were recruited by HIPS by word of mouth

and venue-based recruitment at HIPS and

Whitman-Walker’s health centers. A third focus

group was held at Whitman-Walker’s health

center in Northwest DC on December 19,

2017; participants in that group were recruited

by Whitman-Walker. A total of 27 individuals

participated in the focus groups. Participants

received lunch and each participant received

$50 in the form of a gift card at the end of the

focus group. Individuals could participate in

only one focus group. All three groups were

facilitated by a Whitman-Walker researcher

trained in qualitative research methodologies,

with the assistance of staff from HIPS and

the O’Neill Institute, following the written IRB-

approved focus group protocol.

Prior to the commencement of each focus

group, participants received written and oral

explanations of the study and of their rights, and

each participant signed a consent form. Each

participant then met separately, in a private

setting, with a researcher, who asked IRB-

approved survey questions to the participant

and recorded the participant’s answers on a

standardized form. The survey included questions

about demographic characteristics, experience

with sex work, history of arrest and incarceration,

HIV and sexually transmitted infections (STIs), and

access to health care. Appendix A contains a table

of community focus group participant responses

to survey questions. Participants’ names were

not recorded on the surveys, and during the

focus groups, participants were advised to avoid

referring to other participants, or others engaged

in sex work, by name. Focus group discussions

were taped, and the recordings were transcribed.

The transcriptions were reviewed and the very

few references to an individual participant’s name

were redacted. Formal focus group sessions

lasted between one and one-half hours and two

and a quarter hours.

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 11

Individual Interviews with Institutional
Stakeholders

Institutional stakeholders were recruited jointly

by Whitman-Walker, O’Neill Institute, and HIPS

staff, with the aim of ensuring perspectives

from across DC government, human services,

and legal and public health officials. Individuals

who agreed to interviews included; two officials

of the DC Metropolitan Police Department

(interviewed jointly at their request); officials

of the DC Department of Health and the DC

Office of Police Complaints; an elected Member

of the Council of the District of Columbia and a

member of his staff; an immigration attorney at

Whitman-Walker and two attorneys at a nonprofit

that represents sex workers in criminal and

other cases; an attorney with the ACLU-DC; a

community transgender activist; and two service

providers and advocates for youth and victims of

sex trafficking. Appendix B lists all interviewees.

Interviews were conducted in person and lasted

approximately one to one and one-half hours.

Interviews were taped, and the recordings were

transcribed. Institutional stakeholder affiliations

are listed for context only and their comments

do not necessarily represent the beliefs or policy

positions of the entities listed. While some of the

institutional stakeholders have changed roles,

they are identified in this report by their role at

the time the research was conducted.

Results from Community
Focus Groups

The focus groups with members of the sex

worker community consisted of a discussion

of the following topic areas: (1) motivations and

reasons for engaging in sex work, (2) experiences

of engaging in sex work, (3) experiences with

police and the criminal justice system, (4)

consequences of arrest and incarceration, and

(5) views on reforming sex work criminal laws.

The following section discusses the major focus

group findings in each of these topic areas.

Results from the focus group participant survey

are included to provide a more comprehensive

portrait of the topic areas and to supplement the

focus group findings.

Participants ranged in age from 20 to 55 years

old, with a majority in their 20s and 30s. All but

one of the participants identified as Black. Two-

thirds of participants were transgender women

who identified as a range of sexual orientations,

and 30% identified were cisgender men, all

of whom identified as gay or bisexual. One

participant was a bisexual, cisgender woman.

MOTIVATIONS AND REASONS FOR
ENGAGING IN SEX WORK

Community participants noted various reasons

for engaging in sex work. The most commonly

reported reason for engaging in sex work was

the motivation to earn a livelihood. All but one

participant mentioned the need for money. A

majority of participants (60%) reported that

substance use was tied to their motivation for

engaging in sex work. Specifically, sex work

was a way to earn money to buy drugs. Many

participants discussed their struggles with

substance use and addiction, suggesting that

these sex workers could benefit from behavioral

health services. Substance use may also be a

way of coping with stress and discrimination,

including in the context of sex work. One

participant said, “I may have been at this time

active in my drug addiction. Due to housing,

due to stigma, due to all this, I’m doing the only

thing I know how to cope with.”

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 12

SUMMARY OF FOCUS GROUP RESULTS

As the District considers efforts to improve the health and wellbeing of sex workers, it is important
to heed the voices experiences and recommendations of sex workers. The following themes
emerged from focus groups with community participants who engaged in sex work in the District:

1. Motivations and reasons for engaging in sex work: Community participants stated that
they engaged in sex work to make a living, earn money to buy drugs (noting struggles with
substance use and addition and a need for behavioral health services), and access to housing
and food. Participants, especially those who identified as transgender, faced significant
socioeconomic challenges. While participants had many barriers to housing and employment,
they emphasized their own agency in sex work and viewed sex work as survival.

2. Experiences of engaging in sex work: Community participants noted their desire to protect
their overall health and wellbeing while engaging in sex work. While participants recognized
that sex work places them at risk for contracting HIV and STIs, participants encountered
barriers to effective HIV prevention. Participants living with HIV reported health and mental
health challenges, including stress due to their HIV status and problems with storing and
taking HIV medications. Transgender participants discussed their needs for accessing gender-
affirming health care without stigma and discrimination. The majority of participants reported
experiencing physical or sexual abuse from sex work clients.

3. Encounters with police and the criminal justice system: An overwhelming number of
community participants had negative encounters with police in DC. Officers were reported
to have often mistreated, profiled, and harassed transgender sex workers and physically
and sexually abused sex workers either during arrests or actual client interactions with
officers. Because of mistreatment, sting operations, and officers’ lack of cultural competency,
participants had a strong mistrust of law enforcement. Participants noted that they were
unwilling to call the police when they were victims of crimes because they feared arrest,
worried about being harassed, or just did not think the police would do anything.

4. Consequences of arrest and incarceration: Most community participants reported a history
of incarceration. Arrests and criminal convictions have negatively impacted their lives. When
arrested, community participants were often charged with prostitution or solicitation. Other
common reasons for arrest while engaging in sex work included drug crimes, failure to obey
an officer, and disorderly conduct. The reported negative effects of arrest and incarceration
included reduced access to health care and medication while imprisoned, worse health and
wellbeing, economic instability, housing insecurity, and lack of social support from family
members and community networks.

5. Views on reforming sex work criminal laws: There was a strong consensus that the current
criminalization model regarding sex work was unacceptable. Full decriminalization was favored
as an alternative to the current approach over the options of partial decriminalization and the
legalization of sex work.

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 13

Access to housing (41%) and food (37%) were

commonly cited by participants as reasons for

engaging in sex work. Participants situated

their reasons for engaging in sex work cited

in a larger context where structural factors

(such as socioeconomic status, housing,

and employment) and survival needs play a

significant role in their motivations.

Socioeconomic Status

Community participants faced significant

socioeconomic challenges in their lives. Nearly

three-fourths of our participants (74%) lived below

the federal poverty level ($12,060 annually in

2017), 70% reported unstable housing in the past

2 years, 59% had a high school diploma/General

Educational Development or less, and 85% had

a history of incarceration. Employment options

outside of sex work were limited. In the past two

years, the majority of participants (52%) earned all

or most of their income from sex work, and 70%

engaged in sex work at least once a week.

Housing and Employment

Barriers to housing and employment

contributed most strongly to participants’

low socioeconomic status. Participants often

said their inability to obtain housing or a job

resulted from anti-transgender discrimination.

One participant elaborated on gay, bisexual,

and transgender people not being afforded

educational opportunities that would put them

in a good position for housing and jobs:

“There are not a lot of [LGBT]
people who are in a place to get an
education to qualify for jobs like
yours or yours. But it goes back to
housing and not having food, and
not having this and not having that
because they are not afforded it.”

Participants repeatedly underscored that housing

was a critical issue for sex workers. Securing

housing was not only seen as a motivator for

engaging in sex work, but as a key approach for

better meeting the need of sex workers.

“Housing is very important. Once
you got a house, then everything
else will fall in place.”

“We need housing. Without housing,
we cannot take our pills, we
cannot make meetings, we cannot
have stability. Without housing,
everything is in an uproar.”

“It gets really emotional to talk
about housing. Because it’s a
constant struggle. Homelessness is
a constant struggle because there
is no curb to homelessness…. It’s a
constant struggle. And it gets more
and more emotional because you
are worried about it. You’re worried
about it.”

“I hope some change will come to
get us housing, not so drastic. It all
comes back to housing in the end.
Some housing if you get lucky… I
hope each individual gentleman
and girl in here, if they don’t have
housing have the opportunity to get
it, keep it. Because you don’t know
when you have the opportunity to
get it back. But I hope you have the
opportunity because it won’t stop
until you have some housing.”

Sex Work as Survival

While participants struggled with poverty and

having few options for work and housing, they

repeatedly emphasized their own agency in sex

work. None of the participants characterized

themselves as victims of trafficking. Instead of

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 14

victimhood, participants repeatedly mentioned

“survival” in connection with their sex work.

Survival meant different things to different

participants. For many participants, survival

meant engaging in sex work to cover basic

necessities and to avoid homelessness and

encounters with the police.

“Of course, like I said a lot of
times people just do that because
their back is up against the wall.
Somebody needs a quick dollar.”

“So this is survival and if I don’t
do this then I’m going to be in the
streets, where I gotta deal with the
police. And I’m still dealing with
everything as a whole.”

“Sex work to me has become a way
of life. It was first out of necessity
because I did it to help my family
and then it became something that I
got used to doing.”

At the same time, participants framed survival

in a positive manner. They denoted a sense of

power in their choice to engage in sex work. For

those participants, sex work was empowering

because they could take care of themselves and

did not have to rely on others.

“Taking this word ‘sex work’ that
ya’ll so badly beat up and turned
it in to such a dirty thing, that its
survival to us. Without that sex
work procedure, we don’t eat at
night or we don’t sleep at night, or
we cannot protect ourselves.”

“I was very proud of, because I think
that being a sex worker is very
honorable because you’ve giving
up yourself and you’re getting
money for it. You’re giving services.
This isn’t violence, I’m working for

people, and I’m getting my money
and providing a service. Survival.
It’s an honorable job. It’s a survival,

it’s for survival, I mean right.”

“It’s survival to me. That’s what
makes me want to do sex work
because I don’t like asking people
for money.”

“Sex work to me is survival. I am
doing it just to survive. It’s not
like I am doing it just to be the
hottest thing on the street. That’s
what we do to eat. Appearance,
transportation, everything that
[is] anything that revolves around
money. Even if we were to have help
from our parents, it’s us being how
we are. We would rather make it on
our own.”

Some participants found sex work to be an easy

and acceptable occupation. One sex worker

stated that sex work was a skill that they picked

up and honed. Sex work was also discussed

as a lifestyle or way of life and viewed as a

good option given their wants, aspirations, and

circumstances. Still others found sex work to be

difficult and changed their attitude over time as

they became either used to sex work or tired of it.

“To me sex work is its own career,
it is its own type of work, it is its
own job.”

“Sex work to me is survival and it’s a
skill, because to be honest I’m good
at it. It went from me graduating, life
hit me hard. As soon as I graduated
it was like boom you’re grown, what
you want to do. And I made the best
of it coming from two years ago to
where I’m at now. I can say that I
picked on quick.”

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 15

“A lot of people like it for the
lifestyle…. It’s a lifestyle you looking
for the attention, you looking for the
dollar, it has to be done in order to
meet your everyday needs or your
every month needs.”

“Sex work to me is a way of life,
it’s survival, but I feel like it’s
kind of overrated and sometimes
it’s draining, it’s physically,
mentally, and spiritually draining

sometimes.”

There were participants who discussed stopping

sex work, but how participants felt about

stopping varied enormously. A few participants

stated that they would stop engaging in sex

work if they found a suitable alternative job or

had housing. While discussing this topic, one

participant responded, “A job, a place to lay

my head, a therapist that is just not going to

sit there and write down what I’m saying but

is actually want to get inside my brain and not

judge me.” A transgender participant said,

“A place, and my surgeries and I’ll be out.”

However, not all participants shared this view.

For example, another transgender participant

said, “Nobody can really do anything to make

me stop. Even if I do get a house, a car, and all

that, I’m still going to do what I need to do to

make that extra money.”

EXPERIENCES OF ENGAGING IN
SEX WORK

Prior research has indicated different experiences

of stigma, violence, and criminalization between

sex workers who meet their clients on the street

and sex workers who meet their clients on the

internet. In the past two years, 85% of focus

group participants reported engaging in street-

based sex work, compared to 74% of participants

who reported engaging in internet-based sex

work. While most participants engaged in both

street-based and internet-based sex work, 26%

of participants only met clients on the street,

and 15% only met their partners on the internet.

Other places where participants reported meeting

clients included brothels or massage parlors (11%),

a bar (4%), and a bathhouse (4%). Regardless of

where participants met their clients, participants

commonly engaged in the transactional sex

either at a hotel (64%) or a private home (52%).

Participants also reported sex occurring in

brothels, massage parlors or bathhouses as well

as in a car or outside.

HIV and STIs

HIV and sexually transmitted infections (STIs)

are major health concerns for many sex workers.

Participants discussed their desire to protect

their sexual health, recognizing that sex work

places them at risk for contracting HIV and STIs.

Some participants noted that gay and bisexual

men and transgender women are heavily

impacted by HIV and STIs generally, but they

further discussed how sex work increased risk.

“HIV is a top priority. I’m negative
but I guess it’s easier to say than do
when you don’t have it because you
tend to push it as a back burner.”

“When it comes to HIV even though
I’m not positive, it ranks high for
me too. I think coming into contact
with people who are HIV positive
and seeing the physical struggles
that they go through and the mental
struggles that they go through, to
protect myself from that. It becomes
very high ranking. I used to not
really think about it, but now I do.”

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 16

“To me I would think that catching
STDs is, STIs, would be most
important to me. Because with sex
work and without sex work, there
is a lot of unprotected sex in the gay
community. And that is probably the
main thing on my mind after I finish
having sex with somebody or even
before I think about having sex. It
is the main thing that I’m thinking
about, is who doesn’t have it, if I’m
going to catch it, if I’m not going to
catch it.”

A number of participants noted the importance

of getting tested for HIV and STIs and discussing

their engagement in sex work with health care

providers. All eight participants who reported

not having HIV indicated that they had an HIV

test in the past year, but participants faced

barriers to effective HIV prevention. While

these participants reported that they had heard

of pre-exposure prophylaxis (PrEP), only two

of the eight participants reported using PrEP.

Among the two people who had used PrEP, one

said she was non-adherent (“I don’t really take

it”), and the other said she only used it after an

accident, i.e. condom break. Another barrier

to HIV prevention was that 30% of participants

reported not disclosing to health care providers

that they do sex work. One participant expressed

a reluctance to disclose this information because

of stigma and bias against sex work. Participants

described the stigma of being a sex worker as one

of multiple stigmas they experience, including

the stigma of being gay, bisexual, or transgender,

the stigma of being of person of color, the stigma

of being homeless, the stigma of being in jail or

prison, and the stigma of living which HIV, all of

which can have a negative effect on taking care of

their sexual health.

“I’m free when it comes to talking
about my health care with my
provider…. So I didn’t have any
problem with talking to them about
me being a sex worker. You know I
am frequently asked can I be tested
for STDs. So she asked if I am a sex
worker, I said yes. I don’t feel like I
should hide it. You are my medical
provider. Number one with me.”

“It basically makes you feel
reluctant to mention that you
actually do sex work. You might
want to say oh I do sex work, and
they look at you kind of funny
because of all the stigma and bias
are related to sex work. Like they
don’t want to help you or you’re too
much of risk to help you and certain
other things you have going on.
Like, oh, you might not be a good
fit because you are currently sex
working and things of that nature….
You may not go. You may not
mention that you do sex work.”

Difficulties in negotiating condom usage in

the context of sex work was also discussed.

Participants described that when clients offer

more money to not use condoms, sex workers

sometimes agree because they need the

money to survive. One participant elaborated

as follows: “Everybody don’t have to know if I

use condoms, or I don’t use condoms, I have

to make that rent money because if somebody

comes and says I have $500 for your rent today

and my rent is due, I‘m behind. I trust you’re

gonna remove that condom. We’re gonna make

this work. I’m going to pray to the gods that

I don’t catch nothing, but I need that five, ya

know what I’m saying, because this is survival.”

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 17

The majority of participants (70%) reported

having an HIV diagnosis. For those participants,

accessing HIV treatment and care was considered

one of their top health priorities. Participants

living with HIV said that HIV was stressful and

affected their physical, mental, and social

wellbeing. They emphasized the importance

of accessing health care, making medical

appointments, and adhering to HIV antiretroviral

therapy. One participant worried about having

a secure place to store HIV medication, noting

that sex workers who are unstably housed would

not be inclined to carry pills with them, but also

do not want to leave pills in a location where

they could be stolen. Another participant noted

that an arrest related to sex work can also result

in medication disruption because they did not

receive the medication they needed and asked for

in the DC jail.

“I think probably the most
important health care would be
most likely be like HIV health care
and receiving AIDS care. Being able
to have access to people so you can
go and get them.”

“It’s the highest rank for me because
it’s stressful. It’s just stressful. You
can’t have a normal relationship, you
have to be very healthful because
your immune system is so affected
by it. It is just a lot. That is the most
stressful thing.”

“Make sure you take your meds
everyday if you’re HIV positive, or
um just get regular checks with your
doctor because you never know. You
could be walking around with an STI

and you probably won’t know it.”

“Speaking for me, when I am
homeless, the last thing on my mind
is taking my HIV pills. The first
thing on my mind is where I am
going to lay my head. Then how long
I can lay my head there. Can I leave
my HIV pills there and not come
back and they be gone…. And if you
are not one pill [a] day like me, thank
God. Then if you got seven packs
of pills, you’re not going to carry
them in your purse and they start
jiggling.”

“Every time you go through DC
Court jail system you already know
what’s about to be there….You ask
for some medicine, they don’t have
no medicine.”

Occupational Violence

Participants talked about the dangers and

risks they faced while engaging in sex work.

The majority of participants (56%) reported

experiencing physical or sexual abuse from

clients in the past two years.

“A lot comes from sex work. You get

beat up, you get robbed, you get cut.”

“I can’t tell you how many times I’ve
been in rooms and in different states
with girls and had a gun pulled on

me.”

“Last year I was shot and I almost
died. I was on [deleted] Avenue
prostituting.”

The violence that participants experienced

during sex work also stemmed from people who

were not their clients. In addition to violence

from police officers discussed in the next

section, participants reported violence from

other third parties. Violence from third parties

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 18

such as strangers in the area was an issue that

rendered street-based sex workers particularly

vulnerable.

“I was on [deleted] street and some
boys came out on [deleted] street
with paintball guns and they were

shooting girls on the stroll.”

“That time when [someone] got hit
by a car. You know when you’re
coming from [deleted] Avenue and
the lower ledge that everybody be
at, and the lower fence that’s right
there. Out of nowhere, we were just
all standing there, and you hear her
screaming. And all you see is her
wig scrambling up from up under
the car and she was limping, and
some Mexican man tried to stab her

or something.”

In part due to experiencing violence and other

stressors in the context of sex work, participants

emphasized that mental health was a priority.

They discussed the need to address stigma and

depression as well as alcohol and substance use.

“The main thing for me would be
how to deal with stress. Stress can
take a tear on your body: mentally,
physically, emotionally. Especially
your mental. So if you learn how to
deal with stress, I think your life

will be a lot better.”

“The mental health aspect is
a big deal. Because you got to
understand that we, or I, coming
into this community open and
honest, you have to deal with a lot
of stigma coming from society and
previous people I used to know. The
acceptance piece and am I being
accepted by that. I personally suffer

from depression, so that coupled
with society’s stigmatisms, and a lot
of the unprotected sex, partner to
partner, the non-trustworthiness.
The mental health piece and holistic
health piece is the most important
part…I mean mental, spiritual,
emotional, physical. All that coupled
into one. We are, I am not new, but I
am coming into a point of comfort.
But that comes with mentally,
spiritually, emotionally, just having
a strong outer exterior to deal with
what’s coming at me on a day-to-
day basis”

“I don’t think, um, African
Americans address mental health
issues like they should. We’re
so used to self-medicating, if it’s
drinking, or drugging, or um
substituting drinking with sex.”

ENCOUNTERS WITH POLICE AND THE
CRIMINAL JUSTICE SYSTEM

Nearly all participants talked about negative

interactions with police in DC. These negative

interactions include harassment, abuse, and

violence from Metropolitan Police Department

(MPD) officers as well as from United States

Park Police and Capitol Police. The following

information focuses on the MPD.

Harassment

Transgender sex workers reported

mistreatment associated with their gender

identity. For example, police officers often

mis-gendered transgender sex workers, asked

invasive questions about their anatomy, and

verbally harassed and demeaned them.

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 19

HEALTH NEEDS OF TRANSGENDER SEX WORKERS

Two-thirds of focus groups participants identified as transgender. Transgender sex workers ranked
gender-affirming services as a top health issue. Participants reported that access to gender-
affirming health care was important and generally available to them in DC, but that they face stigma
and discrimination accessing care at health facilities and in jail and prison. They emphasized the
importance of addressing the comprehensive needs of transgender sex workers, including hormone
therapy and surgeries as well as mental health, assistance with name changes and insurance, and
risk for breast cancer and other health problems. Participants indicated that health facilities like
Whitman-Walker Health provide high-quality health care to transgender people and mentioned
that transgender people in the DC Jail are able to receive hormone treatment and therapy and
were housed consistent with their gender identity. However, they noted that in other jurisdictions
it is common to be taken off hormones and other medications in jail or prison. Some participants
told stories of being unable to get trans-competent care in DC and experiencing stigma and
discrimination from providers at health facilities.

“Basically getting your bloodwork done to test your levels of estrogen in
your blood, just checking your blood out, making sure your liver is not being
overwhelmed by every medication.”

“As well as I think another thing as for transgender women, we suffer from
and we get the same thing by us taking hormones we take. We have the risk
of catching breast cancer and things like that, so I think that we need to be
more allowing to speak of and help you with keeping up with whether or not
you have things of that nature.”

“Because that’s a part of treatment, I have to go through mental health first
before they approve me for all my surgeries. The letter is showing you want
to be a woman, they can’t approve you for surgery, you got to go through
mental health first.”

“I was told by them that they couldn’t take me. Because of me being
transgender they didn’t have everything, and the capability to fit my
needs…. That’s just the stigma of being transgender.”

“I can say is, why I love DC more is that they are more transgender friendly.
We go to prison, we have the right to go with women now. We got to
treatment, we have the right to go with women. Unless you take your wig
off, but now DC is only where transgender can be in the prison with women
without sex changes. DC is the only. Almost all transgenders move to D.C.,
they are almost the only ones that have free hormones right now.”

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 20

“On the stroll, they are so nasty.
They call you boy, they call you [male
name]. There used to be an officer
that would snatch the girls’ wigs off,
and he used to ride down the stroll
and if a date would try to pull up to
you, he would be like you know that’s
a boy. His name is [male name].”

“Okay like me, some officers would
try us because your ID says such and
such, or your ID says F, they still try
us, for real what is your real name.
You don’t have the right to ask me
my real name. That is my name. A
lot of officers try in their mind they
can’t take you anymore. So when I
give them my ID, I say “here ya go”,
and they say “so what you got down
there?” And I say “what you mean
what I got down there”, “you wanna
see it?”. That’s harassment.”

“The way the computer systems
are set up is that when you first get
locked up, you get locked up under
your boy name. They call you by
that even if you have a whole name
change, even if your ID says female,
even if you have breast implants,
even if you have a full surgery. They
will still be like [male name].”

In addition, many transgender sex workers

reported being subjected to profiling, i.e., police

targeting them as suspected sex workers merely

for being transgender and for being on the street

at night rather than on the basis of any observed

illegal activity. Participants recount that there is

often the assumption based on appearance, being

known to officers as a sex worker, or being in an

area associated with sex work that individuals are

sex workers, and this is particularly the case for

transgender women of color.

“So it’s just not even being able
to walk down, you’re talking
about harassment you know. It’s
automatically being seen as, you
know as everyone said at the table,
like we’re the problem.”

“He stopped her, and she got smart.
She like why you stopped us. We are
not prostituting. We are not doing

anything.”

“I see the police, it was one day
recently that they had the white
trucks out and the police was like,
me and another transgender were
standing on [street name deleted].
Another car come zooming up really
slowly, and it was the police in the
car like five of them. So of course,
I ran down the street because
I remembered the white truck
coming that day to lock the girls up,
so I’m thinking five police in the car
they are about to lock both us up.”

Still not all participants had negative

interactions with police. One explanation for

this is that some sex workers managed to avoid

encounters with police as a result of luck and

circumstances. One circumstance that made it

more likely for sex workers to encounter police

is working on the street.

“I’ve never had an encounter with
the police. I didn’t say I was never
going to. I have never had a police
encounter.”

“I ain’t never had no problem with
the police because I wasn’t outside. I
never had no problem. It depends on
where you’re doing that.”

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 21

“Working out of a hotel or your home
also makes a difference. Where you
do this, you have to be strategic.”

Violence and Abuse from Police

Fifteen percent of participants reported being

the victim of physical or sexual abuse at the

hands of the police in the past two years. One

participant described the use of excessive force

by an MPD officer. While this incident did not

occur in the past two years, it is illustrative of

the type of abuse to which sex workers continue

to be subjected.

“I remember there was a policeman
years ago that used to constantly
harass the girls. Yes, Officer [name
deleted], he wore the glasses. And I
remember they shut [deleted] street
down so we had to go elsewhere
over…. I remember he had pulled
over, slammed me on the hood of his
trunk and took my wig off, took my
– I had water balloons titties – took
them out threw them on the ground,
they splashed, took everything out
of my purse. I watched my makeup
slide off the hood of the car and
break. My MAC compact broke up.
And it just I felt just so, so bad. I
remember crying and it was raining
and I was standing there in the rain
and everything.”

Participants recounted various instances

of police sexual misconduct toward them or

other sex workers. In many instances, the

victims of misconduct are transgender women

of color, suggesting that some police officers

may target this subgroup of sex workers who

are particularly vulnerable. One transgender

participant recalled being extorted into having

sex with a police officer under the threat of

prostitution charges.

“I got harassed by the police. He
made me try to suck his dick for
free or he was going to lock me up
on [deleted] Avenue.”

Regardless of whether there was extortion or

other forms of coercion, sexual encounters

between police officers and sex workers are

inappropriate, yet participants noted that they

have clients who are police officers. Many

participants viewed this as a double standard

because sex workers are criminalized while police

officers break the law and face no consequences.

“I dated a police officer because too,
as a client.”

“I had one pull up on me in a squad
car, and he was like let me take
you out. I just never trusted him
because I thought he was going to
lock me up.”

“At the end of the day, police we
date them too. Government officials,
we date them too. People who make
these laws aren’t even following the
laws, so why should we?”

Fifteen percent of sex worker
participants reported being the
victim of physical or sexual abuse
at the hands of the police in the
past two years.

In many instances, the victims
of misconduct are transgender
women of color, suggesting that
some police officers may target this
subgroup of sex workers who are
particularly vulnerable.

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 22

“I think that it’s a double standard
because the girls are clearly saying
that they date these governmental
officials. It’s a double standard.”

Additionally, participants called out sting

operations as another double standard. As

a part of sting operations, police officers go

undercover to arrest people involved in sex

work. Undercover officers offer money for sex

and sometimes push the boundary between

their police work and criminal activity. One

participant elaborated as follows:

“To me, that doesn’t make no sense.
They are getting paid to get high,
they are getting paid to have sex,
they are getting paid to do all this
stuff undercover.”

Several participants mentioned police officers

having sex with them during sting operations.

Questions about the fairness and legitimacy

of sting operations suggests that this tactic

undermines trust in police.

Lack of Trust in Law Enforcement

Community participants reported that they

lacked trust in law enforcement. Notably,

participants were unwilling to call the police

when they were victims of crime because they

feared arrest, worried about being harassed, or

just did not think the police would do anything.

“I don’t like the police, so I don’t call
them.”

“You can’t call police about stuff
because they are going to work you
at the end.”

“Sometimes things have happened
to me, like this right here—my head
was busted. Nothing was done

about it. It gets to the point that I
don’t trust the police. It’s trauma.”

“Nothing ever happens. I feel like
they’re treating us like a joke.”

One participant discussed feeling that the police

do not care about sex workers. As a result, the

participant said that they did not trust the police

and did not want to call the police for help.

“There’s no consequences been
done for any type of harassment we
go through. The shopping center,
church, on the streets, there’s no
type of consequences being done
for any of it. It really is crazy and
showing us that police don’t care.
And that makes us not want to go
to the police at all. And not want
even call the police. And with that
we take things into our own hands.
What am I going to do if I feel like I
can’t trust the police and I have to
do what I have to.”

Several participants voiced concerns

about how police misconduct is handled,

which may further undermine trust. One

participant mentioned that there was no

police accountability for mis-gendering

and discriminating against transgender sex

workers, and another participant shared this

sentiment by noting that a complaint against

police officers was generally ineffective.

Sex worker participants were
unwilling to call the police when
they were victims of crimes
because they feared arrest,
worried about being harassed,
or just did not think the police
would do anything.

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 23

“When it comes to us calling and
saying there was discriminating
against us, calling us all some types
of he’s and men, there’s nothing.”

“If there is a direct physical attack,
but mentally, verbally they can say
what they want for real, just like you
can say what you want. I feel like
there is no purpose in reporting that
unless they put their hands on you.”

Need for Cultural Competency

Participants noted that a lot had improved in

DC in terms of police interactions, especially

compared to other jurisdictions, but participants

also wanted police officers to have more

sensitivity training. In discussing how DC has

improved, participants elaborated as follows:

“I can say DC is getting better. They
have gotten better. They are not
as homophobic as times goes on.
Acceptance, the more you grow up,
the more is accepting. As a young
kid at 22, you an asshole. At 30, you
are a better person. So I think it all
goes on the maturity level of the
police officer too.”

“This city’s tolerance has changed.
In one point of time, there was no
tolerance for prostitution. You got
beat up, you got harassed, you got
thrown in the back of the cop car,
driven around for hours, missing
money. And now the tolerance has
changed and with the laws and
things and people like you and
groups like yours that are fighting
for our rights as sex workers. It’s
getting better, but it’s not all the
way better yet.”

A major improvement within MPD was the

creation of the Gay and Lesbian Liaison Unit

(GLLU), also known as the LGBT Liaison Unit.

Participants spoke favorably of GLLU, which is

a team of dedicated officers that focuses on the

public safety needs of the gay, lesbian, bisexual,

transgender and their allied communities. One

participant discussed a positive experience with a

member of GLLU:

“And I told her and she had a whole
conversation with me. And she
said when I write this report, I am
going to write why you’re out here
because they don’t understand
that you are out here to survive.
They don’t understand that you
don’t have a place to live, they
don’t understand it’s hard to find
a place to work. So I really it was
compassion and she gave me her
business card and said if you ever
need someone to talk to, if you
ever need help with a resident, or
anything like that, here’s my card
I’ll help you if you really want to
get out of this situation. I will say
that sometimes it’s good that you
have those type of officers that are
around compared to the regular
officers that come and pick you up.”

A few participants reported that they had

never heard of GLLU. Others mentioned that

police officers only call GLLU or inform them

about GLLU when a case involves a potential

hate crime.

“A lot of stuff I am learning now
about the GLLU unit, I didn’t know
that. If I would have known that, I
would have told the police get out of
my face. I want to see these people.
But they didn’t tell me that.

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 24

I am going to piggyback off what
this gentleman was saying, that he
wasn’t informed that there was a
GLLU unit, that there is the GLLU unit
that is more sensitive to LGBT. And I
definitely agree to what he saying.

And the basis of when they do
address those particular situations
is more on the basis of if it was a hate
crime. That’s more when the GLLU
unit is called. If it’s not and they don’t
feel as though it is a hate crime, then
they really don’t contact them.”

Various participants noted a practice among

some police officers of not contacting GLLU

until officers have all the information from

their investigation. In some instances when

participants would make a request for GLLU, the

request would be ignored, or officers would tell

them that GLLU will slow the process down as a

way of discouraging the request.

“I told them can I get GLLU. So the
whole time they were talking to me
for like a half-hour they were trying
to get GLLU there but they couldn’t
get in contact with them. So they
were trying to speed up the process
and ignore my requests for GLLU.”

“And so then I was like I want the
GLLU unit. When you say the GLLU
unit, the first thing they say is well
if you get the GLLU unit or Blue [sic]
unit, whatever it is, that it’s going
to slow you down the process of
you getting out. They always throw
that in your face because you asked
for the gay and lesbian unit, they
are basically like whatever we have
written we are going to take our
time to be sure we get it before we
swap them over to their hands.”

While participants preferred having no

interaction with the police, those who knew

about GLLU always wanted to have that unit

present if they had to interact with the police.

Participants thought that GLLU was the most

appropriate unit to respond to issues related

to sex work. Additionally, one participant

recommended that MPD be stricter about

who it allows work in areas with high activity of

sex work because many officers have bias and

discriminate against transgender sex workers.

“My only thing that I feel like should
change when it comes to known
prostitution areas is the officers that
they assign to these areas should be
more strict with who they allow to
work those areas because not all of
those officers have our best interest
at heart. Not all those officers want
to see us out there or want to see
us the next day. Sometimes things
have happened to me, like this right
here, my head was busted. Nothing
was done about it. It gets to the
point that I don’t trust the police. It’s
trauma. I feel like there should be
more stipulations of what officers
they allow, they assign to the known
prostitution areas. When you have
something happen to you and the
officer don’t want to touch you
because you’re transgender, I feel
like that’s the only thing that needs
to be changed.”

Despite some improvements and the impact of

GLLU, participants said that there was a need

for more sensitivity training within MPD. One

participant noted that some police officers may

not take the existing training that they receive

seriously: “Every government employee of

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 25

the District of Columbia has taken sensitivity

training. Part of, they have to. Anybody, don’t

matter what agency you work in. [For] police

theirs is more extensive…. But some people

just might not take it seriously because it

doesn’t deal with them.” Other participants

elaborated as follows:

“There should be some type of
sensitivity training. I don’t think a
lot of cops have sensitivity training
because I still see girls that are kind
of hard, they still get harassed and
still called sir and all of that.”

“And a lot of these police don’t have
sensitivity training. I mean I am
thankful for the whole GLLU unit,
but I honestly believe that based
on how society is changing as a
whole, every member of the police
department, everybody should have
some form of sensitivity training.”

CONSEQUENCES OF ARREST AND
INCARCERATION

Community participants discussed the

devastating impact of arrest and criminal

conviction on their lives, driving them into

deeper realms of poverty and vulnerability.

Most participants (85%) reported a history of

incarceration, i.e., they had spent time in jail

or prison for any reason or any amount of time

in their lifetimes. One participant explained,

“I’ve been arrested a total of five times. I’ve

been kind of fortunate. I’ve been a sex worker

for a long time.” Among participants with a

history of incarceration, the majority had been

incarcerated in the past two years. While a few

participants reported spending no more than a

night or two in jail, 41% of participants reported

spending a year or more in jail or prison during

their longest period of incarceration.

Basis for Arrest

Sex workers are commonly charged with

prostitution or solicitation when they are

arrested. In DC, it is unlawful for any person to

engage in prostitution or to solicit prostitution.

In the past two years, nearly a quarter of

participants reported that they had been arrested

while engaging in sex work, and three of those six

were arrested for prostitution. Other common

reasons for arrest while engaging in sex work

included drug crimes, failure to obey a police

officer, and disorderly conduct.

Participants discussed that MPD officers

regularly charge sex workers with drug-related

offenses, suggesting that, even if sex work

were no longer a crime, sex workers would still

be vulnerable to police profiling and targeted

for arrest. Whereas sex workers arrested for

prostitution or solicitation are likely to have their

case “no papered” (i.e., government declines to

file charges despite the arrest) and to spend just

a night in jail, this is less likely to occur for arrests

for drug crimes, and charges for possession or

distribution of a controlled substance can result

in longer periods of imprisonment.

“Now they try to do a buy and bust.
Prostitution charges aren’t enough
for them. They try to get us on drugs
too. Now it is their ambition to keep
you off the streets for a while. With

In the past two years, nearly a
quarter of participants reported
that they had been arrested while
engaging in sex work.

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 26

misdemeanors, they know that you
will get no papered, or a citation, or
you basically get released. They also
know a lot of us are concurrent, we
are self-medicating with different
drugs. They are using us to buy
and arrest us like we are big drug
dealers. That’s the new plot, that the
new catch.”

“I had a similar experience, that
was possession to distribute a
controlled substance. They had me
charged with possession. No, they
had me charged with distribution of

a controlled substance.”

Inside Jail and Prison

Participants who had been arrested recounted

negative experiences in jail or prison.

Participants reported terrible conditions such as

being placed in a freezing cell and being isolated.

“They put you in a freezing cell, and
when you ask for a blanket, they tell
you they don’t have any. And then
they isolate you, and they say it’s
for your safety. You’re sitting on the
cold bench, they don’t care.”

This experience is consistent with reports

citing the DC Jail for inadequate standards

related to environmental conditions, including

room temperatures, sanitary conditions,

pests, broken fixtures, and inadequate

lighting.50 Beyond physical conditions of

confinement, participants also reported facing

mistreatment from jail staff. A transgender

participant explained that she was subjected

to a humiliating strip search during the booking

process and faced verbal harassment in jail.

“When I was there, the way that
they stripped searched me was so

humiliating. They are saying, oh,
does that wig come off? Do you have
a tuck on? They just like stripped
me down, and I felt so humiliated.
And they were just kiki-ing back and
worth [kiki means joking/chatting/
gossiping]”

Barriers to Health Care

Various community participants discussed

how arrest and confinement in jail or prison

impeded their ability to access health care

services. Participants particularly noted that they

faced barriers to medication, suggesting that

incarceration may lead to worse health outcomes.

“You ask for some medicine, they
don’t have no medicine. They sit you
back there and don’t check on you.”

“And mental health you know, they
didn’t get my drugs. They didn’t get
that together right, so I ended up

stop taking them in jail.”

“For me when I went to prison, by
me taking a lot on the streets, when
you go to prison, they take you off
a lot of the medicine that the doctor
put you on.”

Stress and Loss

The level of stress and strain that arrest and

incarceration produce negatively impacts economic

stability, health and wellbeing, and the potential

for future opportunities. Participants emphasized

the detrimental impact of being arrested for even

a short period of time. They often discussed the

impact of incarceration in terms of losing a lot

and taking them backward in their lives. Some

participants discussed returning to society after a

period of incarceration and having to start over.

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 27

“When you get arrested, you do
lose everything, you lose a lot. If
you don’t lose everything, you lose
most things. Police officers play
a part in this. They are arresting
you, they are taking from you. It
can be something so simple like a
sock. You lose a sock because they
took it from you when they arrested
you. That’s in general, when you
get arrested, you take ten steps
backward. When you get arrested,
you’re not going forward. You go

backwards when you get arrested.”

“The impact of arrests is you lose
everything…. Like but when I came
home I lost everything—family,
money, whatever clothes I had. I had
to start all over.”

Financial Costs

Participants reported facing financial

consequences as a result of arrest and

incarceration. An immediate consequence of

arrest is losing out on the sex work job that they

arranged or planned to arrange. One participant

noted, “They locked me up. I lost the job, [and]

didn’t get out until 4 o’clock in the morning.”

Beyond that, participants discussed wide-ranging

consequences for their earning ability because

criminal conviction and incarceration have a

lasting impact on employment prospects and

income mobility. Participants relayed that upon

release from jail, they often do not have jobs

waiting for them. They described that finding

a stable job outside of sex work is even more

difficult with a criminal record.

“So, it was detrimental to me. It cost
me quite a bit. It cost me my earning
ability.”

“I just know coming to the point that
I can reapply for a security license,
with this frivolous ass felony, you
have x-ed me out of making an
amount or a particular amount that
I am used to making.

Financial consequences associated with

navigating the criminal justice system were also

discussed. A significant cost that was mentioned

was money spent on attorney fees following

an arrest related to sex work. One participant

discussed court-related and other costs as follows:

“A lot times with myself or if I
get arrested, you have to pay a
lawyer. You have to prepare [for]
being locked up. You got to pack
your place up. There is a lot you
got to do when you catch a charge
whereas you do go backwards.”

Housing Consequences

Arrest and incarceration can also result in

housing loss or insecurity. Participants reported

significant barriers to stable housing after

release from jail or prison. When applying for

public or other housing opportunities, there

may be criminal background checks. Some

participants reported either being ineligible for

or denied housing because of their conviction

history as well as having limited housing options.

“From my experience, they gave
me my voucher. I got my voucher in
June. I didn’t know the impact now
in Washington, DC of a criminal
record because now they’re using
the record, misdemeanors. They
asked you when is the last time
you’ve been arrested and violent
charges the last seven years…. The
impact of the arrest on filling out

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 28

for getting a simple apartment. My
voucher is for … the market value
rent for my voucher is $2,600. I can
get somewhere real cute for $2,600,
and every year it goes up. Yeah, the
reason I can’t get where I want to get
is because of my criminal record.”

“Now it’s harmful because I’m
paying the piper cause I can’t get
where I want to get, and I’m moving
somewhat drug neighborhoods.
Where I live now is a quiet block. It’s
a quite block, but once I cross the
street they pumping.”

Lack of Social Support

Given the multiple challenges faced by sex

workers due to arrests and incarceration, it is

not surprising that many sex workers rely to

their families and networks for support. Some

participants, however, noted that another

consequence after they leave jail or prison is a

lack of social support.

“The best thing that happened from
being locked up was showing me
who my family was—nobody. You
feel what I saying. And someone
said earlier, you’re good with me
when I’m good, but when I’m fucked
up, you ain’t really got nothing.”

“Financially I didn’t have nowhere to
go. As far as my family, they weren’t
giving me any money or anything
like that.”

VIEWS ON REFORMING SEX WORK
CRIMINAL LAWS

Participants unanimously supported reforming

sex work criminal laws in DC. There was a

consensus that the status quo of the current

criminalization model was unacceptable. The

criminalization model is common in the United

States and involves penalizing the buying and

selling of sex and all related economic activity, like

driving for, leasing to, accompanying, or otherwise

cooperating with sex workers. The harms to sex

workers from policing and incarceration were

a major reason that sex workers rejected this

model. In addition to these harms, which have

been discussed throughout this report, some

participants mentioned that criminalization is

ineffective at deterring participation in sex work.

One participant noted, “People are going to do

whatever they want anyway.” Another participant

emphasized that criminalization was a waste of

governmental resources.

“I feel like it is a waste of, not that
I really care about, taxpayers’
money, but I’m just trying to say it’s
a waste of the taxpayers’ money
for even criminalizing prostitution
and locking people up and having to
feed them, and pulling all of these
officers in, all with something I
want to do with my body.”

Strong Support for Full Decriminalization

Discussion about alternatives to criminalization

centered around the following legal models: Full

Decriminalization, Partial Decriminalization, and

Legalization. These models are summarized

below. Participants reported a strong

preference for full decriminalization over either

partial decriminalization or legalization.

Sex worker participants reported
significant barriers to stable
housing after release from jail
or prison.

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 29

The primary reason that participants strongly

supported full decriminalization was that this

legal model recognized the agency of two adults

to consent to commercial sex. Participants

mentioned that neither sex workers nor their

clients should be penalized. Furthermore,

participants noted that it would be unfair

to penalize clients but not the sex workers.

Some participants also emphasized that full

decriminalization removed barriers to earning a

livelihood, whereas partial decriminalization was

viewed as continuing barriers to making money for

survival. In addition, one participant mentioned

full decriminalization as a way to reduce police

abuse and negate the need for undercover sting

operations in which police officers push the

boundary between their work and criminal activity.

“I am going to say both. I don’t think
the trick should be penalized for
picking me up. Then I won’t make
money because you’ve scared him
from coming back out.”

“I agree that it should be
decriminalized on both ends
because it is a mutual agreement
between two people.”

“I think it’s supposed to be for
both ways. If you’re doing it in
a responsible way, then nobody
[should be criminalized].”

“I don’t feel like police should have
the right, and you see this is what
used to really annoy me, if that what

gives them the right to able to use
drugs to be able to do everything
and break the law, just to lock
you up…. I think that it should be
decriminalized.”

While full decriminalization was the first choice for

the vast majority of participants, some participants

discussed other considerations that are important

to address. Important considerations include

concerns about addressing the spread of HIV and

other STIs in the context of sex work and concerns

about protecting minors from the sex trade, and

these considerations are relevant even if sex work

is decriminalized. Moreover, participants discussed

the fact that full decriminalization of sex work will

not solve all the problems that sex workers face.

Participants noted concerns that law enforcement

will find other ways to arrest and incarcerate sex

workers, such as through criminalization of drugs,

loitering, and other behaviors.

“It could be impactful, but there
are other elements. Just by
decriminalizing sex work, there are
other things that go along with the
sex work. And we have to remember
America is a criminalizing country.
They’re not going to do anything but
find another way to get us.”

“It is the same as decriminalizing
it and legalizing it. It’s reducing the
penalties, but then y’all gonna find
something else to pinpoint on us like
loitering and taxes and evading all the
other stuff.”

Differences of Opinion About Legalization
of Sex Work

It is noteworthy that a few participants spoke

favorably about the benefits of the legalization

model. A perceived benefit was the prospect of

Sex worker participants reported
a strong preference for full
decriminalization of sex work.

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 30

having designated places where sex work would

be permitted, which would mean sex workers

do not have to engage in street-based sex work

and could avoid associated harassment. One

participant explained, “I guess if it was legal

you wouldn’t have to walk the streets because

you would have a place to prostitute just like

in Nevada they don’t hang on the streets.

They have the Moonlight Bunny Ranch or the

Cat Ranch or whatever. They have an actual

location.” Similarly, two participants elaborated

on their desire to have legal protections for sex

workers, including laws that set payment rates

to prevent theft of services.

“I want a minimum and a maximum
rate set. Minimum and maximum
rate and for everyone to understand
and abide by it.”

“I don’t have a problem with it being
taxed, as long as it’s legalized and
it’s protected. I want to be like a
hairdresser. I mean like competition
is what it is, but with it being
legalized we can charge taxes. I can
charge taxes for my work and a time
limit. I will have protection for what
I’m doing now. So, if you come in
and you fuck me and you think you
gonna walk without paying your
bill, I can have your ass arrested
for theft of services. These are the
things I talk about need to be added
in place when you decriminalize. We
need protections as well.”

At the same time, other participants expressed

significant reservations about the legalization

model. In particular, they worried about the

creation of a tiered system of legal and illegal

sex work and had fears about discrimination

against sex workers living with HIV.

“Just because sex work is legal
doesn’t mean if you are HIV
positive, you can do the sex work.
If you are not registered, you have
a stroll that is in back of the legal
stroll that is illegal. So, you still have
the same illegal sex work.”

“It does go that way, but if you are
HIV positive, it goes on your card.
You are not supposed to be dating
on that site. You are not supposed to
be dating on the strip at all. So, they
have a front strip which is legal, and
right behind the front strip is the
illegal back strip. And that’s where
we tend to find a lot of the girls going
instead of the front strip.”

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 31

ALTERNATIVES TO THE CRIMINALIZATION MODEL FOR SEX WORK

Full Decriminalization is the decriminalization of consensual commercial sexual exchange. Advocates
argue that full decriminalization reduces stigma by treating sex work as work, increases safety by
allowing sex workers to legally organize to set standards and cooperate with third parties for safety and
transportation, whereas advocates against full decriminalization believe that decriminalization will lead
to the proliferation of sex work and sex trafficking. New Zealand has implemented full decriminalization
since 2003. Since implementing these reforms, New Zealand sex workers have reported increasing
the use of social services, increasing use of condoms, and increased reporting of violence to law
enforcement.

Partial Decriminalization, known also as the Nordic Model or Prohibition Model, decriminalizes selling
sex, but criminalizes buying sex and economic cooperation of landlords, drivers and others. Jurisdictions
that have implemented partial decriminalization include Sweden, France, Canada, Norway, and Ireland.
Partial decriminalization attempts to end or suppress demand for sex work. While advocates argue
that it has a protective effect for sex workers, a growing body of evidence from researchers in partial
decriminalization jurisdictions indicates that sex workers report increased stigmatization, decreased
access to health and social services, and increased vulnerability to violence from clients.

Legalization describes government regulation of sex work. Nevada is an example of jurisdiction with
a legalization regime. In Nevada, sex work is allowed only in licensed brothels, with registered sex
workers who must receive periodic STI testing. While advocates for legalization believe that regulating
commercial sex is necessary for public health and to protect vulnerable people from exploitation,
legalization creates a tiered system of legal and illegal sex work and often continues to marginalize and
criminalize most sex work, especially among sex work involving transgender women of color and people
living with HIV.

Sources:
(1) Reference Brief, Laws and Policies Affecting Sex Work, Open Society Foundations, (July 7, 2013), https://www.
opensocietyfoundations.org/sites/default/files/sex-work-laws-policies-20120713.pdf.
(2) Susanne Dodille and Petra Östergren, The Swedish Sex Purchase Act: Claimed Success and Documented
Effects. (Paper) DECRIMINALIZING PROSTITUTION AND BEYOND: PRACTICAL EXPERIENCES AND
CHALLENGES, THE HAGUE, pg 4 (March 3, 2011), http://www.petraostergren.com/upl/files/54259.pdf.
(3) André Picard, Canada’s new prostitution laws may not make sex work safer: research, THE GLOBE AND MAIL,
(July 26, 2018), https://www.theglobeandmail.com/canada/article-canadas-new-prostitution-laws-may-not-
make-sex-work-safer-research/.
(4) Lucy Platt, et al., Associations between sex work laws and sex workers’ health: A systematic review and meta-
analysis of quantitative and qualitative studies, PLOS MEDICINE, (December 11, 2018), https://journals.plos.
org/plosmedicine/article?id=10.1371/journal.pmed.1002680.

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 32

Results from Institutional
Stakeholder Interviews

There was a substantial amount of agreement in

the perceptions of the institutional stakeholders

and the experiences recounted by the

community participants.

MOTIVATIONS FOR INDIVIDUALS
ENGAGING IN SEX WORK

Access to Housing

Institutional stakeholders repeatedly discussed

that people engage in sex work to access

housing. The most common example discussed

was paying rent through sex work due to

the rising housing costs in DC. Institutional

stakeholders expressed an understanding that

sex work means survival for many sex workers.

“These are the people that maybe
have sex with the landlord once a
month for a break on the rent or are
trying to put some more food on
their table in addition to a couple
of full time jobs they already have. I
mean, the cost of living is a serious
question in the city.”

– David Grosso, At-Large Council Member,

Council of the District of Columbia

“They’re not out there … because
they want to be out there, many of
them. They are out there because
they have to be out there. This is
their way to have a roof over their
head, to have food in their mouths, to
find health care. It’s the only way.”

– Brett Parson, Former Manager of
Special Liaison Branch, Metropolitan
Police Department

Institutional stakeholders described

that access to housing is a primary

motivator for engaging in sex work

and criminalization of sex work erects

barriers to housing. Housing is a

primary social determinant of health,

and housing insecurity interferes with

access to medical care by reducing

ability to administer medications

regularly and store medications safely.

“[H]omelessness caused my client to
grow more ill and lose a dangerous
amount of weight. He experienced
wasting on the street and didn’t take
his medication because it upset his
stomach and he didn’t have regular
access to a bathroom. Even when
people have access to treatment, if
they don’t have a safe place to store
medication or don’t have access
to bathrooms, that’s a significant
barrier to health, and I’m sure a lot of
people engaged in survival sex work
face those same challenges.”

– Nassim Moshiree, Policy Director,

ACLU of DC

Socioeconomic Factors

Institutional stakeholders believed that

socioeconomic factors like poverty and

education were factors in participating in sex

work. In particular, stakeholders believed that

failures of social programs influenced people to

engage in sex work. Sex work allowed people to

provide support for themselves that the District

government did not provide.

“[T]his has been too much
influenced by cultural factors that
are… in effect, sort of criminalizing
social class status. Because you

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 33

SUMMARY OF INSTITUTIONAL STAKEHOLDER RESULTS

The data portray that DC’s prostitution laws create a landscape that pushes vulnerable people to
the margins. The following emerged from the interviews with institutional stakeholders who served
sex workers in the District:

1. Structural forces create instability: Institutional stakeholders understood that participation
in survival sex work is driven, in part, by the lack of available alternatives. They expressed that
survival sex work arises at the intersection of human need and the anti-trans bias (transphobia)
transgender women experience. Lack of access to employment and increasing cost of living in
the District contribute to a lack of stable housing. Housing instability creates an ecosystem of
insecurity in every area of life.

2. Uncertainty propagates fear: Institutional stakeholders identified that, despite MPD’s
prioritization of crimes of violence and their commitment to culturally competent police services,
there is a lack of confidence in law enforcement. DC’s overlapping jurisdictions contribute to
confusion about the legal rights of individuals who are subjected to stops by officers, uniformed
and undercover. Stakeholders report that sex workers are less likely to engage in health care
services due to distrust, frustrating preventive care and public health efforts. Stakeholders who
provide victims services have developed tactics for engaging with MPD while preserving their
client’s safety.

3. Arrests erase progress: Institutional stakeholders expressed, based on data on MPD
practices, that arrests by the human trafficking unit were largely ineffectual at combating human
trafficking. Stakeholders said that arrests are ineffective at ending sex work. Stakeholders
found incarceration and arrest destabilize the lives of sex workers and disrupt progress toward
education and economic achievements. Incarceration interrupts health care, including gender-
affirming care and HIV prevention and treatment plans, harming physical and behavioral health.

4. Law creates vulnerability: Stakeholders expressed that the law perpetuated stigma against
sex workers and those profiled as sex workers. They also recounted that MPD officers have
perpetrated acts of violence against sex workers, and that such practices contribute to a culture
of impunity and violence toward sex workers. This contributes to illness and injury, fear and
anxiety, and vulnerability to human trafficking.

5. Consensus on Reform: No stakeholders supported DC’s current laws criminalizing sex
work. Stakeholders were all in favor of reducing criminal penalties for engaging in sex work.
Stakeholders report that while vacatur statutes and diversion programs can be helpful for some,
the program requirements and legal standards undermine the agency of sex workers. Most
stakeholders support total decriminalization of sex work on the basis that it would increase trust
in social services, increase safety, and increase engagement in health care.

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 34

are low income or have no income
or the other rest of the system has
failed you, such as the child welfare
system – I used to work in child
welfare – or the child protective
system that failed you or the fact
that your family upbringing was an
unsafe one, that your educational
system failed you, that all these
other parts of our society and
that your only choice is to do this
activity is not – therefore then that
gives – that should entitle you to an
illegal status. That just seems – can
I say ‘ass-backward’?”

– Michael Kharfen, Senior Deputy Director

of HAHSTA, DC Dept. of Health

THE POLICE AND CRIMINAL JUSTICE
SYSTEM

Institutional stakeholders identified law

enforcement, i.e. the police, the courts,

and prisons and jails, as a key mechanism

of criminalization’s effect on the health and

safety of sex workers. As discussed below,

law enforcement treatment of sex workers is

influenced by District laws, as well as the official

MPD policy priorities and the individual discretion

of police and prosecutors.

Training

Generally, institutional stakeholders both inside

and outside the MPD believed that the MPD

received more training for gender sensitivity then

other police departments in the United States.

Stakeholders said that police received training

in LGBTQ cultural competency and were familiar

with the Gay and Lesbian Liaison Unit and other

specialized units of the MPD, like the human

trafficking unit. No one was aware of racial bias

trainings for MPD officers.

“[I]t was one of the original
departments that started its own
LGBT unit, and it still maintains it.
And the, I think the hallmark of that
program right now is that regular
street officers, that are not, that
have never been associated with
LGBT issues, are now assigned
there on rotating basis, so that they
can get exposed to that.”

– Michael Tobin, Executive Director, DC

Office of Police Complaints

“[T]he city and then the police
department put out an entire internal
and external policy on dealing with
people regarding gender identity,
gender expression, right? I mean,
so again, I put us ahead of the game
worldwide, much less nationwide.
So we have that. Then we have our
internal policies on dealing with
transgender individuals”

– Brett Parson, Former Manager of Special

Liaison Branch, Metropolitan Police

Department

“[Y]ou can’t just leave it up to MPD
to do the training for themselves, it’s
all internal. You almost need to make
sure that someone from outside
comes in and does the training.”

– Stacie Reimer, Former Executive Director,

Amara Legal

Priorities

Arrests resulting from prostitution-related crimes

were not seen as a priority by police. Police

stakeholders said that MPD prioritizes crimes

related to human trafficking and over the past

decade have been deprioritizing non-violent

crimes. Enforcement of prostitution laws in the

District is initiated primarily by neighborhood

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 35

complaints of nuisances related to the presence of

sex work, e.g. used condoms on the street.

“[O]fficers over the last probably
seven, eight, nine years have seen us
kind of shift some of our resources
to more violent crimes, and a de-
emphasis on the larger prostitution
operations that we used to do.”

– Brett Parson, Former Manager of Special

Liaison Branch, Metropolitan Police

Department

“Officers who are on beats that have
a visible problem of commercial
street sex work are obviously
responding to complaints from
the community and public safety
issues and nuisance complaints.
So they have to enforce those laws.
But they also spend an awful lot of
time responding to protecting those
individuals who were engaging in
those activities who become victims
of crime. And so we find ourselves
in kind of a balancing act of moving
back and forth between, “you need
to get off this corner, people are
complaining” and “Oh my God, are
you OK? What can I do to help you?”

– Brett Parson, Former Manager of Special

Liaison Branch, Metropolitan Police

Department

Discretion

Institutional stakeholders reported that

enforcement of District prostitution laws was

discretionary based on individual officer experience

and training. Discretion in policing resulted in

different attitudes toward police, depending on the

experience and relationship with specific officers or

police precincts. Discretion in law enforcement was

seen as positive by police stakeholders. Others

cited differential enforcement and deviation from

police department protocols and policies as a

barrier to trust.

“[D]ifferent units, like I said, are
doing different things…. I only work
with police that I’m comfortable
with and I know they push it. So, I
call the ones that we work with, so
it would be a different answer for
me. It’s always going to be right,
because I’m going to make sure
it’s right and I already made that
connection.”

– Tina Frundt, Founder, Courtney’s House

“There is also vast amount of
judgment and discretion provided
to police officers, which is
necessary in our society. We can’t
arrest our way out of any problem.
Right?”

– Brett Parson, Former Manager of Special

Liaison Branch, Metropolitan Police

Department

“It’s because they’ve had direct
experiences with police interactions
over decades and decades that have
taught them that they can’t trust the
police. And this is true, I think in the
sex work industry too. There’s just a
long time in the eighties when the sex
work industry was predominantly
along 14th, Logan circle area and
stuff. There were raids all the time
that were very violent. They were
patty wagons chasing people down.
It was a very violent time, the whole
city was violent. We haven’t healed
from that time.”

– David Grosso, At-Large Council Member,

Council of the District of Columbia

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 36

Accountability

Institutional stakeholders had different

understandings of police accountability methods

and different views on the efficacy of police

accountability mechanisms. The Office of Police

Complaints (OPC) described the District’s efforts

to improve police accountability. The OPC is

administratively independent from the MPD

and receives and assesses complaints against

the MPD and submits its recommendations

to the MPD. The MPD has discretion in

responding to recommendations from the

OPC. The OPC expressed that the office has

made efforts to make submitting complaints

accessible for community members by allowing

complaints to be submitted by phone, email,

fax, social media, in-person, or through internet

forms. Complainants can submit information

anonymously, but this was seen to limit the ability

of the OPC to respond effectually.

“We’ve long had an Office of Police
Complaints in the District, as an
independent organization. But
it was just recently – since 2017
– that all citizen complaints are
falling under their jurisdiction for
investigation. If there is a criminal
allegation as part of a complaint, it
will also be investigated by MPD.
But if it’s allegations that an officer
was harassing someone – they keep
coming around or they’re mis-
gendering them or things like that
– OPC will handle it.”

– Kelly O’Meara, Executive Director,

Strategic Change Division, Metropolitan

Police Department

“Whenever anyone believes
that they’ve been the victim of
misconduct or whenever someone

believes they are a witness to
police misconduct, they can file a
complaint in the District and they
can do it by one of many different
ways. They can go to any District
station, they can pick up the phone
and call us or the police department.
They can come to our office at 14th
and I street, and they can Google
it and when they Google “police
complaints” or “police misconduct
Washington DC” they’ll come up
with the Office of Police Complaints,
our website, and you can file a
complaint right through our website
in an online filing system. They can
file a complaint through Facebook,
through our Facebook page. They
can notify us through Twitter. They
can do it by fax. They can do it by
email and if they’re not comfortable
with any of those things, they can
go to one of our 15 or 16 community
partners throughout the District,
and they can go to that community
partner, community group, and start
the complaint process with them.”

– Michael Tobin, Executive Director, DC

Office of Police Complaints

Complaints

Other institutional stakeholders were unsure

how to make a complaint of police misconduct.

Most stakeholders were unsure of how police

complaints were processed, and some expressed

the belief that reports by sex workers and

homeless residents are often not viewed as

credible. Barriers to police accountability

include the discretion MPD has in acting

on recommendations from the OPC, public

awareness of how to make complaints about

police conduct, and how complaints are handled.

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 37

The OPC reported an increase in the number

of complaints received by their office but were

unable to ascribe the increase to a specific cause.

“[T]he consensus is nationally,
[internationally] even, is that
complaint-based systems,
regardless of whether it’s police or
health care or traffic conditions,
they privilege certain people, and
they privilege folks that already
feel access and feel empowered
to speak. And so, if you’re from a
marginalized community, you’re
not going to do that as much most
likely. … [I]t ought to be more about
not waiting for those complaints
to come in, but going out and
auditing the agency, the body, the
community, whatever it is, and
investigating into their practices
and actively recruiting people to
find out what is going on.”

– Darby Hickey, Former Legislative

Advisor, Council of the District of Columbia

“Is there a process? I believe there
is. Is it an adequate and culturally
sensitive process? No. Is it victim-
blaming? Yes. Is it something that
is encouraging and taking away the
burden from the people reporting
abuse? No.”

– Activist and educator

Overlapping Jurisdictions

The presence of multiple uniformed police forces

in DC contribute to confusion for DC residents

when interacting with the police. This confusion

contributes to violence when civilians are unable

to determine if an arresting officer has the

authority to detain them or deport them, or if

they are being subjected to police misconduct or

someone impersonating a police officer.

“[E]lements that lead to better
public safety for all, and that
includes … differentiating between
the police units, enforcement
units, and immigration, customs
enforcement for example, so
people feel confident that when
they… reach enforcement they
won’t be detained themselves and
subsequently deported.”

– Activist and educator

Negative Encounters with Police

Institutional stakeholders reported that

criminalization of sex work had a largely negative

impact on police encounters with sex workers.

Stakeholders report that police officers have

harassed and extorted sex workers, including

coercing them to perform sex work under threat

of arrest. Service providers interviewed report

that there have been reductions in instances

of police harassing community health workers

conducting outreach to sex workers.

“We’ve also gotten several complaints
either from our clients… that law
enforcement officers are sexually
assaulting people or sort of like
trading, not arrest for sexual favors.”

– Yvette Butler, Former Director of Policy

and Strategic Partnerships, Amara Legal

“[W]e used to get tons of reports
for when I was at Different Avenues,
and then when I was [out] real
early talking with HIPS peer health
workers [in] the HIPS van, and peer
health workers at Different Avenues
who were walking around on foot
getting stopped by police and being
messed with, you know, and being

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 38

told, “What are you doing?” and
“Why are you here? Why are you
talking to those people?”… “You can’t
be out here. I might arrest you.”
Right? I think that’s gotten a lot
better”

– Darby Hickey, Former Legislative Advisor,

Council of the District of Columbia

Fighting Human Trafficking

Institutional stakeholders expressed that

prostitution enforcement is an ineffective

method of enforcing human trafficking laws

because they fail to assist in apprehending high-

level traffickers, due to fear of traffickers and

lack of trust in law enforcement. Stakeholders

expressed that police are not supposed to be

targeting sex workers and their clients in human

trafficking stings.

“[T]he Human Trafficking Unit, who
is supposed to be viewing everybody
and not charging anyone involved
in prostitution – like, figuring it out
and connecting those to services
– isn’t doing the job that the unit is
supposed to be doing.”

– Tina Frundt, Founder, Courtney’s House

“With the sting operations that I’ve
seen they’re not really arresting the
people that are the traffickers. If
there’s a trafficker in the situation,
he typically doesn’t get arrested just
because he’s not there. He’s across
the street or miles away. They’re
arresting everyone and then they’re
saying you need to testify against
somebody in order to get your
charges dropped. Of course, that’s
a really dangerous thing to do and
they don’t want to testify. So they’ll

just then move forward on these low
level misdemeanor charges. There’s
no effort to get the kind of the
masterminds behind it.”

– Stacie Reimer, Former Executive Director,

Amara Legal

A few stakeholders were particularly concerned

about the sexual exploitation of minors and

children. They expressed that approaches to

trafficking interventions and victims’ services

that relied on arrest could be counterproductive,

noting traffickers may use the threat of police

involvement to coerce and control their victims.

“[I]n some cases, it can be
paternalistic and unnecessary
involving young people in the court
system. That kind of reemphasizes
the whole criminal/offender
narrative, which we’re trying to
move away from. That’s one of the
things traffickers tell youth, “If you
go forward and try to get help, they’re
just going to treat you like a criminal.”

– Yasmin Vafa, Executive Director,

Rights4Girls

Particular harms to immigrants

Stakeholders report that a criminal record of

prostitution-related offenses is particularly

harmful for immigrants because federal

immigration law creates bars for immigrants

with criminal convictions for prostitution-related

offenses. In an immigration court, participation

in diversion programs, nolo contendere pleas,

probation, and court-ordered rehabilitation

programs are all considered convictions and

potentially bar future immigration relief. Further,

stakeholders expressed that expungement

or sealing the criminal records of sex workers

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 39

and trafficking victims are ineffective in the

immigration context because immigration

authorities can access sealed and expunged

criminal records, and immigration documents

require disclosure of participation in sex work,

whether legal or illegal, performed in the 10

years prior to the application for change in

immigration status.

“[I]f people are afraid of law
enforcement bringing charges
against them because, well, and
particularly for immigrants
because it will affect their potential
immigration status, they’re very
reluctant to come forward and
report trafficking situations.
Oftentimes if their traffickers are
afraid that they are going to report,
a lot of traffickers threaten to
contact either law enforcement or
ICE to keep people in a trafficking
situation as well, as kind of a power
and control method. The threat
of deportation is very common in
trafficking, domestic violence, in
situations like that.”

– Denise Hunter, Senior Staff Attorney,

Whitman-Walker Legal Services

Fear of Deportation and Other Adverse
Immigration Outcomes

The impact of criminalization on immigrant sex

workers is over their whole lives. Institutional

stakeholders expressed that arrest,

incarceration, and prosecution for immigrant sex

workers implicates the risk of being deported

and sent back to a dangerous situation in their

country of origin. They elaborated that the

fear of deportation creates a vulnerability that

means immigrants are especially susceptible

to coercion, the negative health effects from

underutilization of health care services,

increased fear and anxiety when interacting with

any government entity, and additional barriers

in housing, education, and employment when

compared to their non-immigrant counterparts.

“[F]or the most part there’s a
reluctance among immigrants
to – so, they’re kind of two-fold.
One is that clients are reluctant
if they are the victims of crime,
for example, are reluctant to
report. So, if they’re the subject of
violence, are reluctant to report
those crimes, so if, especially… if
it occurred during the process of
an encounter of exchanging sex
for an exchange of goods. So, they
are reluctant to come forward
and report to law enforcement
for the fear of being criminalized
themselves for engaging in that
practice. And then as a secondary,
particularly with immigrants are in
general very concerned about any
cooperation with ICE, Immigration,
Customs, and Enforcement,
between law enforcement if
they are – particularly if they’re
undocumented, and even if they
have a more temporary status that
can put – any kind of arrest history
can put someone who is not a US
citizen in jeopardy.”

– Denise Hunter, Senior Staff Attorney,

Whitman-Walker Legal Services

Impact of Arrest and Incarceration

Institutional stakeholders generally expressed

that the effects of arrest and incarceration

were traumatizing to sex workers and people

profiled as sex workers. The stakeholders

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 40

expressed that arrest, incarceration, and

prosecution resulting in a criminal record has

a negative impact on access to housing and

employment, increasing vulnerability to violence

and increasing barriers to transition into other

employment. These barriers act to further

entrench sex workers into cycles of poverty and

underground economies.

Exclusion and Discrimination

Criminal records from repeated arrests due to

sex work can exclude people from accessing

public housing or housing assistance programs,

and employment or employment programs.

Institutional stakeholders articulate that

employers discriminate based on criminal records

and that spending time in legal proceedings or

incarcerated is a barrier to employment.

“I think people are oftentimes
engaging with law enforcement,
developing a record and therefore
experiencing farther difficulties
in getting a job despite the fact
that it’s really hard to get a job
and be employed when you
are transgender, when you’re
transgender and black, when you’re
transgender and undocumented. …
I do think that there needs to be a
more critical understanding of the
sociological elements that lead to …
vicious cycles of engagement with
the sex industry, and that’s absent.”

– Activist and educator

Destabilizing Trauma

Incarceration resulting from arrest and

prosecution interrupts the development of

stability in employment that can lead to higher

incomes. Incarceration and arrest are seen

as traumatizing and harmful events that delay

needed medical care and interrupt pathways

to independence. Incarceration and arrest are

particularly traumatizing for young gay, bisexual,

and transgender people.

“The offense of prostitution is a
misdemeanor, but people often
get charged multiple times which
can lead to stacked charges and
increased penalties, leading to
lengthy periods of incarceration.
Women are the fastest growing
population in our prison system. A
lot of people think of misdemeanor
charges and arrests as slaps on the
wrist, but they don’t realize that
when someone gets arrested for
prostitution and for other low-level
offenses, they get caught in a cycle
of criminalization that prevents
them from accessing health care,
employment, housing. Sex workers
are stigmatized for engaging in sex
work, but the system also leaves
them without the tools to move
beyond survival sex work. And the
criminal justice costs go up as a
result. This is money that could be
redirected to actually improve the
lives of those engaged in sex work.”

– Nassim Moshiree, Policy Director,

ACLU of DC

“It’s time and money plus stigma
plus emotional distress plus a
criminal record, and it may not even
change behavior.”

– Stacie Reimer, Former Executive Director,

Amara Legal

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 41

Interruptions in Care

Institutional stakeholders also identified

that incarceration interrupts medical care, a

particular bad result for gender-affirming care.

Stakeholders identified that criminalization

negatively impacted health due to exposure

to violence while incarcerated and disruptions

in medical care from time spent incarcerated.

Incarceration and arrest were major barriers

to engagement and retention in medical and

behavioral health care.

“[O]ne of the concerns is especially
for trans-identified clients, they’re
very afraid of law enforcement
because they don’t want to be put in
populations where, they don’t want
to be put into detention facilities
where they’re going to be put in
based on their sex assigned at birth,
which is a big problem which leads
to further criminalization, people
agreeing to plea bargains that they
ordinarily wouldn’t because they’re
in a detention circumstance where
they feel unsafe. I’ve seen that a lot
with my trans immigrant clients
where I would never recommend
them taking a plea bargain because
it affects their immigration status,
but they end up doing it out of fear
for themselves and for their safety.”

– Denise Hunter, Senior Staff Attorney,

Whitman-Walker Legal Services

HEALTH

Institutional stakeholders revealed that

criminalization of sex work negatively affected

the health and wellbeing of sex workers and

people profiled as sex workers through exposure

to danger and violence, propagating stigmatizing

messages, and interrupting medical care,

including gender-affirming care and HIV care and

prevention.

Danger and Violence

The state imprimatur of criminality creates

stigma and a culture of impunity and violence

toward sex workers and people profiled as sex

workers. Institutional stakeholders report that

criminalization increases the danger that sex

workers and the Black and Brown gay, bisexual,

and transgender communities profiled as sex

workers will face violence. They identify that

sex workers experience violence from clients

and from community members, including law

enforcement.

“[S]o much of the violence that
does happen… is precisely because
sex work is illegal. That’s why
it happens, because there is a
perception, this goes back to the
stigma and the criminalization,
that, “Oh, they’re just whores. I can
do whatever I want to them, and no
one’s going to care.”

– Darby Hickey, Former Legislative

Advisor, Council of the District of Columbia

“And by the way they are not
reporting it that it was a John.
They’re not reporting that they
were out there. “Hey officer,
detective, I just want to be honest.
I was out here last night and this
guy came up for one of my services
and then pulled the gun on me and
took my cash.” What we get is she’s
going to the hospital, the emergency
room calls us because she’s clearly
been the victim of an assault. We
got there while I was walking home
from work and some guys just

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 42

randomly walk, but then we pull
footage of the video when she was
out there for two hours walking in
circles and so we put two and two
together, but they aren’t reporting
to us in many, many instances
the circumstances surrounding
why they were victimized or what
they were engaging in at the time
because they’re afraid that we’re
going to investigate them and that’s
a hard message to send to them, but
it gets to the US attorney offices. So
we catch the guy, you don’t think
of defense attorney is going to go
after? So now do I sponsor her
as a witness? Now we have moral
turpitude issues, and they could go
after her credibility. It’s all part of
that horrible thing that our society
has created.”

– Brett Parson, Former Manager of Special

Liaison Branch, Metropolitan Police

Department

Stigma

Criminalization is known to reduce the ability

of sex workers to effectively report crimes of

violence for fear of arrest by law enforcement.

Stakeholders expressed that criminalization

contributes to internalized and external feelings

of stigma and perceptions that sex work is an

inherently dangerous profession, causing people

to blame sex workers for violence perpetrated

against them.

“[I]t’s a real challenge for people in
the sex trade to be able to report
any instances of violence. One of the
things that I think just culturally
we see is that people in prostitution
and the sex trade are still largely
seen as outside of the category of

those who experience violence.
Some of the comments made in the
context of the Me Too movement
about how powerful men should
have just solicited women in the
sex trade instead of soliciting their
employees at work are a good
example of demonstrating how as
a society, we still see people in the
sex trade as outside of the realm of
“everyone else” and as a category of
people who we expect to be raped
and harassed.”

– Yasmin Vafa, Executive Director,

Rights4Girls

Barriers to medical care

Criminalization of sex work limits access to

health care for sex workers by creating an

environment of stigma and fear. Institutional

stakeholders perceived that fear of entering

DC government buildings for fear of potential

negative interactions with law enforcement

reduced access to public services and benefits.

“One story that sticks out involved
the person examining them putting
on two sets of gloves. And just
feeling like that was a judgment and
not wanting to come back to even
get the results of their tests.”

– Yasmin Vafa, Executive Director,

Rights4Girls

“I think that the current
criminalization farther perpetrates
stigmas that lead to people’s self-
worth and self-esteem to decrease.
That leads to people’s apprehension
in reaching social workers and
different health programs due to
concerns around being demonized
and subsequently put in contact

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 43

with enforcement bodies and
personnel that will criminalize them
for, in their attempts to monitor
their health”

– Activist and educator

Gender-affirming care

Criminalization was generally seen to impede

gender-affirming care for transgender sex

workers. Institutional stakeholders expressed

that transgender people can defer seeking

services if they anticipate experiences of stigma.

One stakeholder expressed that the policies at

the DC Jail around access to gender-affirming

care have improved due to the advocacy of

LGBTQ and transgender-focused groups.

“They can be reluctant to access
health services because of what
they perceived their – the level of
care that they will receive and not
being in a very affirming, competent
environment. So, they will defer, or
they will utilize resources that are
maybe limited in their capacity to
provide those, or in some cases, as
I’ve heard anecdotally, persons who
aren’t really competent to provide
those services. As I’ve heard in terms
of anecdotes of person[s] going to
others for hormone injections, for
instance, that might not be done as –
as informed as possible.”

– Michael Kharfen, Senior Deputy Director

of HAHSTA, DC Dept. of Health

“You can get hormones. We got
really good policies passed on that
about a decade ago that D.C. Trans
Coalition, Different Avenues, HIPS,
GLAA, everybody involved.”

– Darby Hickey, Former Legislative Advisor,

Council of the District of Columbia

HIV and STIs

Criminalization limits access to care, treatment,

and prevention of HIV and other sexually

transmitted infections (STIs). Institutional

stakeholders report that criminalization makes

sex workers less likely to disclose their sex

work to their providers out of fear of stigma and

discrimination, resulting in poorer preventive

medical care. Stakeholders did not identify

any barriers to accessing condoms for the

prevention of HIV and other STIs.

“I think it’s hard to have a
relationship with a primary care
provider, which is what we all
really should be doing this – doing
preventative care – because if you’re
afraid that if you tell your primary
care provider, it’s just this constant
fear that it’s going to get out, that
you’re doing this and that it’s
illegal.”

– David Grosso, At-Large Council Member,

Council of the District of Columbia

“Something that is very important
is to make public health particularly
preventive health care accessible to
our communities.”

– Activist and Educator

Condoms

MPD stakeholders and others with legal training

communicated that carrying condoms is not

sufficient cause for an arrest but can be used

as evidence of sex work in court. The legal

distinction between “cause for arrest” and “used

as evidence” contributes to continued confusion

and may act as a barrier to public health efforts

to stop the spread of HIV and other STIs.

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 44

“[A] few years back I was involved
in conversations with MPD around
issues of condoms and possession
of condoms and whether or not
that can be considered ‘evidence of
commercial sex work’ of which we
argued as vigorously as possible
to our colleagues in government
that this is actually a public health
intervention that we’re doing in that
we’re providing those condoms.
And then if you’re taking that and
using that as evidence for law
enforcement, that’s sort of counter-
indicative of what our strategy is.”

– Michael Kharfen, Senior Deputy Director

of HAHSTA, DC Dept. of Health

Public Health

Institutional stakeholders communicated the

belief that under a criminalization regime, sex

workers are treated as vectors of disease rather

than people, and that effective public health

efforts can engage sex workers as partners in

prevention.

“Sex workers are part of the
solution to maintain a safe
environment. And the way to go
about this should be about ensuring
that there are public health
concerns addressed, and the people
are having access to ongoing and
adequate testing, and that there
are enough economic opportunities
that are actually reaching those
who need it the most. So, they can
make the best, informed decisions
about themselves, their health, their
lives, and their families, and by
extension, communities.”

– Activist and educator

Access to PrEP

Low rates of PrEP use among community

participants indicate that sex workers find it difficult

to effectively engage with available PrEP programs.

Institutional stakeholders reported that same-day

initiation programs for antiretroviral theory and

PrEP for the treatment and prevention of HIV are

available to the uninsured, undocumented, and

homeless populations through public programs.

Access to insurance was not identified as a barrier

in Washington, DC. Some stakeholders articulated

that public and private programs lack resources

for supportive services, like peer health workers,

community support groups, and transportation

assistance that help retain people in care.

“I think that’s universal, is a failure
to understand how human rights
and empowerment and fighting
stigma of specific communities that
are hit super-hard by bad health
outcomes, particularly HIV and
STDs, how critical those kinds of
interventions are, and how there
is not funding for them. There’s
funding much more for the bio-
medical approach which is fine. It’s
important, and we need funding
for that, for sure. But I remember
we used to do like awesome like
support group sessions, and, peer
training, and peer advocacy, and
peer education and, passing out
condoms, but it was also about
building networks.”

– Darby Hickey, Former Legislative

Advisor, Council of the District of Columbia

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 45

ONLINE-BASED SEX WORK

District laws and federal laws work together to

criminalize online sex work. Most institutional

stakeholders indicated that online sex work is

safer and more lucrative than street-based sex

work. Online sex work allows for negotiation

of terms of sexual exchange, location,

duration, sexual acts, and price. Institutional

stakeholders reported that FOSTA/SESTA

has decreased the ability of sex workers to

communicate with clients online, pushing them

into street-based sex work. FOSTA/SESTA

decreased income for sex workers because sex

workers can make more from online sex work

than street-based sex work. Street-based sex

work was perceived to be more dangerous than

online work because it increases exposure to

violence and arrest.

“If it were to be shut down, I think
it gives them less control their own
business and less control over the
ways that they can get clients. I think
anytime you have less control over
something that can be a safety issue.”

– Stacie Reimer, Former Executive Director,

Amara Legal

POLICY AND LEGAL REFORM

Institutional stakeholders presented a variety

of attitudes toward reforming criminal laws

and policies around sex work. Stakeholders

expressed views of policy reform around vacatur

statutes, diversion programs, and reform

of criminal laws. Generally, the institutional

stakeholders’ viewpoints on criminal law reform

can be characterized as falling into two camps:

those supportive of partial decriminalization

and those supportive of full decriminalization.

Institutional stakeholders were careful that

their policy proposals were effective for the

most marginalized communities; to that effect,

no one supported a legalization regime with

government regulation of sex workers.

Vacatur Statutes

Stakeholders expressed that vacatur statutes

were potentially useful for victims of trafficking.

DC’s vacatur statute permits victims of

trafficking to vacate convictions for crimes

committed while under duress and potentially to

expunge the related offenses from their record.51

However, stakeholders understand that

vacatur statutes have complex evidentiary and

procedural barriers to expungement which make

them difficult for many sex workers to access.

“People really love to categorize
other people and there’s a lot
of compassion and concern for
someone if they identify as a victim of
trafficking versus if they identify as
a sex worker, they don’t really have
any legal remedies to things like a
criminal record that might have been
wrongful. So, the vacatur statute is
great and I’m really glad that we’re
probably going to have it, [but] there’s
a portion of the population that it’s
not going to help at all.”

– Stacie Reimer, Former Executive

Director, Amara Legal

Vacatur statutes were understood to not be

useful for immigrant sex workers, whose criminal

records are accessible by the Department of

Homeland Security. Institutional stakeholders

expressed that expungement and vacating

criminal records from prostitution and solicitation

removed barriers to housing and employment

and could be helpful for some people.

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 46

“[I]t helps you for everything, right?
Getting a job, getting an apartment.
That’s one of the barriers to even
getting an apartment right now, if
you have a record.”

– Tina Frundt, Founder, Courtney’s House

Diversion Programs

Institutional stakeholders expressed that

diversion programs were a kind of recognition that

imprisonment is not an appropriate reaction to

consensual commercial sexual exchange. Diversion

programs were understood to vary widely, but

central features include community service, court

appearances, and probationary periods with

heightened consequences for re-arrest.

“We’re giving them all of these
requirements that they may or may
not be able to meet, especially if
they continue in sex work. They
don’t have a way to continue in
sex work and have this diversion
agreement in place because if they
get arrested again then the whole
thing falls apart. Then the third
thing that I think is a real concern is
that you’re connecting the receipt of
services to being arrested.”

– Stacie Reimer, Former Executive Director,

Amara Legal

Stakeholders understand that the effectiveness

of diversion programs varies widely between

programs. Some expressed that diversion

programs should be voluntary and should

not require an arrest or law enforcement

involvement to participate.

“Some of the diversion programs…
are surprisingly good and have good
outcomes and are non- punitive in

their approach. But others kind of
as you signaled, do more harm or do
what we call net widening. They just
basically pull more people into the
system for a longer period of time,
unnecessarily.”

– Yasmin Vafa, Executive Director,

Rights4Girls

“It’s up to the District and we could
do our own diversion program, but
it’s really important that it not be a
system in which you are penalized
by being threatened with jail time if
you don’t participate in the services
or complete goals of the program.
Any diversion program must involve
voluntary participation or I think it
doesn’t work.”

– Nassim Moshiree, Policy Director,

ACLU of DC

Partial Decriminalization

Institutional stakeholders seeking partial

decriminalization (decriminalization of the sale

of sex, but maintaining criminalization of buyers)

state that sex work is performed by marginalized

communities and suggest that partially

decriminalizing sex has a protective effect

on marginalized communities. Stakeholders

advocating for partial decriminalization

articulate a belief that criminalizing buyers

empowers sex workers to report abuse from

buyers. These stakeholders are more likely

to openly equate sex trafficking and sex work,

believing that all sex work is the result of

coercion. They also advocate for maintaining

criminalization of third parties, claiming that

third-party benefactors of sex workers are

coercing sex workers through emotional and

physical violence and manipulation.

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 47

“From our perspective, a lot of the
dynamics in the sex trade mirror
other forms of gender-based
violence. It’s an industry that’s
predicated on racial, gender, and
income inequality that has a very
problematic historical legacy rooted
in colonization and slavery and
is fueled predominately by white
powerful men of means.”

– Yasmin Vafa, Executive Director,

Rights4Girls

There is a desire stated by proponents of partial

decriminalization for regulation or monitoring

of sex workers to ensure that minors and

trafficked persons are not involved. Proponents

of partial decriminalization express a view

of sex work as socially undesirable and are

concerned that full decriminalization sends a

message of acceptability that will proliferate

professional sex workers and the sex tourism

industry. Additionally, these stakeholders

expressed fears include fear of corporatization

of sex work whereby managers control the

services and prices that sex workers charge,

fear that decriminalization leads to more human

trafficking, and fear that legitimizing sex work

removes the incentive of governments to

provide social services.

“Full decriminalization, which
includes decriminalizing acts of
pimping, pandering, sex-buying
and brothel keeping…proliferates
the sex trade and makes it
vulnerable to corporate interests
and corporate influence.”

– Yasmin Vafa, Executive Director,
Rights4Girls

“[I]f this is an adult person who’s
never bought a child and all they do is
buy adults who don’t have a controller,
I can’t really say nothing. But we need
a way to monitor these things.”

– Tina Frundt, Founder, Courtney’s

House

Full Decriminalization

Full decriminalization was favored by other

institutional stakeholders. A common reason

for support of full decriminalization was the

belief that laws criminalizing sex work have a

discriminatory impact on Black communities.

Proponents of full decriminalization state that

current criminal laws are sources of violence

for sex workers and communities of gay and

bisexual men and transgender women profiled

as sex workers.

“[L]et’s be nonjudgmental
and accepting. …[Y]ou know,
criminalization hurts people. And
I don’t know if this is more like,
a Black community argument,
but there’s too much. There are
too many police and too much
criminalization and too many
people have records and this is a
racist system”

– Darby Hickey, Former Legislative
Advisor, Council of the District of
Columbia

Stakeholders who advocate for full

decriminalization believe that removing

criminality will improve the ability of sex

workers to operate safely through increased

access to public services and the ability to work

together without fear of arrest. Advocates for

full decriminalization state that if sex work was

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 48

decriminalized, sex workers would be able to

organize themselves and look out for each other.

They argue that if sex work was not a crime, sex

workers would be more likely to call the police in

the event of violence.

“We strongly believe that if sex
work were decriminalized, it
would actually make it safer for
sex workers to come forward and
report incidents of trafficking or
other serious crimes to police. Sex
workers are on the front lines and
often best positioned to identify
that someone is being subject to
abuse and not there of their own
volition, and they could report this
to police if they didn’t have to fear
arrest.”

– Nassim Moshiree, Policy Director,
ACLU of DC

Diverse stakeholders commented on or

participated in the conflation of sex trafficking with

sex work. Stakeholders were more likely to conflate

sex work and human trafficking if they believed that

no person would voluntarily engage in sex work.

“Trafficking and sex work are
often conflated, and everything
gets wrapped up and labeled as
trafficking. And so someone who
is engaged in consensual sex work
for any variety of reasons – because
they simply want to, because they
find it empowering, or because they
need to pay rent – gets caught up in
anti-trafficking efforts.”

– Nassim Moshiree, Policy Director,
ACLU of DC

Effects of Decriminalization

Stakeholders generally believed that

decriminalization would make sex workers

more likely to report incidences of violence

to the police, would increase trust between

sex workers and police, and would assist anti-

trafficking efforts by allowing sex workers

to safely identify when someone is being

coerced. Stakeholders expressed the belief

that decriminalization would increase access to

the District’s supportive services and increase

retention and engagement in health care.

“I hope that it would bring them
more safety. I hope that they would
be able to call the police when they
had a problem and that they could
actually get some help. I think it
would reduce stigma.”

– Stacie Reimer, Former Executive
Director, Amara Legal

Comparing Perspectives

There was a substantial amount of agreement

between community participants in the focus

groups and the institutional stakeholders who

participated in the interviews.

MOTIVATIONS OF SEX WORKERS

Both data sets captured that participation in

sex work is primarily motivated by earning a

livelihood and accessing housing and food.

These motivations are understood to arise from

socioeconomic circumstances, like poverty, which

create situations of economic necessity where

participation in sex work is a pathway to self-

sufficiency and survival. Community participants

and institutional stakeholders agreed that criminal

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 49

penalties were unsuccessful at stopping or

deterring people from engaging in sex work.

SEX WORK VERSUS TRAFFICKING

All community participants and most institutional

stakeholders distinguished between sex work

and human trafficking. The gay and bisexual

men and transgender women sex workers in

focus groups remarked on their agency when

participating in sex work. Most stakeholders

agreed that enforcement of the District’s

prostitution and solicitation laws was ineffective

in the fight against human trafficking, in particular

the fight against the sexual exploitation of

minors. The few stakeholders who believed

that criminalizing sex work helped fight human

trafficking were particularly concerned with the

sexual exploitation of minors. When speaking

about adults, these stakeholders expressed that

the economic circumstances for sex workers were

so intense as to be coercive, removing meaningful

capacity for choice in those situations. Because

homelessness and access to necessities of daily

living like food and clothes are primary motivators

for participation in sex work, increasing access

to social programs may decrease the economic

necessity for participation in sex work.

NEED FOR SOCIAL SERVICES

Community participants and institutional

stakeholders noted that a lack of sufficient

funding for social programs and widespread

employment discrimination created the economic

circumstances that disproportionately impact

Black transgender women and gay and bisexual

men. Both groups agreed that additional resources

to provide housing support, employment programs,

and medical and supportive services would improve

the health and wellbeing of sex workers. Notably,

both groups agreed that access to insurance

was not a major barrier to medical services in the

District. This result indicates that District policies

to improve health care access are successful at

reaching the District’s communities of sex workers.

LAWS CREATE BARRIERS

Both groups agreed that criminalization of sex

work created barriers to housing, employment,

and health. These barriers arise from legal

mechanisms, such as policies that bar people

with criminal records from housing assistance

or federal grant programs, and through less

direct psychosocial mechanisms like stigma,

which contributes to the vulnerability of sex

workers to violence and discrimination. The law

created social stigma related to criminality that

has normalized violence toward sex workers and

those stereotyped as sex workers. The law was

also seen to propagate stigmatizing messages

that are internalized by sex workers. Internalized

stigmas created a sense of anticipatory

discrimination in sex workers, discouraging them

from reporting crimes when they were victimized

and discouraging them from communicating with

their health care providers.

SUPPORT FOR LEGAL REFORMS

All community participants and institutional

stakeholders believed that the current laws

needed to be reformed. Most supported the

decriminalization of consensual commercial

sexual exchange, with some desiring additional

requirements and conditions on employment,

but stopping short of a governmental

legalization regime. In particular, there was

strong support for the full decriminalization

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 50

of sex work. Some supported the partial

decriminalization of sex work, believing that

criminalizing the buying of sex is needed to

continue to give the law enforcement officers

authority to investigate potential sexual

exploitation and human trafficking.

CONCERNS ABOUT LEGALIZATION

Nearly all community participants and

institutional stakeholders voiced concerns

about creating a regulatory and legalization

regime in the District. There was widespread

agreement that legalization would result in

continued marginalization of immigrants,

people living with HIV, and transgender women

of color. There was a sense that legalization

resulted in the promulgation of commercialized

and corporatized structures of sex work, an

outcome which was not favored by community

participants nor institutional stakeholders. All

of the stakeholders and community participants

sought to reduce sources of violence and

coercion for sex workers, including potentially

coercive and exploitative legal employment.

LIMITATIONS OF VACATUR AND
DIVERSION

While not every institutional stakeholder and

community participant discussed the subject

of vacatur statutes and diversion programs,

there was generally agreement that these

interventions had limited applicability for most

sex workers due their complex procedural

requirements and high evidentiary burdens.

In particular, vacatur statutes and diversion

programs were perceived as requiring people to

stop engaging in sex work without establishing

supports for housing and employment training

that would facilitate leaving the sex trade.

DISTRUST OF THE MPD

There was agreement between community

participants and institutional stakeholders that

current MPD practices and policies undermine

trust and create barriers to community safety.

Discrimination, harassment, and violence against

sex workers by MPD officers were viewed as

severely detrimental to building trust with law

enforcement, in particular a barrier to fighting

trafficking. Community participants felt that it

is hypocritical of MPD officers who are clients

of sex workers to enforce laws criminalizing

sex work. MPD accountability processes,

mediated by the OPC, were perceived to be

an improvement over previous practices, but

a lack of transparency around how complaints

are handled contributed to feelings of mistrust.

Notably, both MPD stakeholders and sex workers

agreed that criminalization of sex work is barrier

to MPD’s handling of reports of violence against

sex workers—both in reporting these crimes and

prosecuting them.

CULTURAL COMPETENCY TRAINING

There was agreement between the community

participants and institutional stakeholders

that MPD officers should receive additional

training on the LGBTQ community as well as

on race and systemic racism. The Gay and

Lesbian Liaison Unit (GLLU) was understood to

be a leader in the nation in advancing cultural

competency of law enforcement officers, but

levels of cultural competency varied among MPD

officers. Community participants expressed that

they liked that all members of the GLLU have

expertise in LGBTQ cultural competency, while

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 51

institutional stakeholders from the MPD implied

that including non-specialized officers in the

GLLU was a strength of the program.

Recommendations

Based on the research findings, we recommend

the following to remove barriers to health and

wellbeing for transgender women and sex

workers in the District of Columbia.

REFORMS THAT WE RECOMMEND

We recommend that the DC Council:

1. Reform the criminal code of the District
of Columbia to eliminate criminal
penalties for consensual commercial
sexual exchange between adults.

Criminalization causes arrest and incarceration,

vulnerability to state and non-state sponsored

violence, homelessness, lack of employment,

and barriers to health care. Criminalization also

contributes to stigma, discrimination, and early

death for sex workers and those stereotyped as

sex workers. Decriminalization of consensual

commercial sexual exchange between adults

removes a driver of racial inequalities in arrest

and incarceration, is a cost-effective method of

reducing crime and improving community health,

and recognizes the inherent dignity of individuals

to control their own body and the conditions of

their existence.

2. Increase access to affordable housing.

Increased resources for supportive housing and

prioritizing populations of transgender women of

color would remove or alleviate barriers to access-

ing housing and address a primary motivation for

participation in sex work.

3. Increase resources for job training and
employment programs.

Increased resources focused on providing pop-

ulations of greatest need, identified here as sex

workers and transgender women of color, with

skills-building programming, secondary educa-

tion, apprenticeships, and employment readiness

programs will ameliorate a gap in access to other

employment for sex workers.

4. Increase efforts to address
discrimination against LGBTQ people.

Our research identifies discrimination against

transgender people as a primary driver of survival

sex work. Additional resources to help fight dis-

crimination in employment, education, and other

areas will increase access to careers and gainful

employment for LGBTQ people and help improve

the health and wellbeing of people engaged in com-

mercial sexual exchange.

REFORMS THAT WE DO NOT RECOMMEND

Partial Decriminalization of Sex Work

We do not recommend partial decriminalization

or decriminalizing only selling sexual

services and maintaining criminal penalties

for buying sexual services and third-party

participation. Our research indicates that

partial decriminalization does not reduce

experiences of violence for sex workers or

allow them to access law enforcement. Partial

decriminalization maintains existing stigma on

sex workers by seeking to eradicate sex work,

and consequently fails to address the identified

harms of stigma on sex workers and those

stereotyped as sex workers.

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 52

Legalization of Sex Work

We do not recommend legalization of sex

work or the regulation of commercial sexual

exchange, often through mandated licensing and

screening and limitations on where and under

what circumstances consensual commercial

sexual exchange may be conducted. We do

not recommend legalization because it fails

to ameliorate the marginalization sex workers

experience. In particular, transgender women

of color and people living with HIV are likely to

continue to be marginalized under legalization

due to not being able to access legal venues for

sex work.

Additional information on the emergent

effects of decriminalization may support

some governmental regulation of commercial

sexual services, but these should be created in

consultation and agreement with the District

of Columbia’s communities of sex workers.

Voluntary, accessible, and culturally competent

health care services are more effective than

mandated screening requirements and

compliant with international standards for

realizing the human right to health.

Vacatur Statutes

We do not recommend vacatur statutes as a

potential solution for the harms arising from

criminalization of consensual commercial sexual

exchange. Existing vacatur or sealing statutes

allow for some people to expunge or seal their

criminal records. However, these statutes

have complex procedural requirements, high

evidentiary standards, and limited applicability

to many potential beneficiaries, in particular

immigrant sex workers. Because of the high

evidentiary standards, vacatur statutes are

most useful for extreme cases of human

trafficking where traffickers clearly coerced their

victims into committing criminal acts.

RESEARCH LIMITATIONS

Applicability

The application of this research is limited by the

timing of our research, conducted during 2017,

and our sampling and interview methods. This

research is unable to speak to the effects of the

reform efforts initiated in 2020, but does reflect

the enforcement practices and policies of the

MPD through 2020. While our description and

explanation of the effects of criminalization on

the health and wellbeing of sex workers may be

generalizable within DC and to other jurisdictions,

the results and recommendations of our report

are limited in applicability to Washington, DC’s

local governance. Our legal analysis is limited

to the local ordinances regarding solicitation,

prostitution, and brothel-keeping.

Our research focuses on communities of Black

sex workers, with a focus on Black transgender

women as a group that experiences overlapping

marginalization based on their intersecting

identities. This focus is a strength of the

research, as policies which address the most

marginalized groups are likely to address

conditions that create vulnerability for all groups.

It is reasonable to conclude that the sex

worker’s experiences with criminalization

and enforcement in Washington, DC are

generalizable to a wider population of sex

workers in the United States. The present

findings align with previous DC-based research

in the Move Along Report52 , the DC Trans

Needs Assessment53 , and the research

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 53

conducted by the United Nations54 , Amnesty

International55 , and Human Rights Watch56 in

other jurisdictions.

Our qualitative analysis engages with the

harms from criminalization as understood by

sex workers. Our report uses interviews by

institutional stakeholders to highlight how

criminalization produces the effects that sex

workers experience. Research published in

medical journals on health outcomes in other

jurisdictions serves to provide additional evidence

of the connection between the health outcomes

and structural factors.57

Our analysis regarding the impact of FOSTA-

SESTA on the health and wellbeing of sex

workers is likely generalizable, but additional

research on the national impact is necessary to

identify outcomes with epidemiological rigor.

Sampling

Nearly all focus group community participants

were Black, and most were transgender

women. We used convenience sampling to find

participants. Transgender women of color report

high levels of survey fatigue as a population. This

feeling of being research specimens rather than

research participants may suppress responses

and decrease the pool of potential participants

or cause non-random self-selection of survey

naïve participants who may have different

experiences with law enforcement. However, the

characteristics of our sample contribute to the

strengths of this research because they match

the demographic breakdown of street-based

sex workers who are disproportionately affected

by the two epidemics of HIV and hate crimes in

the District of Columbia.58 Additional research

could expand the pool of potential participants

to determine if our findings are anomalous. We

did not recruit and sample Latinx sex workers

in this research. The focus group participants

were all English-speaking and none were recent

immigrants, potentially limiting the application

of our research to address the concerns of DC’s

communities of immigrants and English-language

learners. Our interview data provide a number of

ways in which the legal status of immigrant sex

workers creates barriers to health and wellbeing;

however, future research would benefit from

collecting information on the lived experiences of

immigrant and non-English speaking sex workers.

Future Research

This project is a cross-sectional sampling of

current and former sex workers. A longitudinal

study would be able to observe the potential

consequences of legal changes to identify

causal relationships with more accuracy. This

research strengthens our understanding of the

material processes of criminalization’s effects.

Additional research specific to Washington,

DC would strengthen the theoretical bridge

between law and its effects. For example,

quantitative analysis of policing practices and

policies, analysis of prosecutions, trials, and

incarceration, and an analysis of medical and

legal outcomes and effects on marginalized

transgender communities.

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 54

Appendix A: Community Participant Survey Data

RELEVANT CHARACTERISTICS OF PARTICIPANTS WERE:

Age. Participants ranged from age 20 to age 55, with a majority in their 20s and 30s.

Race, ethnicity, sexual orientation and gender identity. Almost all participants identified as Black

and almost none identified as Latinx. 67 percent identified as transgender women; 30% identified

as cisgender men; two participants identified as non-binary; and one participant as a cisgender

woman. All of the cisgender men identified as gay or bisexual; the transgender and non-binary

individuals identified as a range of sexual orientations.

Income and housing. 37 percent of participants were homeless at the time of the survey; 70% had

experienced unstable housing in the previous two years. 57 percent reported annual incomes of

less than $6,000 at the time of the survey; only 7% reported annual incomes of $30,000 or more.

Amount of commercial sex work. 52 percent of participants reported that all or most of their

income came from sex work, and another 26% reported that sex work accounted for one-half or

more of their income. 15 percent reported that sex work accounted for less than one-quarter of

their income. 59 percent engaged in sex work more than once a week; another 11% reported sex

work about once a week; 30 % reported that they engaged in sex work less often.

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 55

Health insurance self-reported health; HIV status and use of PrEP; STI testing. Almost all of the

participants reported that they had health insurance, mostly through Medicaid. Few reported that they

had been unable to get health care they thought they needed; 74% rated their own health as “Good” or

better. 59 percent had been diagnosed as HIV-positive. Most of the rest had tested HIV-negative within

the past year. All of the HIV-negative individuals reported that they had heard about PrEP, but most of

them had not used it. Two participants reported that they had PrEP prescriptions, but one said that they

were not taking the drug and the other said they only used it after a sexual accident, such as a broken

or slipped condom (which essentially means they were not adherent). Most participants said they had

been tested for other STIs within the past year; 63% had been diagnosed with one or more STIs at

some point in time. 67 percent of participants said that when last tested for HIV or other STIs, they had

disclosed to the tester or doctor that they had engaged in sex work.

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 56

Appendix B: Institutional Stakeholder Interview Participants

NAME TITLE/ORGANIZATION
Yvette Butler Former Director of Policy and Strategic Partnerships, Amara Legal

Stacie Reimer Former Executive Director, Amara Legal

Denise Hunter Senior Staff Attorney, Whitman Walker Health

Yasmin Vafa Executive Director, Rights4Girls

Brett Parson Former Manager, Special Liaison Branch (oversees LGBTLU); Lieutenant, MPD

Kelly O’Meara Executive Director, Strategic Change Division

Michael Kharfen Senior Deputy Director of HIV/AIDS, Hepatitis, STD, and TB Administration
(HAHSTA), DC Department of Health

David Grosso Chairperson of the Committee on Education, At Large Councilmember,
Council of the District of Columbia

Darby Hickey Former Senior Legislative Advisor for CM Grosso

Nassim Moshiree Policy Director, ACLU of DC

Tina Frundt Founder of Courtney’s House

Anonymous Activist and educator

Michael Tobin Office of Police Complaints, Executive Director

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 57

Appendix C: DC’s History of Sex Work Policing

Historically, the policy approach to sex work

has changed in response to community action

and emerging public health evidence. For

example, in the 1800s, due to the presence

of standing armies and the rapid increase in

District population during and after the Civil

War, the number of sex workers increased

rapidly.59 At that time, authorities believed

that sex workers helped contain disease and

were a necessary outlet for excess male sexual

energy. Consequently, sex work was confined to

several red-light districts adjacent to centers of

commerce and government. 60

When public opinion changed in the late 1800s

and early 1900s, sex work was described as

morally wrong and degrading to the cohesion of

families.61 Early in the 20th century, Congress

sought to abolish sex work and passed laws to

“define and prohibit” “pandering…and provide

for the punishment thereof” (1910) and to “enjoin

and abate houses of lewdness, assignation and

prostitution” (1914) in the District.62,63 In 1935,

Congress criminalized solicitation for prostitution

in District.64

In 1989, counter to the policy of the MPD, District

police removed sex workers from downtown

street corners and marched them toward the

Virginia state line via the 14th Street Bridge.65

During the 1990s, the “broken window” theory—

which argues that policing low-level offenses can

prevent more serious crimes, was popular,66 and

the DC Council passed a number of measures

restricting freedom of movement and expanding

the ability of police to stop, search, and arrest

people suspected of sex work.

67

In 1998, the DC Council passed a 90-day bill

criminalizing people for wearing revealing clothing

and for repeatedly engaging in conversation

with passersby for the purpose of prostitution.68

Street signs were erected in the late 1990s

prohibiting right turns between 9pm and 5am

at certain intersections in an effort to keep

clients from circling blocks where sex workers

gathered.69

In response to these restrictions on their

freedom of movement in DC and increasing

violence, in 2005, sex workers and communities

of transgender people organized the Alliance

for a Safe and Diverse DC.70 In 2006, the DC

Council enacted omnibus crime legislation which,

among other provisions, sought to suppress

sex work in DC. 71 The laws enacted include

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 58

provisions declaring indoor sex work a nuisance,

impounding vehicles used in furtherance of a

prostitution-related offense, and empowering the

police chief to create “prostitution free zones”

(PFZ). A PFZ could be declared over city blocks,

and police could order anyone suspected of being

a sex worker to “move along.” Due to concerns

about constitutionality, prostitution free zones

were repealed by the DC Council in 2014.72

Traffic restrictions, nuisance laws, and vehicle

impounding are still in effect.

Organizing efforts and community-based

research conducted by the Alliance for a Safe and

Diverse DC in 2007 and 2008 were successful in

challenging MPD policies and securing positive

statements of support from city government

employees, elected officials, and other LGBTQ

and human rights organizations.73

In July 2012, Human Rights Watch published

a report on police, including MPD officers,

using the presence of condoms as evidence of

sex work.74 The MPD responded with a public

education campaign, publishing and distributing

cards to officers and sex workers clarifying that

carrying condoms is not an arrestable offense.75

The MPD noted, however, that while condoms

alone are not sufficient evidence of sex work,

condoms may still be used as “supplementary

evidence in some cases and will continue to be

collected at the scene.”76 This distinction may

continue to cause confusion and have negative

effects on public health.

Throughout the summer of 2015, the

Human Trafficking and Narcotics Units of

MPD conducted prostitution enforcement

operations.77 These enforcement operations

resulted in over 200 arrests for solicitation and

prostitution.78

In an effort to move away from “broken window

policing,” in 2016, the DC Council passed the

Neighborhood Engagement Achieves Results

Act, or the NEAR Act.79 The NEAR Act asserts

a public health approach to crime, seeking

to interrupt violence through investments in

community resources and seeking to improve

MPD relationships with surveys and data on

policing. In 2019, a Working Group was convened

by the Mayor to explore potential diversion

programs for sex workers.80 In 2019, after court-

ordered compliance with the NEAR Act’s reporting

requirements on all police stops, the data revealed

significant racial disparities in policing practices.81

The data showed that MPD stopped Black people

in excess of their demographic make-up by 14%-

39%, depending on the outcome and type of

police encounter. 82

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 59

Endnotes

1 Laws in the United States use the term “prostitution”, which has connotations of criminality
and immorality. Many people who sell sexual services prefer the term “sex work” and find the term
“prostitution” demeaning and stigmatizing, which contributes to their exclusion from health, legal,
and social services. Throughout the report, we use the term “sex work” but we occasionally use the
term “prostitution” when refer to DC law or other state or federal laws.

2 Move Along: Policing Sex Work in Washington, D.C., alliance FOr a saFe & diverse
dc, WashinGtOn, d.c. 1, 21 (2008), https://dctranscoalition.files.wordpress.com/2010/05/
movealongreport.pdf; d.c. cOde § 2-1401.01 (2020).

3 Elijah A. Edelman et al., Access Denied: Washington, DC Trans Needs Assessment Report,
dc trans cOal. (2015), https://dctranscoalition.files.wordpress.com/2015/11/dctc-access-denied-
final.pdf.

4 Throughout this report, we use sex worker as an umbrella term to refer to individuals working
“in all aspects of the sex trades, indoor or street-based, legal and criminalized, and [it] can include
people who trade sex for money as well as safety, drugs, hormones, survival needs like food, shelter,
or clothing, or immigration status or documentation.” Policing Sex Work, INCITE! (July 12, 2018),
https://incite-national.org/policing-sex-work/#sthash.FJvFHpdK.dpuf.

5 Footer KHA, Silberzahn BE, Tormohlen KN, Sherman SG. Policing practices as a structural
determinant of HIV among sex workers: a systematic review of empirical findings. J Int AIDS Soc.
2016;19(Suppl 3):20883.

6 Marya Annette McQuirter, African Americans in Washington, DC: 1800-1975, a brieF histOry
OF aFrican americans in WashinGtOn, dc, (Reprinted with permission in Washington: Cultural Tourism
DC, 2003), https://www.culturaltourismdc.org/portal/a-brief-history-of-african-americans-
in-washington-dc. See also Peter Bonds, Stonewall on the Potomac: Gay political activism in
Washington, DC, 1961-1973, James madisOn university, Thesis, (2016).

7 Michael Miller, In 2018, they all became victims of a record-setting year of hatred in D.C.,
Wash. pOst (Aug. 21, 2019), https://www.washingtonpost.com/graphics/2019/local/dc-hate-
crimes/.

8 HIV Basic Statistics, centers FOr disease cOntrOl and preventiOn, https://www.cdc.gov/hiv/
basics/statistics.html (last reviewed July 1, 2020).

9 Edelman et al., supra note 3.

10 Edelman et al., supra note 3.

11 Jae M. Sevelius, et al., HIV Testing and PrEP Use in a National Probability Sample of Sexually
Active Transgender People in the United States, 84 J. acquired immune deFiciency syndrOme 437 (2020).

12 Addressing Anti-Transgender Violence, hum. rts. campaiGn, trans peOple OF cOlOr cOal. (2015),
https://assets2.hrc.org/files/assets/resources/HRC-AntiTransgenderViolence-0519.pdf.

13 Kate Shannon et al., Global epidemiology of HIV among female sex workers: influence of
structural determinants, 385 the lancet 55 (2015).

14 Brad Sears & Christy Mallory, Documented Evidence of Employment Discrimination & Its
Effects on LGBT People, Williams inst. (2011), https://williamsinstitute.law.ucla.edu/wp-content/
uploads/Effects-LGBT-Employ-Discrim-Jul-2011.pdf.

15 Teresa Rainey et al., qualified and transgender, OFF. hum. rts. (Nov. 2015), https://ohr.
dc.gov/sites/default/files/dc/sites/ohr/publication/attachments/QualifiedAndTransgender_
FullReport_1.pdf.

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 60

16 UN Human Rights Council, Human rights in the response to HIV, 1 May 2019, A/HRC/41/27,
available at https://undocs.org/A/HRC/41/27 [accessed 14 Oct. 2020].

17 Amnesty International Policy on State Obligations to Respect, Protect and Fulfill the Human
Rights of Sex Workers, amnesty int’l (May 26, 2016), https://www.amnesty.org/en/documents/
pol30/4062/2016/en/.

18 Response to UN Women’s consultation on sex work, GlObal alliance aGainst traFFic in WOmen
(Oct. 16, 2016), https://www.gaatw.org/events-and-news/68-gaatw-news/857-response-to-un-
women-s-consultation-on-sex-work.

19 Human Trafficking and Sex Workers Rights, FreedOm netWOrk usa (Apr. 2015), https://
freedomnetworkusa.org/app/uploads/2018/07/HT-and-Sex-Workers-Rights.pdf.

20 Neela Ghoshal, Stop Criminalizing Sex Work in DC, hum. rts. Watch (July 11, 2019), https://
www.hrw.org/news/2019/07/11/stop-criminalizing-sex-work-dc.

21 Response to UN Women’s consultation on sex work, supra note 18.

22 Prevention and treatment of HIV and other sexually transmitted infections for sex workers in
low- and middle-income countries, World Health Org. (WHO Dept. of HIV/AIDS eds., 2012), https://
www.who.int/hiv/pub/guidelines/sex_worker/en/.

23 Fast-Track and human rights, unaids (May 27, 2017), https://www.unaids.org/en/
resources/documents/2017/fast-track-human-rights.

24 UN Human Rights Council, Report of the Special Rapporteur on the right of everyone to
the enjoyment of the highest attainable standard of physical and mental health, 27 April 2010, A/
HRC/14/20, available at https://www.refworld.org/docid/4c076fb72.html [accessed 14 Oct. 2020].

25 Agenda for zero discrimination in health care, UNAIDS (Feb. 17, 2017), https://www.unaids.
org/sites/default/files/media_asset/Agenda-zero-discrimination-health care_en.pdf.

26 M4BL Policy Platform, End the war on Black women, mOvement FOr black lives, https://m4bl.
org/policy-platforms/end-the-war-black-women/ (last visited Oct. 12, 2020).

27 Ashley Nellis, The Color of Justice: Racial and Ethnic Disparities in State Prisons, the
sentencinG prOJect (June 14, 2016), https://www.sentencingproject.org/publications/color-of-
justice-racial-and-ethnic-disparity-in-state-prisons/; see also Ilan H. Meyer et al., Incarceration
Rates and Traits of Sexual Minorities in the United States: National Inmate Survey, 2011–2012, 107
am. J. public health (2017), http://ajph.aphapublications.org/doi/10.2105/AJPH.2016.303576.

28 Response to UN Women’s consultation on sex work, supra note 18.

29 Kate Shannon et al., supra note 13; see also Sushena Reza-Paul, et al. Sex worker-led
structural interventions in India: a case study on addressing violence in HIV prevention through
the Ashodaya Samithi collective in Mysore the indian J. OF medical research vol. 135,1 (2012): 98-106.
doi:10.4103/0971-5916.93431.

30 Melissa Ditmore, Sex Work, Trafficking and HIV: How Development is Compromising Sex
Workers’ Human Rights, in develOpment With a bOdy: sexuality, human riGhts & develOpment 54–66
(Andrea Cornwall et al., eds. 2008).

31 Robert Y. Thornton, Organized Crime in the Field of Prostitution, 46 J. crim. l. and
criminOlOGy 775 (1956), https://scholarlycommons.law.northwestern.edu/cgi/viewcontent.
cgi?article=4440&context=jclc.

32 Kimberly Hehlman-Orozco & William D. Snyder, Legalizing prostitution could end
sex-trafficking investigations, the hill (Mar. 19, 2019), https://thehill.com/opinion/criminal-
justice/434272-legalizing-prostitution-could-end-sex-trafficking-investigations.

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 61

33 Jonah Newman & Nikki Baim, Prostitution-loitering law likely to target women of color for
arrest, chicaGO repOrter (July 24, 2018), https://www.chicagoreporter.com/prostitution-loitering-
ordinance-likely-to-target-women-of-color-for-arrest/.

34 d.c. cOde § 22-2701.

35 Hedgpeth & Hermann, infra note 78.

36 Joshua Kaplan, Police Reports Raise Questions about MPD’s Tactics During Undercover
Prostitution Stings, Wash. city paper (Oct. 18, 2019), https://washingtoncitypaper.com/
article/178010/police-reports-raise-questions-about-mpds-tactics-during-undercover-
prostitution-stings/.

37 Keith Alexander, Off-duty D.C. police officer convicted of assault with a deadly weapon,
Wash. pOst (Oct. 26, 2012), https://www.washingtonpost.com/local/crime/off-duty-dc-police-
officer-convicted-of-assault-with-a-deadly-weapon/2012/10/26/de37f176-1fa1-11e2-ba31-
3083ca97c314_story.html; see also Keith Alexander & Paul Duggan, D.C. police officer indicted on
sexually assaulting three women since ’06, Wash. pOst (July 14, 2011), https://www.washingtonpost.
com/local/dc-police-officer-indicted-on-sexually-assaulting-three-women-since-06/2011/07/14/
gIQAFBC6EI_story.html; Marina Marraco, Transgender prostitutes who accused cops in sex scandal
meet with US prosecutors, FOX 5 DC (Nov. 20, 2018), https://www.fox5dc.com/news/transgender-
prostitutes-who-accused-cops-in-sex-scandal-meet-with-us-prosecutors.

38 Community Safety and Health Amendment Act of 2019, Pub. L. No. B23-0318 (D.C. 2019),
http://lims.dccouncil.us/Legislation/B23-0318.

39 Comprehensive Policing and Justice Reform Amendment Act of 2020 (Introduced July 31,
2020) (https://lims.dccouncil.us/Legislation/B23-0882).

40 Paul Wagner, DC police chief tells officers the city council has “completely abandoned” them,
FOX 5 DC (June 13, 2020), https://www.fox5dc.com/news/dc-police-chief-tells-officers-the-city-
council-has-completely-abandoned-them (stating “They forgot about our 20 years of reform, and
they insulted us by insinuating that we were in an emergency need of reform.”).

41 Keith Alexander, D.C. police union seeks court injunction to stop release of body-
worn camera footage, officers’ identity following fatal interactions, Wash. pOst (Aug. 10, 2020),
https://www.washingtonpost.com/local/public-safety/dc-police-union-seeks-court-
injunction-to-stop-release-of-body-worn-camera-footage-officers-identity-following-fatal-
interactions/2020/08/10/deb8785a-db28-11ea-8051-d5f887d73381_story.html.

42 “Congress has power over transportation ‘among the several states;’ that the power is
complete in itself, and that Congress, as an incident to it, may adopt not only means necessary but
convenient to its exercise, and the means may have the quality of police regulations.” Hoke v. U S,
227 U.S. 308 (1913). See also Committee on the Commercial Sexual Exploitation and Sex Trafficking
of Minors in the United States, Confronting Commercial Sexual Exploitation and Sex Trafficking of
Minors in the United States, inst. med. (2013), https://www.nap.edu/read/18358/chapter/7#145.

43 Trafficking Victims Protection Reauthorization Act of 2003, Public Law 108-193, 117 Stat.
2875; see also Elizabeth Kaigh, Whores and Other Sex Slaves: Why the Equation of Prostitution
with Sex Trafficking in the William Wilberforce Reauthorization Act of 2008 Promotes Gender
Discrimination, 12 SchOlar 139, 150 (2009) at 149 (citing “The inherent problem with the statute
is the definition of sex trafficking, which does not require coercion to distinguish it from common
prostitution”).

44 H.R.1865 – Allow States and Victims to Fight Online Sex Trafficking Act of 2017, Public Law 115-
164, 132 Stat. 1253 (codified at 47 U.S.C. 230(e)) (Approved Apr. 11, 2018), https://www.congress.gov/
bill/115th-congress/house-bill/1865/text.

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 62

45 About FOSTA, craiGslist, https://www.craigslist.org/about/FOSTA (last visited Oct. 12,
2020); see also Samantha Cole, Sex Workers Say Porn on Google Drive is Suddenly Disappearing,
vice (Mar. 21, 2018), https://www.vice.com/en/article/9kgwnp/porn-on-google-drive-error;
Samantha Cole, Furry Dating Site Shuts Down Because of FOSTA, vice (Apr. 2, 2018), https://www.
vice.com/en/article/8xk8m4/furry-dating-site-pounced-is-down-fosta-sesta.

46 Danielle Blunt, Ariel Wolf & Naomi Lauren, Erased: The Impact of FOSTA-SESTA, hackinG//
hustlinG 1, 20, https://hackinghustling.org/wp-content/uploads/2020/01/HackingHustling-
Erased.pdf (last visited Oct. 11, 2020).

47 As of Oct. 19, the Senate has placed EARN IT Act of 2020 on the legislative calendar. See
S.3398 – EARN IT Act of 2020 Congress.gov, (Oct. 19, 2020) https://www.congress.gov/bill/116th-
congress/senate-bill/3398/all-actions.

48 Eliminating Abusive and Rampant Neglect of Interactive Technologies Act of 2020, S. 3398
116th Cong. (2d Sess. 2020).

49 Hannah Quay-de la Vallee & Mana Azarmi, The New EARN IT Act Still Threatens Encryption
and Child Exploitation Prosecutions, center FOr demOcracy and technOlOGy (August 25, 2020),
https://cdt.org/insights/the-new-earn-it-act-still-threatens-encryption-and-child-exploitation-
prosecutions/.https://cdt.org/insights/the-new-earn-it-act-still-threatens-encryption-and-child-
exploitation-prosecutions/.

50 Ed Pound et al., Poor Conditions Persist at Aging D.C. Jail; New Facility Needed to Mitigate
Risks, OFF. d.c. auditOr (Feb. 28, 2019), http://dcauditor.org/report/poor-conditions-persist-at-
aging-d-c-jail-new-facility-needed-to-mitigate-risks/.

51 D.C. Law 22 §§ 279, 515 (Enacted April 5, 2019).

52 Move Along: Policing Sex Work in Washington, supra note 2.

53 Edelman et al., supra note 3.

54 UN Human Rights Council, supra note 16.

55 Amnesty International Policy on State Obligations to Respect, Protect and Fulfill the Human
Rights of Sex Workers, supra note 17.

56 Neela Ghoshal, supra note 20.

57 Kate Shannon et al., supra note 13.

58 Michael Miller, In 2018, they all became victims of a record-setting year of hatred in D.C.,
Wash. pOst (Aug. 21, 2019), https://www.washingtonpost.com/graphics/2019/local/dc-hate-
crimes/. See also Edelman et al., supra note 3 and HIV Basic Statistics, centers FOr disease cOntrOl
and preventiOn, https://www.cdc.gov/hiv/basics/statistics.html (last reviewed July 1, 2020).

59 Matt Blitz, Meet the Madam on the Mall, smithsOnianmaG.cOm (Feb. 20, 2015), https://www.
smithsonianmag.com/history/meet-madam-mall-180954371/?all; see also Claudia Swain, The
Oldest Profession in Washington, bOundary stOnes (June 3, 2015), https://boundarystones.weta.
org/2015/06/03/oldest-profession-washington.

60 Within sight of the White House: Section of Washington, D.C., known as “Hooker’s Division,”
which contains 50 saloons and 109 bawdy-houses–list of 61 places where liquor is sold with
government sic but without city licenses. [Map] library OF cOnGress, (Accessed July 2020), https://
www.loc.gov/item/87694066/.

61 Jacqueline Shelton, Evil Becomes Her: Prostitution’s Transition from Necessary to Social Evil in
19th Century America, elec. theses and dissertatiOns (2013), https://dc.etsu.edu/etd/1172/; see also George
P. Dale, Moral Prophylaxis: Prostitutes and Prostitution (Continued), 12 am. J. nursinG 1, 22-26 (1911).

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 63

62 Title 22, DC Code, Ch. 27 § 22-2705, An Act In relation to pandering, to define and prohibit the
same and to provide for the punishment thereof, (Approved June 25, 1910, last codified October 9,
2020) (Federal law incorporated into DC Code).

63 Title 22 DC Code Ch. 27 § 22-2713, An Act To enjoin and abate houses of lewdness,
assignation, and prostitution; to declare the same to be nuisances; to enjoin the person or persons
who conduct or maintain the same and the owner or agent of any building used for such purposes;
and to assess a tax against the person maintaining said nuisance and against the building and owner
thereof, (Approved February 7, 1914, last codified October 9, 2020) (Federal law incorporated into DC
Code).

64 An Act for the Suppression of Prostitution in the District of Columbia, Pub. L. No. 276, 74th
Cong. § 546 (1935), https://www.loc.gov/law/help/statutes-at-large/74th-congress/session-1/
c74s1ch546.pdf.

65 Bill Dedman & Jeffrey Goldberg, March Clears Out Prostitution Zone; D.C. Police Criticized
After Ordering Women to Walk to Va. Line, Wash. pOst (July 26, 1989).

66 Sarah Childress, Frontline: The Problem with “Broken Windows” Policing, pub. brOad. serv.
(June 28, 2016), https://www.pbs.org/wgbh/frontline/article/the-problem-with-broken-windows-
policing/ (referencing a theory that argues that policing low-level offenses can prevent more serious
crimes).

67 Image courtesy of Stephen Jaffe.

68 Street Solicitation for Prostitution Emergency Act of 1998, Pub. L. No. B12-719 (D.C. 1998),
http://lims.dccouncil.us/Download/6282/B12-0719-INTRODUCTION.pdf; see also Maria
Elena Fernandez, D.C. Poised to Run Out Prostitutes, WASH. POST (July 12, 1998), https://www.
washingtonpost.com/archive/local/1998/07/12/dc-poised-to-run-out-prostitutes/25989434-
35c5-4830-ad57-8c6dbb673afd/.

69 See supra note 2, at 10; see also Ron Shaffer, Good News for the I-66 Crowd,
WASH. POST (Nov. 26, 1992), https://search-proquest-com.dclibrary.idm.oclc.org/
docview/140749450?accountid=46320.

70 See supra note 2; see also d.c. cOde § 2-1401.01.

71 Omnibus Public Safety Amendment Act of 2006, DC Law 16-306 (Effective April 24, 2007)
https://code.dccouncil.us/dc/council/laws/16-306.html.

72 Repeal of Prostitution Free Zones Amendment Act of 2014: Hearing on Bill 20-760 Before
the Comm. of the Judiciary and Pub. Safety, Council of the District of Columbia (July 17, 2014), http://
lims.dccouncil.us/Download/31535/B20-0760-HearingRecord1.pdf.

73 Agenda: 2008 An election-year guide to local GLBT issues in Washington, D.C., Glaa (July 2,
2008), http://glaa.org/archive/2008/agenda2008.shtml#partII.

74 Megan McLemore, Sex Workers at Risk: Condoms as Evidence of Prostitution in Four
US Cities, HUM. RTS. WATCH 1 (July 2012), https://www.hrw.org/sites/default/files/reports/
us0712ForUpload_1.pdf.

75 Advocacy Coalition Supports MPD Clarification of Condom Policy, dc trans cOal. (Mar. 11,
2013), https://dctranscoalition.wordpress.com/2013/03/11/advocacy-coalition-supports-mpd-
clarification-of-condom-policy/.

76 See McLemore, supra note 65, at 42.

77 Additional Arrests Made in Solicitation of Prostitution Operation, metrO. pOlice dep’t (Aug.
28, 2015), https://mpdc.dc.gov/release/additional-arrests-made-solicitation-prostitution-
operation-14.

Improving Laws and Policies to Protect Sex Workers and Promote Health and Wellbeing | 64

78 Dana Hedgpeth & Peter Hermann, Prostitution sting: Police Arrest 30 men in Northwest D.C.
crackdown, Wash. pOst (July 21, 2015), https://www.washingtonpost.com/local/crime/thirty-men-
in-dc-charged-with-soliciting-prostitutes/2015/07/21/a14c092a-2f9b-11e5-8f36-18d1d501920d_
story.html.

79 NEAR Act, saFer strOnGer dc, https://saferstronger.dc.gov/page/near-act-safer-stronger-
dc (last visited Oct. 9, 2020).

80 Mayor Bowser Launches New Initiatives to Reduce Prostitution, Illegal Dumping Along
Eastern Avenue, OFF. OF the mayOr (Apr. 10, 2019), https://mayor.dc.gov/release/mayor-bowser-
launches-new-initiatives-reduce-prostitution-illegal-dumping-along-eastern.

81 Martin Austermuhle, D.C. Police Release Long-Delayed Stop-And-Frisk Data, Showing Racial
Disparities In Stops, WamU (Sept. 10, 2019), https://wamu.org/story/19/09/10/d-c-police-release-
long-delayed-stop-and-frisk-data-showing-racial-disparities-in-stops/.

82 Id.

  • Authors
  • Acknowledgments
  • Executive Summary
  • Introduction
    • Overlapping Crises
  • Background
    • A Source of Vulnerability
    • Theories of Criminalization
    • Current Legal Landscape
    • Timeline of DC’s Prostitution Policies
  • Research on Protecting Sex Workers and Promoting Health and Wellbeing
    • Research Methods
  • Results from Community Focus Groups
    • Motivations and Reasons for Engaging in Sex Work
    • Experiences of Engaging in Sex Work
    • Encounters with Police and the Criminal Justice System
    • Consequences Of Arrest And Incarceration
    • Views on Reforming Sex Work Criminal Laws
  • Results from Institutional Stakeholder Interviews
    • Motivations for Individuals Engaging in Sex Work
    • The Police and Criminal Justice System
    • Health
    • Online-Based Sex Work
    • Policy and Legal Reform
  • Comparing Perspectives
    • Motivations of Sex Workers
    • Sex Work versus Trafficking
    • Need for Social Services
    • Laws Create Barriers
    • Support for Legal Reforms
    • Concerns about Legalization
    • Limitations of Vacatur and Diversion
    • Distrust of the MPD
    • Cultural Competency Training
  • Recommendations
    • Reforms That We Recommend
    • Reforms That We Do Not Recommend
    • Research Limitations
  • Appendix A: Community Participant Survey Data
  • Appendix B: Institutional Stakeholder Interview Participants
  • Appendix C: DC’s History of Sex Work Policing
  • Endnotes

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