Abstract
Recurrent interpersonal violence is a major cause of death and disability among young Black men. Quantitative studies have uncovered factors associated with reinjury, but little is known about how these factors work together.
We interviewed young Black male victims to understand their experience of violence. Qualitative analysis of their narratives revealed how their struggle to reestablish safety shaped their response to injury. Aspects of the “code of the street” (including the need for respect) and lack of faith in the police combined with traumatic stress and substance use to accentuate their sense of vulnerability. Victims then reacted to protect themselves in ways that could increase their risk of reinjury.
We describe a model with implications for reducing rates of recurrent violent injuries.
Violent injury is a major cause of disability and death among young Black men in the United States. Homicide is the leading cause of death among male Blacks between the ages of 15 and 24 years.1,2 Despite recent declines in homicide rates, violent injury is on the increase in major cities across the United States.3 Nonfatal violent injury leads to both physical and mental disability and accounts for substantial health care costs.4–6 According to the Centers for Disease Control and Prevention, there are 94 nonfatal intentional injuries for every homicide death.7 Study estimates indicate that the average medical cost of a nonfatal firearm injury is about $17000, and national costs totaled more than $2 billion in 1994.8 Each year, intentional injury accounts for $23 billion in lost productivity and almost $145 billion in reduced quality of life (in 1989 dollars).9
Violent injury is also a chronic, recurrent problem. Previous studies have revealed recurrence rates of between 5% and 45% over the 5 years subsequent to the initial injury.10–12 Risk factors for reinjury include alcohol and substance use, school failure, weapon possession, poverty, neighborhood disorganization, male gender, Black race, exposure to television violence, and gang involvement.10–15
Despite this body of work, little is known about how risk factors work together to precipitate victimization. Health care providers who see victims of urban violence are often frustrated by the knowledge that their patients may soon return with another wound. Yet, few hospital-based interventions designed for victims of nonfatal violence have proven effective in decreasing reinjury rates.16,17 After victims leave the hospital, most return to communities where violence is all around them and where they feel especially vulnerable. Many are physically disabled or emotionally traumatized. However, we know little about the meaning of violence for these men or how the experience of injury reshapes their lives. How do they attempt to reconstruct their safety after injury? How do they respond to trauma? How do drugs and alcohol fit into the cycle of violence for victims?
We undertook this study to generate hypotheses about recurrent violent injury based on the narratives of young Black male victims of violence. Throughout the research process, we explored the stories that victims told about their injuries in an attempt to understand how these young men make sense of their trauma. Consistent with the tenets of qualitative research, we pursued the work without prior theories or hypotheses. Rather, the interviews consisted mainly of open-ended questions, and the data were analyzed inductively. Themes that emerged from these data shed light on how young Black male victims think about and respond to their injuries. We then looked to the available literature to identify frameworks that helped to illuminate these findings.
An important framework for interpreting the results produced by our study comes from the work of Elijah Anderson. On the basis of his ethnographic work in inner-city Philadelphia, he has described a “code of the street” that he defines as “a set of informal rules governing interpersonal public behavior, particularly violence.”18(p33) These rules revolve around the idea of respect (defined as receiving the deference that one deserves) and its central role in how young Black men protect themselves in the inner city. Anderson has demonstrated how this code, which emerges from the hostile context of the inner city and lack of faith in formal systems of justice, contributes to violence and aggression among young Black men in inner cities.
We believe that Anderson’s framework can be applied to the phenomenon of recurrent injury. Our study focused only on young Black male victims of violence. In the same manner as the young men that Anderson studied, these victims are influenced by the code of the street and its inherent demand for respect. These issues are particularly salient for them in that they have just sustained a violent injury, which most interpret as an extreme act of disrespect. Their narratives highlight how their understanding of the code of the street, together with the disturbing symptoms of traumatic stress, sets the stage for recurrent injury. We augment Anderson’s framework with the concepts of traumatic stress and substance abuse to develop a hypothetical model of recurrent injury.
We recruited young Black men between the ages of 18 and 30 years who had been hospitalized after being shot, stabbed, or physically assaulted by another individual. Patients were excluded if they were under arrest or incarcerated, had a severe head injury or diagnosis of a major psychiatric disorder, had a self-inflicted injury, or had an injury that prevented them from being able to consent or to participate. Participants consented to be interviewed within 1 to 2 weeks of their injury. A subset of participants volunteered to be interviewed again 4 to 12 weeks later. Participants were informed that their interviews would be audiotaped and transcribed and that all identifying information would be deleted from the transcripts. They were also informed that the research data were covered under a certificate of confidentiality from the US Department of Health and Human Services. Participants were paid $25 for each interview.
We developed a semistructured interview guide composed of open-ended questions about the circumstances of the injury, past trauma, substance use, safety after the injury, and experiences with the criminal justice system. We gathered basic demographic information as well. The follow-up interview was also semistructured and included questions about the participant’s life subsequent to the injury along with a standardized assessment of posttraumatic stress disorder (PTSD) (i.e., the PTSD Symptom Scale).19 According to their preference, we interviewed participants in the hospital, the Boston University Medical Center General Clinical Research Center, or their homes. The interviews were audiotaped and transcribed in accordance with standardized transcription rules. Narrative texts were parsed into lines and stanzas on the basis of Gee’s method.20
We analyzed the data through multiple readings and used narrative analysis21,22 and grounded theory23–25 approaches in an attempt to determine stories and themes that represented the experiences of the young men taking part in the study. (In portraying these themes, we include quotations from the participants. We have substituted pseudonyms for their real names to protect their identities.) We used QSR NVivo qualitative analysis software to code interview data.26
The analysis presented here is based on initial interviews with 49 participants. Twenty-three (47%) participants completed a second interview. Demographic characteristics of the participants are shown in Table 1.
All of the participants identified themselves as Black men, and the majority indicated that they were African American (71%). Most of the participants had been shot (59%) or stabbed (35%), reflecting the fact that we recruited only patients admitted to the hospital, who tend to have more severe injuries. Twenty-one participants (42%) reported that they had been injured seriously in the past. Thirty-nine participants (80%) had been arrested in the past, and 27 (55%) had been incarcerated. About half of the participants had children.
The circumstances leading to the injury were derived from patient narratives. About a third of the participants portrayed themselves as innocent bystanders (including victims of robberies and victims struck by crossfire). Sixteen participants (33%) attributed their injury to an escalating argument, and 12 (25%) reported that they had been assaulted by someone exacting revenge for a past act of disrespect. Three main aspects were identified that related to safety after violent injury: “being a sucker” (loss of respect), “the last people I call” (lack of faith in the police), and “feeling shook” (trauma-related symptoms).
Respect, defined as receiving the deference that one deserves, is a central part of how young urban men make their way through the dangerous world in which they live.18 Anderson identified respect as a central component of the code of the street whereby urban young Black men protect themselves physically while also safeguarding their fragile personal identities. The code of the street dictates that when someone disrespects you, whether physically, emotionally, or materially, you must respond aggressively to regain your respect. The idea is especially salient for victims of violence, since an act of violence committed against them is viewed as extreme disrespect.
As mentioned, we found that our participants identified a concept called “being a sucker.” The idea is best captured in a quote from an 18-year-old shooting victim who stated:
A sucker is a person that if someone says something to them or does something to them they just sit there and take it and don’t retaliate.
If you’re living in the inner city, you wouldn’t want to be a sucker ’cause everybody will take advantage of you.27
This participant’s words demonstrate the widely held idea that if one fails to actively defend oneself after having been disrespected, one will be victimized by others.
Participants understood that someone who has been disrespected and has not retaliated becomes known as a “sucker,” “chump,” or “punk.” Forty-one (84%) of the participants recognized and could provide a definition for the word “sucker.” These victims believe that if they do not retaliate or respond aggressively, they send the message to other potential assailants in their community that they tolerate victimization. They perceive that others will “take advantage” of any victim who is seen as a “sucker.” This commonly held understanding leaves victims feeling vulnerable and compels them to think about retaliating.
The participants also expressed the view that being seen as a “sucker” or “punk” may lead not only to physical harm but also to a damaged identity. Ian, another young shooting victim, described how tolerating disrespect damages his self-identity:
Like, you’re a punk if you let somebody come up in your face and disrespect you. If you let somebody hit you, and you don’t hit ’em back, if you let somebody take what belongs to you without you saying anything about them taking what belongs to you, it means you’re a punk.
If they take your self-esteem away from you, then you’re a punk.
Since these young men understand the code of the street, they know that people who have the reputation of “sucker” or “punk” are vulnerable to repeated victimization because potential assailants believe they will not defend themselves. Victims may feel compelled to become aggressors, a posture that puts them at risk for conflict, either because they are trying to project an image of strength or because they are actively seeking to retaliate. In either case, they place themselves at risk for reinjury when they confront their assailants or gather weapons in an effort to avenge the act of disrespect and relieve themselves of the “sucker” label.15
Another aspect of the code of the street that arose vividly from these victims’ narratives was a profound lack of faith in the police. According to Anderson, “The code of the street is actually a cultural adaptation to a profound lack of faith in the police and the judicial system—and in others who would champion one’s personal security. The police, for instance, are most often viewed as representing the dominant white society and not caring to protect inner-city residents.”18(p34)
The victims of violence in the present study echoed these views about the police. These victims reported that they do not rely on the police if they feel threatened or fear being confronted by their assailants. Rather, they maintain the belief that if they face a threat, they must “handle it” themselves. Some victims, faced with this looming danger, simply withdraw into their homes, avoiding public transportation and the streets altogether. A few move away, most often “down south,” to stay with extended family. Other victims, faced with the burden of protecting themselves, may assume a more aggressive posture, arm themselves, or recruit friends to exact revenge on their assailant.
Thirty-two (65%) of the participants in our study reported that they do not have faith in the police. Most declared a general distaste for the police. At best, they view the police as unhelpful; at worst, they regard them as abusive. They often perceive that the police are doing little to arrest their assailant. Consequently, these young men are reluctant to call the police if they are in danger. Ian demonstrated this view when asked whether he would call the police if he needed them.
If I needed ’em? Personally, I wouldn’t call ’em. I’d say, they’d be the last people I call.
If I really, really didn’t have no other choice, then I would call them. If I had an option . . . not to call them? I’d use that option before I call ’em.
It’s like, I feel nauseated, even when I talk to ’em.
Ian saw the police as the option of last resort. He did not specify what other “option” he would pursue, but this might mean carrying a weapon or recruiting friends for protection. Jamal, a young man who was shot by an assailant at a nightclub, answered in a similar fashion when asked whether he would call the police if he had a problem.
Depends on the situation. If I can handle it myself, I try to handle it,
but if I think I can’t, I call the cops.
’Cause I hate ’em I mean, other than that, you might need ’em one day— even though they be ignorant you still might need their help.
Gabriel, a young man stabbed in the abdomen during a robbery, reported that he is skeptical about whether the police are even looking for his assailant.
Police? They ain’t catched the people yet. I doubt if they even looking. They stopped looking for little incidents like that.
But if a cop get killed, then they go crazy, look all day. Shot, stabbed, or whatever. They look all day, all month, all year.
But if you get stabbed or shot, they’ll look for that day, probably the next day.
Gabriel compared the police reaction to his assault with how they react when one of their own is injured or killed. He expressed the idea that they see his trauma as unimportant. His words exemplify a fundamental belief that the police are less concerned about violence against young Black men and therefore play a limited role in keeping them safe.
Jamal expressed the same sentiment when asked whether the police had made any progress in arresting the person who shot him.
The one that did it? The police didn’t ever catch him. I doubt they were ever lookin’.
The police? No, they ain’t doin’ their job. I don’t think they’re doin’ their job.
The victim’s lack of faith that the police are actively pursuing his assailant is compounded by his reluctance to cooperate with the police. Victims frequently refuse to provide information because they do not trust that the police will offer them or their families any protection as witnesses, such as anonymity or relocation to a safer neighborhood. Will, a young man who was shot in a drive-by shooting, talked about the risks of cooperating with the police in an investigation.
When you help [the police] out, it’s like they can’t even help the person that helps them out. They don’t give them no protection or help them move away, or even leave their name anonymous.
Because when you go [to] the grand jury, you got to use your real name for whoever you tell on.
Will’s comments capture the shared notion that if you cooperate with the police, you may be targeted for retaliation, while the criminal justice system has no way to protect you from the assailant.
Participants commonly told stories of police harassment and racial profiling. Even participants who expressed some faith in the police told of instances in which the police assumed that they were involved in wrongdoing. Cedric, a 22-year-old shot after an altercation in a bar, illustrates the perception that the police look down on young Black men in the streets.
Police officers? Police officers? I just feel like they’re troublemakers, you know?
I feel like they just like to look at everybody on the streets as demons. I think they look at us as demons.
They’ll pull you over for no reason. I mean, they’ll find a reason.
Earl, a 23-year-old stabbed in an argument over money, complained about the common police practice of asking young Black men to identify themselves.
I can’t say I really like the police ’cause they always tend to harass young Black men, you know? They always think we are doin’ somethin’ bad, or about to do somethin’ bad.
So they always watchin’ or spyin’ on you. And they come out of nowhere and harass you.
Ask your name, “Where do you live?” “Where are you goin’?” You know? Stupid questions.
I just never really liked the police for that reason.
Zachary, a 24-year-old shot during an argument, provided an example of perceived racial profiling.
I’ve had cops come up to me, tellin’ me that I match this description, fit that description.
Or told me they saw me smokin’ a blunt [marijuana] when it was actually a cigarette just to search me.
I feel basically it’s racial profilin’, you know? And a lot of that goes on around [our neighborhoods].
These participants provided powerful examples for why they lack faith in the police. The effect of their shared perceptions is that these victims may actively devise other ways to stay safe. Anderson noted this situation in his study of Philadelphia streets: “Feeling they cannot depend on the police and other civil authorities to protect them from danger, residents often take personal responsibility for their security.”18(p109) Victims, who have a heightened sense of danger, feel even more pressed to protect themselves, a posture that may place them at risk for recurrent violence.
Symptoms of traumatic stress were common among these victims. Twenty-three of the participants were assessed to determine whether they met the criteria for PTSD, and 15 (65%) met the full criteria for the disorder.28 The participants’ narratives tell of nightmares, flashbacks, and emotional numbing in the days and weeks after their injuries. In the following poignant example, Baron reads from rap lyrics (also called “rhymes”) that he composed to help him deal with his nightmares:
As the day darkens, I’m feeling shook. I guess that’s why I stay high, constantly fighting to keep the nightmares from turning to reality.
Nightmares of bloody days and court dates circulating in my mind. Nightmares seem to always turn into reality, and reality seems to fade into nightmares. . . .
Baron reported that he uses marijuana constantly to ward off his nightmares. His nightmares of “bloody days” and “court dates” refer to images of his injury and to his pending legal issues stemming from the altercation. He concludes his rap with a haunting prediction that “nightmares” will turn to “reality” and “reality” will fade to “nightmares.” Baron’s rap composition eloquently describes the spiral, common in victims’ narratives, that leads from violent injury to symptoms of trauma and then to substance use.
Intrusive thoughts about the assailant also haunted the victims, further compromising their sense of safety. Kari, a young man who was shot by a robber who stole his gold chain, spoke about his assailant:
I can’t get this dude out my head. I see him every day, every day. Every night I see this dude. And he’s locked up.
Emotional numbing is another important symptom of traumatic stress. Here Ian talks about how he feels he has lost his normal feelings of fear in situations that he would have perceived as dangerous before his trauma.
So a lot of things that made me scared or made me nervous, they don’t scare me no more. They don’t affect me.
Like, if a whole bunch of dudes kept on lookin’ at me, I used to feel nervous. And, if someone kept on like giving me mean looks? I used to get nervous.
It don’t happen no more. It’s like some of the feelin’ is just gone. If they look at me mean now, I look at them right back like, “What?”
Ian described how the loss of a sense of appropriate fear makes him more likely to confront others who seem threatening to him. Whereas he was more likely to avoid such a confrontation in the past, now he faces up to it, a response that could easily precipitate conflict.
Our participants also reported a heightened sense of awareness or “jumpiness.” This state of arousal, termed hypervigilance, has been well described as a symptom of PTSD. While 15 (65%) of the 23 participants who were screened for PTSD met the full diagnostic criteria for the disorder, all of those surveyed endorsed one or more of the items focusing on hypervigilance. These men frequently return to the same neighborhoods where they were assaulted. As they do, this hypervigilance escalates into a generalized sense of danger. Vashon, a 21-year-old who was stabbed in an altercation, recounted his reaction to an approaching car in his neighborhood:
Seen a car, just looked at each other, just gave each other the eye. Looked like something was gonna jump off for a minute there, but he just took off.
In this example, Vashon understands eye contact as a potential threat, but a confrontation does not materialize. This kind of hyper-awareness and expectation of conflict among trauma victims is neither uncommon nor unexpected. However, it may lend clues to why violence recurs in victims. Their responses to their trauma may set them up for more conflict, especially given that most reside in neighborhoods where rates of violence are high and weapons are plentiful.
The end result of these manifestations of traumatic stress is disruption of victims’ lives through impairment of their sense of safety. Some symptoms, such as loss of fear emotions and hypervigilance, have a direct relationship to recurrent injury in that they affect victims’ reactions to potentially volatile situations.
To this point, we have presented themes that support the conclusion that victims feel particularly vulnerable in the aftermath of injury because of the code of the street, their lack of faith in the police, and their post-trauma symptoms. We now turn our attention to 2 of the ways in which they try to address their fear and the ways in which these reactions place them at risk for violence.
Some young Black men who feel unsafe after an injury, who have symptoms of trauma, or who lack confidence in the police consider obtaining a weapon for self-protection. Thirteen (27%) of the present victims acknowledged that they sometimes carry a weapon, particularly when they feel they might be in danger. But even those who previously did not own or carry a weapon at the time of their assault often began to contemplate acquiring a weapon to protect themselves. Gabriel, a 19-year-old stabbing victim, illustrates how victims view weapons as a means of protection.
[Getting stabbed] changed my life a whole lot. Stuff like that can make a person go crazy, go out and buy a gun— just for protection.
’Cause it’s not that hard to get a gun on these streets. It’s not that hard. It’s like buyin’ candy from a store if you know the right people.
Gabriel pointed out, and other participants confirmed, that obtaining a gun is easy in the inner city. As a result, young victims who previously would not have considered carrying a weapon may do so if they feel acutely unsafe after their injuries. Another young robbery victim expressed the same sentiment after his assault:
So now I feel like I gotta stay strapped with somethin’ to protect myself, from now on, ya know? ’Cause I never know when it’s gonna happen again. That’s how it makes me feel.
Fear of future victimization led these victims to consider the option of carrying a weapon.
Thirty-three (67%) of the young men taking part in this study reported that they smoke marijuana on a regular basis. The reasons for their use were varied. Some use it purely as a social lubricant when they gather with friends; others use it much more frequently, essentially smoking it throughout the day, virtually every day. Close analysis of victims’ narratives revealed that some of the young men have increased their use of marijuana or altered it in an attempt to allay their symptoms of trauma. Baron, the young man who wrote rap songs about his nightmares, talked about how he uses marijuana to help him sleep:
The thing that really makes me go to sleep at night or that makes the nightmares go away, and helps me knock out— I smoke.
I don’t even smoke during the day no more. I take like a little weed and I’ll save it for night.
I’ll go outside and just smoke it. When I come in the house, the first thing I do is knock out.
Whenever I don’t do that, I get nightmares.
Baron’s case provides an example of the relationship between symptoms of trauma and drug use, a pattern that emerged from our inductive analysis and was discernible in a small number of the participants. All of the participants were asked about their use of marijuana; however, not all were asked about changes in use after their injury, since this insight emerged well into the course of the study. Nonetheless, this finding suggests hypotheses about the relationship between substance use, PTSD, and recurrent trauma. Self-medication of symptoms of traumatic stress may drive substance use in some victims of violent injury.
The narrative analysis just presented demonstrates that young men feel unsafe after their injuries and suggests possible pathways to recurrent injury. As shown in the model illustrated in Figure 1, the experience of injury disrupts their sense of safety in 3 ways: it activates the need to acknowledge the code of the street and to avoid being a “sucker”; it intensifies lack of faith in the police; and it precipitates symptoms of traumatic stress.
This disrupted sense of safety creates a need to find a way to deal with a new sense of danger. Young men have few options for avoiding danger. Our participants suggested alternatives such as moving away (most often “down south”), staying in the house, and avoiding public transportation. These options are impractical in the long run. Given that they lack faith in the police, they will rely on this option only as a last resort. Faced with these realities, they may feel they have few options other than obtaining a weapon to stay safe. Studies have shown that carrying a weapon raises the risk of reinjury, perhaps because it emboldens the victim to confront potential victimizers.27,29,30
Our model includes the complications brought on by traumatic stress. Some symptoms, such as blunted emotions and hypervigilance, can make day-to-day situations seem more threatening than they are31,32 and can lead young victimized men to self-medicate with marijuana or alcohol.
Use of marijuana has consequences that may contribute to recurrent violence. For example, low-income men competing for low-wage jobs often face drug testing, and a positive drug test disqualifies them from employment. Likewise, possession of marijuana places them at risk for arrest and prosecution. A criminal record further limits their job options given that criminal background checks are commonly required for workers at all levels. Faced with dim prospects for employment, young men may see few options other than turning to the underground economy of selling drugs, which further heightens their risk of gun violence and injury.15
Listening to the voices of young male victims of violence can deepen our understanding of how these young men feel in the aftermath of a violent assault. Their shared understanding of the code of the street and the basic need for physical and psychological safety drives their actions after violent injuries. The meaning of disrespect was a prominent theme in the narratives of our participants, closely paired with its perceived consequence of “being a sucker.” These individuals hold the strong perception that if they fail to retaliate against their assailant, they will be at greater risk for future victimization.
In Code of the Street, Anderson emphasized the meaning of respect in urban communities: “In the inner-city environment, respect on the street may be viewed as a form of social capital that is very valuable, especially when other forms of capital have been denied or are unavailable. Not only is it protective; it often forms the core of the person’s self-esteem, particularly when alternative avenues of self-expression are closed or sensed to be.”18(p66)
The meaning of disrespect is central to recurrent violence since it creates the pressure that many young men feel to retaliate. Any young man who understands the meaning of being a “sucker” will perceive that retaliation functions to shield him from physical danger by showing others that he is not weak and does not tolerate being victimized. A suggestion of this same finding was noted by Cooper et al. in their quantitative study of factors predictive of injury recurrence.15 They observed that 86% of individuals who were reinjured felt that “disrespect” played a role in their injury. Retaliation may also come from attempts to recover damaged self-esteem and a wounded sense of masculinity.27
Also consistent with Anderson’s rendering of street life, these victims lack faith in the police. They do not view the police as helpful, and their narratives retell experiences of racial profiling at the hands of the police. As a consequence, they view the police as a last resort and seek other options for safety, such as obtaining a weapon. Even young men who would have avoided weapons before the assault now consider acquiring them.
The existence of racial profiling of Black men by the police is well documented. Recent studies conducted in Massachusetts demonstrate that Black men are more likely than their White counterparts to be searched when they are stopped by the police, even though they are less likely to possess contraband.33,34 Similar patterns have been found in major cities across the United States. These studies confirm that conscious and unconscious racial biases affect the actions of the police. The participants in the present study have firsthand experience with racial profiling, and it erodes their faith in the police as a resource when they are in danger.
About two thirds of the participants interviewed at least a month after their injury met the criteria for PTSD. Symptoms of hypervigilance were especially prominent in the narratives, along with blunting of normal fear emotions, nightmares, and flashbacks. These symptoms exaggerate the sense of vulnerability that these men already feel because of their injury and seem to compel other behaviors such as acquisition of weapons. We hypothesize that PTSD symptoms play a role in recurrent injury.
Few studies of PTSD have focused on urban victims of intentional violence. Breslau and colleagues35,36 detailed a PTSD prevalence rate of almost 24% among individuals exposed to traumatic events in an urban population. Studies conducted with combat veterans and sexual assault survivors show a powerful relationship between trauma, PTSD, and substance use. Other studies conducted by Breslau and colleagues have revealed a relationship between previous trauma and subsequent development of PTSD, as well as a relationship between PTSD and substance use.37,38
Marijuana use was common among our participants. This finding is consistent with results of studies showing that victims of recurrent violence report higher levels of substance use than control participants.35 Some victims self-medicate to relieve their symptoms of trauma. Although it is often assumed that victims’ substance abuse precipitates their injury, several studies involving combat veterans and female sexual assault victims demonstrate that symptoms of PTSD precede substance dependency.39–41 Studies of New York City residents conducted after the September 11 terrorist attacks revealed increased use of marijuana among those with symptoms of PTSD.42 These studies indicate that traumatized victims self-medicate their distressing symptoms and that this practice leads to substance dependency. In the case of our participants, use of substances as self-medication led to other life disruptions that could limit their employment opportunities and lead to arrest.
The present model also suggests points of intervention to break the cycle of recurrent violence. The code of the street—especially the meaning of respect and “being a sucker”—should be acknowledged and incorporated in violence prevention strategies targeting young Black men. Alternate ways of establishing a sense of safety, strength, self-esteem, and masculinity, if made available to these young men, might reduce their drive for retaliation as a response to disrespect. Educational programs that allow undereducated men to complete high school and begin college, in addition to job training programs that prepare men for meaningful work, could provide an alternative way to establish an identity.
Efforts to improve relationships between the police and young Black male victims might address fears of racial profiling and lead to victims cooperating with the police to apprehend their assailants. As noted in a report published by the US Department of Justice’s Office for Victims of Crime:
The health care, criminal justice, and media response to [African American male] victims may be less sympathetic than responses to other crime victims. Whatever the reason for the disparate treatment of these victims, we must not ignore them. Assumptions about the blameworthiness of young African-Americans and Hispanics shortchange a large segment of the population and perpetuate racial stereotyping.43(p9)
Community policing efforts have attempted to place police officers within urban neighborhoods, where they can become familiar with community residents. Approaches such as these may yield benefits if racial profiling and abuse can be addressed.
Health care providers should work to ensure that victims are safe when they are released from the hospital, particularly if they could be targeted as key witnesses or are at high risk for retaliation. The Department of Justice, according to which there are currently fewer than 12 hospital centers in the country that offer comprehensive services to victims of gun violence, has advocated for hospital-based interventions targeting victims of non-fatal violence.43
Diagnosis and treatment of symptoms of trauma could remove one of the forces driving perceptions of vulnerability. In our experience, few victims are routinely referred for mental health services after their assault. Lack of insurance coverage and lack of culturally competent mental health services make it difficult for those who are in distress to find treatment. Effective treatment of symptoms could potentially interrupt a cascade toward weapon carrying, substance abuse, and further alienation from stabilizing institutions such as employment, education, and health care.
Our study raises many questions for future research, including the following: What is the prevalence of PTSD and self-medication among victims of interpersonal violence? Can the factors identified in the hypothetical model described here be incorporated into approaches designed to predict recurrent violence among young male Blacks or other groups? How would diagnosis and treatment of PTSD influence substance use and risk of recurrent violence? Future studies involving multimethod, prospective approaches should expand our understanding of this phenomenon.
In regard to limitations of the present study, our data were gathered in Boston, and thus the model described is not necessarily generalizable to other young men residing either in Boston or in other parts of the country. Furthermore, the purpose of this qualitative inquiry was to seek the perspective of the participants and deepen understanding of the phenomenon of violent injury. We have presented numerical summaries of their responses, but these results are not population based and should be interpreted with caution.
The participants in this study had been admitted to the hospital for their injuries and thus tended to be those who were more seriously injured. Victims who declined to volunteer for the study may have differed in unknown ways from those who consented. It is possible that some victims who were deeply involved in crime or violence did not volunteer because they did not trust that the data would not reach the police. On the other hand, victims whose injury was completely random may have declined because the study of recurrent violence seemed irrelevant.
Participants may have felt compelled to present themselves to us in the best possible light, as is always the case with self-report data. However, many of the participants disclosed deeply personal stories and acknowledged past and present involvement with illicit activities. They did so in spite of being informed that they could decline to answer any or all of the interview questions. We believe that their accounts are trustworthy.
The interviews were conducted by the authors, both African American men who are college educated and employed by the Boston University Medical School. The participants’ perceptions of the interviewers inevitably shaped the contours of their narratives. We mention this not as a limitation but rather as a reflection on the influences that shaped the interviews themselves. From the perspective of qualitative research, these influences should be viewed as data in themselves, useful for understanding the stories that emerged from the particular interactions between the interviewers and participants in this study.
Note. PTSD = posttraumatic stress disorder. an = 23. FIGURE 1— Model illustrating pathways to recurrence.
Characteristic No. (%) Race/ethnicity African American 35 (71) Puerto Rican 5 (10) Cape Verdean 4 (8) Caribbean 2 (4) Haitian 3 (6) Injury type Stabbing 17 (35) Gunshot 29 (59) Assault 3 (6) Circumstances of injury Innocent bystander 16 (33) Crime victim 7 (15) Crossfire 6 (12) Random violence 3 (6) Argument 16 (33) Object of revenge 12 (25) Mistaken for intended victim 4 (8) Defending a friend 1 (2) Meets diagnostic criteria for PTSDa Yes 15 (65) No 8 (35) Endorsed 1 or more items on PTSD scale assessing hypervigilancea 23 (100) Past violent injury Yes 21 (43) No 23 (47) Unknown 5 (10) Smokes marijuana Yes 33 (67) No 13 (27) Unknown 3 (6) Uses alcohol Yes 41 (84) No 4 (8) Unknown 4 (8) Used marijuana on day of injury Yes 7 (14) No 22 (45) Unknown 20 (41) Used alcohol on day of injury Yes 15 (31) No 14 (29) Unknown 20 (41) Mistrusts police Yes 32 (65) No 13 (27) Unknown 4 (8) Currently carries a weapon Yes 13 (27) No 27 (55) Unknown 9 (18) Ever been arrested Yes 39 (80) No 7 (14) Unknown 3 (6) Ever been incarcerated Yes 27 (55) No 18 (37) Unknown 4 (8) Has children Yes 24 (49) No 20 (41) Unknown 5 (10) Knows the meaning of word “sucker” Yes 41 (84) No 2 (4) Unknown 6 (12) Accepts “sucker” definition/code of the street Yes 25 (51) No 18 (37) Unknown 6 (12) 
This research was supported by the National Institute of Mental Health (grant K08 MH01339) and the General Clinical Research Center (grant M01RR00533).
We are grateful to Drs Jacquelyn Campbell, Felton Earls, Thomas Inui, Elliot Mishler, Catherine Kohler Riessman, and Terry Williams for their guidance throughout the research. We also thank Drs Theodore Corbin and Jeffrey Samet for their helpful reviews of the article. Most of all, we are deeply indebted to the young men who contributed their voices to this work.
