understanding victims’ use of formal services after

The Pennsylvania State University

The Graduate School

UNDERSTANDING VICTIMS’ USE OF FORMAL SERVICES AFTER VIOLENCE:

A NEEDS-BARRIERS FRAMEWORK

A Dissertation in

Criminology

by

© 2021 Keith L. Hullenaar

Submitted in Partial Fulfillment

of the Requirements

for the Degree of

Doctor of Philosophy

May 2021

ii

The dissertation of Keith L. Hullenaar was reviewed and approved by the following:

Eric P. Baumer

Professor of Sociology and Criminology

Dissertation Adviser

Chair of Committee

Thomas A Loughran

Professor of Sociology and Criminology

Chair of the Graduate Program

David Ramey

Associate Professor of Sociology and Criminology

Jocelyn C. Anderson

Assistant Professor of Nursing

iii

ABSTRACT

Violence has detrimental and long-lasting effects on victims’ physical health, emotional

well-being, and social relationships. Formal services, such as law enforcement, health services,

and victim service agencies, provide victims a means to mitigate these harms, but not all victims

use them. This dissertation seeks to understand and predict these help-seeking outcomes.

Building on the theoretical principles of rational choice theory, I offer a needs-barriers

framework to explain why victims may use (or avoid) formal services after a crime. This

framework rests on two parsimonious assumptions: (1) Victims use a formal service when they

perceive that it can satisfy one or more of their physiological, safety-related, psychological, or

social needs and (2) Perceived physical, psychological, and social barriers serve as disincentives

for victims to use formal services. I argue that this approach provides insight into how the

sequelae of violence (e.g., physical, emotional, social harms) and the situational factors of

victimization (e.g., victim-offender relationship and sexual violence) interact to influence whether

and how victims utilize formal services after a crime.

Using violent victimization data collected by the National Crime Victimization Survey

(2008-2018), this dissertation provides two studies that examined the scope of violence harms and

how these harms, and certain situational factors of violence, influence victims’ formal help-

seeking outcomes. The first study examines the short- and long-term physical, emotional, and

social harms of violent victimization. The findings suggest that injury severity and victim-

offender relationship are key risk factors of harm, but in unique ways. Victims who reported a

greater degree of injury and a closer relationship with their offender had worse physical,

emotional, and social outcomes. These victims were also more likely to report long-term physical

and psychological symptoms months after the crime occurred. However, the link between injury

severity and these other sequelae of violence depended on the victim-offender relationship.

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Specifically, the degree of injury had a significantly weaker effect on the emotional, social, and

long-term consequences of victimization when the attacker was a family/intimate partner than

when the offender was a stranger.

The second study investigates violence victims’ use of formal services after the crime,

including police, medical, and victim services. Overall, victims used formal services in roughly

half of the violent victimizations, with police services being the most common (94% of incidents

involving a formal service). Consistent with the needs-barriers framework, the physical,

emotional, and social harms of violence were strong and consistent predictors of whether violence

victims reported to the police, sought medical care, or contacted victim service agencies after the

crime. However, the results regarding victim-offender relationship were mixed. Victims were

generally most likely to use formal services when the offender was a family member/intimate

partner or a stranger instead of an acquaintance. In analyses of victims’ use of follow-up

emotional care months after the crime, victims were most likely to use formal services when the

offender was a family member/intimate partner. Similar to the previous study, the link between

the harms of violence and victims’ use of formal services was partly conditioned by the victim-

offender relationship. Injury severity and social distress had a weaker relationship to victims’ use

of formal services when the offender was a family member/intimate partner than when the

offender was a stranger. However, in analyses of victims’ use of follow-up care, this interaction

was not significant.

Violence victims’ formal help-seeking outcomes result from a complex interplay between

their needs for formal services and the barriers they face in accessing them. A needs-barriers

framework lends insight into the unique ways commonly studied measures of violence—e.g.,

injury severity and victim-offender relationship—influence victims’ help-seeking outcomes.

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TABLE OF CONTENTS

LIST OF FIGURES ................................................................................................................. vii

LIST OF TABLES ................................................................................................................... viii

ACKNOWLEDGEMENTS ..................................................................................................... ix

Chapter 1 Seeking Help After Violent Victimization ............................................................. 1

Theory on Victim Help-seeking: An Integrative Approach ............................................. 4 Organization of Dissertation ............................................................................................ 6

References ........................................................................................................................ 8

Chapter 2 Understanding Victims’ Help-seeking ................................................................... 13

Rational Choice in Victim Crime Reporting .................................................................... 13 Limitations of Gottfredson and Gottfredson’s RCT Framework ............................. 17

Toward a Needs-Barriers Framework .............................................................................. 19 Needs ........................................................................................................................ 19 Barriers ..................................................................................................................... 21

Harm, Victim-offender Relationship, and Formal Services ............................................. 24 Violence Harms and Victim-offender Relationship ................................................. 26 Victims’ Need for Formal Services .......................................................................... 28 Contextualizing Harm .............................................................................................. 29 Barriers: Victim-offender Relationship and Sexual Violence .................................. 30

Conclusion ....................................................................................................................... 32 References ........................................................................................................................ 32

Chapter 3 The National Crime Victimization Survey ............................................................. 39

A Brief History ................................................................................................................. 39 Instrument and Sample ..................................................................................................... 42 Strengths and Limitations ................................................................................................ 43 Conclusion ....................................................................................................................... 43 References ........................................................................................................................ 43

Chapter 4 Contextualzing the Harms of Violence .................................................................. 48

Data ................................................................................................................................. 48 Measures .......................................................................................................................... 50

Outcomes .................................................................................................................. 50 Predictors .................................................................................................................. 52

Analytic Strategy .............................................................................................................. 54 Results .............................................................................................................................. 56

Injury Severity .......................................................................................................... 60 Emotional Distress and Social Distress .................................................................... 66

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Long-term Physical and Emotional Problems .......................................................... 69 Conditioning Injury Severity by Victim-offender Relationship ............................... 72


Chapter 5 Victims’ Use of Formal Services After Violence................................................... 84

Data ................................................................................................................................. 85 Measures .......................................................................................................................... 86

Outcomes .................................................................................................................. 86 Predictors .................................................................................................................. 87

Analytic Strategy .............................................................................................................. 87 Results .............................................................................................................................. 89

Patterns and Trends in Formal Service Use ............................................................. 89 Models of Formal Service Use ................................................................................. 94

Police Services vs. Only Medical Care/Victim Service Agencies .................... 98 Follow-up Medical Care ........................................................................................... 99 Conditioning Harm by Victim-offender Relationship .............................................. 102


Chapter 6 Discussion .............................................................................................................. 113

Limitations ....................................................................................................................... 119 Final Remarks .................................................................................................................. 121 References ........................................................................................................................ 121

Appendix A Descriptive Statistics of Analytic Sample .......................................................... 125

Appendix B Serious Injury Profile.......................................................................................... 127

Appendix C Full Models of Emotional and Social Distress ................................................... 128

Appendix D Full Models of Long-term Emotional and Physical Problems ........................... 130

Appendix E Full Models of Follow-up Care for Long-term Emotional and Physical

Problems........................................................................................................................... 132

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LIST OF FIGURES

Figure 2-1: Gottfredson and Gottfredson’s Rational Choice Framework. ............................... 16

Figure 2-2: Needs-barriers Framework for Victims’ Use of Formal Services. ....................... 24

Figure 2-3: Applying the Needs-barriers Framework. ............................................................ 25

Figure 4-1: Predicted Probabilities of Minor Injury and Serious Injury by Victim-

Offender Relationship. ..................................................................................................... 64

Figure 4-2: Predicted Probabilities of Emotional Distress and Social Distress by Victim-

Offender Relationship. ..................................................................................................... 69

Figure 4-3: Expected Count of Long-term Physical Problems and Long-term Emotional

Problems .......................................................................................................................... 72

Figure 4-4: Conditional Association of Injury Severity and Emotional Distress by

Victim-offender Relationship........................................................................................... 75

Figure 4-5: Conditional Association of Injury Severity and Social Distress by Victim-

offender Relationship. ...................................................................................................... 76

Figure 4-6: Conditional Association of Injury Severity and Long-term Physical Problems

by Victim-offender Relationship...................................................................................... 78

Figure 4-7: Conditional Association of Injury Severity and Long-term Emotional

Problems by Victim-offender Relationship...................................................................... 79

Figure 5-1: Trends in Police, Medical, and Victim Service Use for Violent

Victimizations Involving Serious Injury (1994-2018). .................................................... 92

Figure 5-2: The Decline in Medical Services Use After Accounting for Covariates

(2009-2018). ..................................................................................................................... 93

Figure 5-3: Conditonal Association of Injury Severity and Victims’ Use of Formal

Services by Victim-offender Relationship. ...................................................................... 104

Figure 5-4: Conditonal Associations of Emotional Distress and Social Distress with

Victims’ Use of Formal Services by Victim-offender Relationship. ............................... 106

viii

LIST OF TABLES

Table 4-1: Selected Descriptive Statistics: Harms of Violence. .............................................. 57

Table 4-2: Injury Severity and the Other Sequelae of Violence .............................................. 59

Table 4-3: Multinomial Logit Model of Injury Severity .......................................................... 61

Table 4-4: Logistic Regression Models of Emotional Distress and Social Distress ................ 67

Table 4-2: Negative Binomial Models of the Long-term Harms of Violence ......................... 70

Table 5-1: Hypotheses Regarding Victims’ Use of Formal Services ...................................... 84

Table 5-2: Selected Descriptive Statistics: Victims’ Use of Formal Services ......................... 90

Table 5-3: Logistic Regression Models of Victims’ Use of Formal Services ......................... 95

Table 5-4: Logistic Regression Models of Victims’ Use of Follow-up Medical Care ............ 100

ix

ACKNOWLEDGEMENTS

To Erin, Mom, and Mike, thank you for supporting my dreams and goals. I could not

have done this without your support.

To Barry Ruback, thank you for being a supportive mentor and role model when I needed

one the most. Our work together has been incredibly valuable to me.

To Eric Baumer, Thomas Loughran, David Ramey, and Jocelyn Anderson, your support

and feedback has been invaluable. Thank you for helping me reach my dream of obtaining a PhD.

Chapter 1

Seeking Help After Violent Victimization

In the U.S., interpersonal violence is among the top 5 leading causes of death for people

under age 45 (CDC 2018). From 2015 to 2018, violent victimization increased among men,

women, and adults in most age groups, with reports estimating 3.3 million victims of nonlethal

violence and 16.2 thousand homicide victims in 2018 (Morgan and Oudekerk, 2019; FBI 2019).

In other words, every second brings six more Americans into contact with violence.

While people may be safer from violence than they were in the 1990s, exposure to

violence still has real physical, emotional, and social consequences for their lives (Sharkey

2018a). Roughly one-fourth of violent victimizations involve bodily injury, and one-third of these

injuries require medical treatment (Truman and Morgan, 2014). These injuries place victims at

greater risk for chronic physical disability and pain (Raza, Thiruchelvam, and Redelmeier 2020).

In addition to causing physical trauma, violence often is associated with severe emotional distress

(Kliewer 2016) that can manifest into long-term psychiatric disorders (Zatzick et al. 2007) and an

increased risk of suicide (Koyanagi et al. 2019). Exposure to violence also has social

consequences. Victimization can increase social isolation (Newman, Holden, and Delville 2005),

increase distrust (Janoff-Bulman 2010), and reduce school and work productivity (Sharkey

2018a; Speroni et al. 2014). Even though violent crime has declined for almost thirty years

(Baumer and Wolff 2014; Sharkey 2018b), limiting the far-reaching consequences of violence

remains a public health priority (Rivara et al. 2019).

Societies and violence victims may mobilize formal services to mitigate the harm of

violence. Examples of these services include (but are not limited to) law enforcement, hospitals,

and victim service agencies. When used by victims, research suggests that these types of services

2

can mitigate—or even prevent—violence. For example, victims who report to the police have a

lower likelihood of revictimization (Ranapurwala, Berg, and Casteel 2016; Xie and Lynch 2017)

and can access funds to reimburse some of their financial losses.1 If victims decide to seek health

services (e.g., emergency care), they can expect lower odds of physical complications, re-injury,

and death (Gallagher 2005; Shackelford et al. 2017). Seeking psychiatric or social services also

may benefit victims by improving their quality of life (Wathen and MacMillan 2003), reducing

mental health symptoms (Arroyo et al. 2017; Iverson, Shenk, and Fruzzetti 2009), and increasing

safety behaviors that reduce revictimization (McFarlane et al. 2002).

Yet despite the benefits formal services provide, evidence suggests that victims

infrequently use them. In 2019, two out of five violent victimizations were reported to the police,

and even serious violent crimes (i.e., rape, robbery, and aggravated assault) were reported only

half of the time (Morgan and Truman 2020). Studies on victim health care use also find that only

half of victimizations involving serious injury are treated by a medical professional (Hullenaar

and Frisco 2020). The Victims of Crime Compensation Act sets aside funds to reimburse victims’

financial losses caused by crime, but some evidence suggests that only one-quarter to one-half of

eligible victims receive these funds (Parent, Auerbach, and Carlson 1992). Finally, reports from

the National Crime Victimization Survey estimate that only one-in-ten victims of serious violence

use victim service agencies. This estimate is even lower for victims of non-intimate partner and

non-sexual violence (Langton 2011).

This consistent pattern of service underutilization hinders interventions from reaching

most violence victims, which may reduce their ability to mitigate violence harms. Take the case

of hospital-based violence intervention programs (HVIP). HVIPs connect victims with services

after they are discharged from the hospital, including organizing follow-up health care

1 Most states require victims to report to the police to gain access to victim compensation funds.

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appointments, psychological counseling, conflict mediation services, alcohol/drug abuse

rehabilitation, and social and economic resources (Juillard et al. 2016). But HVIPs serve only the

small fraction of victims who use hospital care, and only if the victim qualifies for the program.

For injured victims who avoid medical care or do not qualify, i.e., the vast majority, the services

provided by HVIPs are out of reach. Victims of the most serious types of violence may typically

receive help-providing services, such as HVIPs, but evidence suggests that formal help-seeking

may be unlikely even among victims who report serious trauma (Hullenaar and Frisco 2020;

Truman and Morgan 2014)

Given the apparent benefits of formal services, it is critical to understand victims’ help-

seeking behaviors (Xie and Baumer 2019). However, the scientific literature on this topic is

limited in three ways. First, the development of victim help-seeking theory in criminology has

stagnated even as conceptual frameworks for help-seeking in other fields—such as sociology and

psychology—have advanced. Second, there is a critical link between the harm of violence and

whether a victim seeks help, but research in this area has not provided any new insights regarding

this link for almost twenty years. Thus, scholars treat the link as “common sense” (Black 1979)

rather than theoretically insightful (Gottfredson and Hindelang 1979). But it may be not as

“common” as once believed. Recent research suggests there are compelling reasons why victims

may contextualize the harms they experience from violence in a way that impacts their help-

seeking outcomes (Hullenaar and Frisco 2020). Third, the help-seeking literature, as developed

within criminology, remains out of touch with the range of formal help-seeking options that

victims may access. Most notably, existing criminological theory says little about why victims

may decide to use medical care or victim agencies, instead of the police.

Theory on Victim Help-seeking: An Integrative Approach

Theories on victim help-seeking stretch across multiple disciplines, including

criminology, psychology, sociology, and public health, and address factors at multiple levels,

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such as person-, situational-, and macro-level characteristics. In criminology, situational-based

rational choice theory (RCT) has been the most commonly cited framework to explain victims’

formal help-seeking behavior, and research in this area has mostly emphasized victims’ decisions

to notify the police (Gottfredson and Gottfredson, 1987; Xie and Baumer, 2019).

The fundamental assumption of RCT is that people behave according to the perceived

utility of an action, which is often judged by the perceived benefits of the act relative to its

perceived costs. Given information about benefits and costs, people make choices that optimize

personal utility. From this perspective, the perceived harm of violence is critical because help

seeking is likely to have greater benefits for victims who experience injury, distress, or

intimidation (Gottfredson and Gottfredson 1987). This expectation is strongly supported in the

literature, as the harm of crime (e.g., criminal violence) is typically the strongest correlate of

whether victims use formal services (McCart, Smith, and Sawyer 2010; Skogan, 1984).

RCT offers a parsimonious and well-supported explanation for the fundamental factors of

victims’ help-seeking decisions, but this popular approach is not without critics. For example,

scholars have criticized RCT for being a simplistic representation of victims’ help-seeking, or a

“common sense” explanation (Black 1979). Additionally, others argue that RCT has an

unnecessarily narrow focus on the harms of violence while ignoring how attitudinal, social-

psychological, normative, and social factors influence crime reporting decisions (Xie and

Baumer, 2019).

Indeed, applications of RCT to victim help-seeking have not advanced much in the

literature. For instance, the link between violence harms and help-seeking is never disputed, but it

also has not provided new insight for almost thirty years since Gottfredson and Gottfredson’s

seminal 1987 work on rational decision making in the criminal justice system. The theory has

failed to grow even as new perspectives on help-seeking emerged. As a result, scholars (Xie and

Baumer 2019) juxtapose RCT against perspectives that explain the contextual, attitudinal, or

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social factors of help-seeking. Even though RCT may also explain why following social norms

and adhering to personal values are important incentives to victims’ crime reporting decisions

(see Felson et al. 2002 or Hullenaar and Ruback 2020), this type of theoretical integration leaves

much to be desired.

In a push toward integration, Xie and Baumer (2019) offered a multilevel, dynamic

model of help-seeking that combines insights from RCT and other theories from sociology and

psychology. Based on literature from multiple fields, they argue that victim help-seeking is

motivated by three sets of factors: the severity of the crime (i.e., harm), the external environment

(e.g., macro-level characteristics), and the victim’s characteristics (e.g., demographics and

attitudes). Help-seeking is also a dynamic process, in which prior help-seeking experiences

influence future help-seeking behavior. While Xie and Baumer’s (2019) integrative approach

expands traditional help-seeking models, it is limited in important ways. Most importantly, the

model omits core concepts from help-seeking theories in areas such as medical sociology

(Andersen 1995; Champion, Skinner, and others 2008) and psychology (Maslow 1958; Maslow

and Lewis 1987; McLeod 2007). Thus, it is somewhat difficult to discern the interdisciplinary

component of the framework. For example, the concept of need, and how it relates to whether and

how victims use formal services, is central to theory on health care utilization (Andersen 1995;

Champion, Skinner, and others 2008) and motivated behavior (Maslow 1958), but it is not

explicitly discussed as a factor or mechanism in their model.

Regardless of these limitations, the push toward integrating victim help-seeking theories

shows promise and could particularly benefit RCT approaches. For example, RCT has largely

conceptualized and measured violence harm based on victim injury and the level of intimidation

from the offender (Blumstein 1974; Gottfredson and Gottfredson 1987; Gottfredson and

Hindelang 1979; Wolfgang 1985). However, we know now that the harms of violence are multi-

faceted (Rivara et al. 2019; Sharkey 2018a) and dependent on social context. Concepts from

6

medical sociology can inform how interrelated, but distinct, harms of violence (e.g., injury,

emotional distress, social distress, and chronic physical or emotional problems) encourage certain

types of help-seeking. Emerging evidence also suggests that the influence of harm on victim help-

seeking behavior depends on certain situational factors of violence, such as the victim-offender

relationship (Hullenaar and Frisco 2020). Ideas from sociology and social network theories

(Black 2010; Pescosolido 1992) may help RCT explain how this contextualization of harm

impacts victims’ help-seeking decisions.

Perhaps most importantly, integrating theory that encompasses basic RCT assumptions

would better explain why victims seek help from other formal services besides the police, such as

medical care and social services. To date, Gottfredson and Gottfredson’s research (1987)

provided the foundation for rational choice approaches to victims’ help-seeking decisions.

However, this approach typically explains only victims’ interactions with the criminal justice

system, even though Gottfredson and Gottfredson (1987) acknowledge the significance of

alternative formal help-seeking services. Integrating the literature from fields that focus on

medical care (e.g., medical sociology) and social services (e.g., psychology) would provide rich

insight into the benefits different interventions offer to mitigate violence harms.

Organization of the Dissertation

The dissertation's overarching goal is to provide the field with a richer understanding of

when and why violence victims seek help from three types of formal services: the police,

hospitals, and victim service agencies. Two research questions guide this dissertation:

1) How do victims contextualize the harms they experience from violence?

2) How does the degree, type, and context of harm violence victims experience

influence whether and what types of services they use?

7

To address these questions, I examine victim help-seeking using rational choice

principles but develop a theory that is driven by key ideas from medical sociology and

psychology. I argue that insights about help seeking from these disciplines provide conceptual

tools that offer richer insight into how violence victims contextualize the harm of violence and

determine utility of seeking different types of formal help. The dissertation contributes to the

literature by articulating these interdisciplinary arguments, deriving several predictions from the

expanded theoretical model, and testing them with data from the National Crime Victimization

Survey (NCVS).

The dissertation is organized as follows. Following this introduction, the second chapter

reviews the key factors of victim help-seeking and describes the interdisciplinary framework

driving the study. I argue that victims’ use of any formal service results from a complex interplay

between their physical, emotional, and social needs (i.e., benefits of help-seeking) and the

potential barriers to obtaining services (i.e., costs of help-seeking). Following RCT, this needs-

barriers framework suggests that the physical, emotional, and social harms of violence are the

primary determinants of whether victims seek help and the type of services they use. I advance

RCT, however, by arguing that the link between harm and help-seeking may be highly

conditional; that is, victims’ perceptions of harm and how it influences their decision-making

likely depend on the other situational factors of violence. More specifically, I assert that the

victim’s social relationship with the offender shapes how they perceive harm, which impacts their

decisions to use formal services after a crime.

The third chapter provides a detailed overview of the data used to test my theoretical

expectations. As noted above, the NCVS serves as the centerpiece of the dissertation. The NCVS

is a nationally representative survey of personal and household victimization experiences in the

United States. The NCVS provides detailed characteristics of criminal victimization, including

8

information about consequences to the victim, offender characteristics, incident characteristics,

and victims’ formal help-seeking decisions.

The fourth chapter applies the NCVS to examine the physical, emotional, and social

harms associated with violent victimization. More specifically, it tests whether serious violence

(as measured by the presence of physical injury) has the same effects on emotional distress and

long-term psychological and physical health problems across different victim-offender

relationships. The chapter provides a detailed description of violence harms, focusing on the

heterogeneous effects of serious violence on victims’ well-being.

The fifth chapter also applies the NCVS data, but the focus is on examining the

prevalence and correlates of victims’ use of police, medical, and victim services after the crime.

In multivariable models, the analysis specifically tests whether distinct indicators of harm (e.g.,

injury, weapon use, and emotional distress) predict the types of services victims use (e.g., the

police vs. medical care/victim service agencies). Additionally, building on the research presented

in Chapter 4, this analysis will consider whether the most common predictor of victims’ help-

seeking—injury severity—is conditioned by the victim-offender relationship.

Finally, the sixth chapter discusses the primary implications of this dissertation for

understanding the dynamics of victims’ use of formal services.

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Chapter 2

Understanding Victims’ Help-seeking

This chapter reviews help-seeking theory in criminology and develops an integrated

framework to explain why violence victims use formal services. I separate the chapter into three

parts. First, I review the assumptions, evidence, and limitations of rational choice approaches to

victim help-seeking (i.e., RCT), focusing on Gottfredson and Gottfredson’s (1987) application of

RCT principles to victims’ crime reporting decisions. Second, I offer a needs-barriers framework

that reconceptualizes the utilitarian principles of RCT into a theory that explains when victims are

most likely to use formal services and the types of services they use. Third, using this needs-

barriers framework, I develop new empirical expectations for the two most well-studied

predictors of victim help-seeking: the harm of violence and the victim-offender relationship.

Rational Choice in Victim Crime Reporting

Criminologists have loosely applied rational choice assumptions and concepts to explain

why victims report crimes to the police (Felson et al. 2002; Galvin and Safer-Lichtenstein 2018).

The basic premise of rational choice is that victims have crime reporting preferences, which are

represented by a utility function (Hechter and Kanazawa 1997). Given complete information

about the potential benefits and costs of reporting (vs. not reporting), victims choose the option

that maximizes personal utility. In short, victims most often report (or avoid reporting) to

“minimize the cost of crime and its aftermath” (Block 1973: 557).

In their research on criminal justice decision-making, Gottfredson and Gottfredson

(1987) argued that a victim’s choice to report a crime reflected a rational decision-making

process. This claim followed three basic assumptions. First, reporting to the police fulfills one or

more of the victim’s goals, such as fulfilling a societal obligation to control crime, carrying out

14

retribution against the offender, or providing a means to solve a current crisis. Second, the victim

has alternatives to reporting to the police, such as “doing nothing” or handling it privately.

Rationality is absent without a decision to be made. Third, victims have some information about

their choices that would be directly relevant to their goals. This knowledge should specifically

inform the potential consequences (i.e., benefits and costs) of their reporting decisions.

While rational choice theory is a useful lens through which to view victim decision-

making, it is questionable whether victims make truly rational decisions after a crime. Because

victims experience high levels of stress and trauma, they often make help-seeking decisions with

poorly articulated goals or incomplete information about potential consequences—limiting their

ability to maximize utility. Still, Gottfredson and Gottfredson (1987: 4) argued that the victim’s

reporting decision is still rational insofar that it is a “decision among those possible for the

decision-maker which, in the light of the information available, maximizes the probability of the

achievement of the purpose of the decision-maker in that specific and particular case.” Even if

victims’ decisions do not fully optimize expected outcomes, they use available information to

make decisions as if they were rational.

According to this perspective, factors that provide victims with the most relevant

information regarding the utility of reporting to the police should be the most influential on their

crime reporting decisions. This expectation has been largely supported in the literature. For the

most part, whether a victim reports to the police depends on information directly related to the

incident (e.g., victim injury). In the words of Skogan (1984: 129), crime reporting is an “incident-

based phenomenon.”

The central factor of whether victims report to the police is the perceived seriousness of

the crime (Gottfredson and Hindelang 1979; Ruback, Greenberg, and Westcott 1984). For

Gottfredson and Gottfredson (1987), bodily harm, weapon use, sexual violence, and financial loss

are the key situational factors of violence severity that increase the likelihood of reporting to the

15

police.2 Severity is critical to crime reporting because victims tend to be highly utilitarian in their

motivations to call the police. Victims who report to the police most often do so to incapacitate

the offender or secure protection from the police (Felson et al. 2002). Victims who do not report

to the police most often indicate that reporting was not worth it or that the police were not needed

(Goudriaan et al. 2004)

In addition to crime severity, offender characteristics also influence victims’ reporting

decisions, particularly the victim’s social relationship to the offender (i.e., victim-offender

relationship; Block 1973; Kang and Lynch 2014; Kaukinen 2002). In their original work,

Gottfredson and Gottfredson (1987) found that victims who know their offenders are slightly less

likely than victims of strangers to report to the police. Implying a severity-based mechanism, they

argued that stranger-perpetrated crimes may be perceived as more “reprehensible and as creative

of the fear necessary for invoking crime control aims” (Gottfredson and Gottfredson 1987: 333).

Indeed, surveys on social perceptions of crime severity indicate that the same violent crime

committed by a stranger is perceived to be more serious than when it is committed by a known

offender (Rossi et al. 1974)

However, the victim help-seeking literature has provided mixed evidence regarding the

influence of the victim-offender relationship. Some research suggests that victims are generally

less likely to report to the police or use medical care when attacked by a known offender than a

stranger offender (Felson and Paré 2005; Hullenaar and Frisco 2020). By contrast, studies of

cyberstalking suggest that victims are less likely to report incidents to the police when the

perpetrator is a stranger (Fissel 2018). Other studies suggest that the victim-offender relationship

2 Gottfredson and Gottfredson’s (1987) indicators of crime seriousness were derived from Wolfgang’s

(1985: 131) national survey of crime severity. Note that some scholars questioned the ability of these

surveys to measure national consensus on crime severity (Cullen et al. 1985).

16

is unimportant to crime reporting (Skogan 1984), perhaps because there are conflicting motives

for and against reporting a known offender to the police (Felson et al. 2002).

Figure 2-1 illustrates the empirical implications of Gottfredson and Gottfredson's (1987)

theory for victims’ decisions to report to the police. Based on their theory, situational factors—

i.e., bodily harm, victim-offender relationship, weapon use, sexual violence, and financial loss—

provide information about the seriousness of the crime to victims. For example, serious injury,

stranger offenders, the deadliness of a weapon, sexual attacks, and greater financial loss increase

the perceived severity of the crime. As perceived severity increases, victims are more likely to

articulate personal and criminal justice-oriented goals—e.g., protection, incapacitation of the

offender, and retribution against the offender—that increase the perceived utility of reporting to

the police. One study that modeled victims’ reasons for reporting (and not reporting) violence, for

instance, found that victims attacked by a weapon are more likely to report for personal protection

and less likely to avoid reporting because the crime was “trivial” or “unimportant” (Felson et al.

2002). While other factors are present in the model, this figure underscores the centrality of harm

and victim-offender relationship in victims’ crime reporting decisions.

Crime

severity

Situational factors 1) Severe injury

2) Stranger offender

3) Weapon use

4) Sexual violence

5) Financial loss

CJ

Goals

Police

report

+

+ +

Figure 2-1. Gottfredson and Gottfredson’s Rational Choice Framework

Limitations of Gottfredson and Gottfredson’s RCT Framework

As mentioned in the introduction, scholars have criticized the RCT framework of victim

help-seeking for being narrowly focused on crime severity and situational factors (Xie and

Baumer 2019), but I argue that this is not a critical limitation. Research consistently shows that

the strongest determinants of victim help-seeking decisions are found in the variability of crime

incidents, particularly in the variability of harm victims experience (e.g., injury severity;

Greenberg and Ruback 1992; Skogan 1984). Additionally, evidence across multiple countries

suggests that victims most often give pragmatic and utilitarian reasons for help-seeking that imply

a rational choice decision-making process or “cost-benefit analysis” (Fugate et al. 2005;

Goudriaan et al. 2004).

Overall, in terms of explanatory power, generalizability, and parsimony, the RCT

perspective offered by Gottfredson and Gottfredson (1987) is valuable, but the theory has three

features that limit its general applicability to victim help-seeking. First, Gottfredson and

Gottfredson (1987) frame victims more as criminal justice agents than decision-makers facing a

crisis.3 Some of the goals they highlight as shaping victim help-seeking, such as a victim’s desire

to fulfill social obligations of crime control or to obtain justice, seem irrelevant to their decisions

to use non-police services, such as medical care or social service agencies. These services can

help victims meet physical needs (e.g., medical care from a hospital) or socio-emotional needs

(e.g., counseling or resources from a victim service agency) not easily fulfilled by law

enforcement. Clarifying these non-criminal justice goals would likely bring greater clarity to

3 Gottfredson and Gottfredson (1987) acknowledge that victims’ decision to report to the police may be

also a solution to a perceived crisis. However, after examining reporting patterns and victims’ reasons for

their reporting decisions, they conclude that, “Salient features of what is known about victims’ purposes are

thus that the gravity of the offense is a principal dimension of concern, and that aside from personal

(idiosyncratic) utilities, the major utilitarian and desert goals of the [criminal justice] system appear to be

reflected in decisions whether or not to report to the police” (p. 338, punctuation added for clarity).

18

victims’ help-seeking motives and better predict whether and what types of alternative services

they use.

Second, Gottfredson and Gottfredson's (1987) theoretical framework provides limited

insight into the perceived and actual barriers that hinder victim help-seeking. More specifically,

their framework does not address how factors relevant to severity—such as victim-offender

relationship and sexual violence—may also relate to the perceived costs of using formal services.

Intimate partner violence victims may desire medical care, but the offender may prevent them

(physically or otherwise) from seeing a healthcare provider to avoid police involvement. These

victims may also refuse to seek help to avoid public stigmatization from family members, police

officers, and medical professionals (Overstreet and Quinn 2013). Moreover, while Gottfredson

and Gottfredson (1987) assert that violence that involves sexual perpetration increases perceived

severity and thus increases victim reporting, sexual violence may also carry a stigma that prevents

victims from using formal services (Campbell et al. 2001; Patterson, Greeson, and Campbell

2009). Rather than being more likely to seek help, national-level data on victimization indicate

that sexual violence victims are particularly unlikely to report to the police (Truman and Morgan

2020) or use medical services (Hullenaar and Frisco 2020).

Third, the RCT framework developed by Gottfredson and Gottfredson (1987) does not

address the complex ways situational factors may condition the effects of perceived harm on

help-seeking behaviors. From their perspective, victim-offender relationship influences crime

reporting because there is an apparent societal consensus that stranger violence, in and of itself, is

more severe than violence by a known offender. This argument ignores harm as perceived by the

victim. In this regard, it is important to understand the physical, psychological, or social

consequences of stranger violence and violence by known offenders, as reported by victims. This

approach is more sensitive to how the victim-offender relationship contextualizes victims’

19

perceptions of their violence injuries and how this process may affect their help-seeking

outcomes.

Toward a Needs-Barriers Framework

To advance the literature, I present a need-barriers framework that integrates key

theoretical ideas from help-seeking research in criminology, psychology, and sociology to explain

why victims use formal services after a violent crime. This framework builds on Gottfredson and

Gottfredson (1987) and follows the general RCT principle that help-seeking is a rational behavior

driven by victims’ goals and needs. It also considers how barriers may prevent victims from using

services, even when they need them. The framework makes three basic assumptions:

1) Victims use a formal service (e.g., police, hospital, and victim agencies) when they

perceive that a given service can satisfy one or more of their physiological, safety-

related, psychological, or social needs.

2) Actual or perceived physical, psychological, and social barriers serve as disincentives

for victims to use formal services, even if such services can satisfy their needs.

3) Victims use available and relevant information to determine their needs for, and

barriers to, formal services.

The following sections detail these assumptions and their implications for understanding

the factors that predict violence victims’ use of formal services.

Need

Violence can harm victims’ physical health, mental health, and social lives, and when

such harms are perceived to be significant, victims use formal services to alleviate them. If

victims do not experience harm, they typically will not need—and thus not use—a formal service.

In this regard, need is analogous to the “benefits” of rational choice theory on help-seeking and is

20

a common factor in medical sociological theories on health service utilization (Andersen 1995).

Need is the most central factor in the needs-barriers framework.

The link between need and help-seeking is rooted in psychology and motivational theory.

Maslow (1958) argued that human beings have a hierarchy of needs that drive their instrumental

behavior. In order of importance, these needs include physiological needs (e.g., physical health),

safety needs, social needs (e.g., maintain social relationships), esteem needs (e.g., dignity and

confidence), and cognitive needs (e.g., self-actualization). Needs are often most evident when

people experience deprivation (Maslow and Lewis 1987). For example, the sick or injured use

medical care to address the deprivation of physical health. Compared to cognitive needs, Maslow

suggests that people are most concerned with needs caused by deprivation, or “deficiency needs”

(i.e., physiological, safety, social, and esteem needs). In this regard, people typically prioritize

physical health and safety above all (Maslow 1958; McLeod 2007).

Deficiency needs may explain whether and what types of services victims use in the

aftermath of a crime. For example, a victim with a life-threatening knife wound has a greater

physiological need for medical care than a victim with minor bruising (Resnick et al. 2000;

Zinzow et al. 2012). Furthermore, a victim threatened by a weapon or multiple offenders may rely

on the police, rather than only medical or victim services, because they expect the police to

guarantee their safety (e.g., neutralize imminent threats or incapacitate offenders) and prevent

(further) injury. To fulfill social needs or psychological needs, domestic violence (DV) victims

may seek out social workers and counselors, instead of reporting to the police, to restore their

social relationships and improve their mental health. Understanding the needs of violence victims

lends insight into whether and how they access formal services.

Need can also explain the dynamic nature of help-seeking, in that help-seeking decisions

are driven by prior help-seeking experiences (Xie and Baumer 2019). While need is rooted in

victims’ perceptions, they may also learn about their needs from others, such as service

21

professionals. As a result, victims who seek help may be more incentivized to use formal services

in the future. If diagnosed with a long-term ailment by a health professional, victims may be more

likely to regularly use physical or psychiatric therapy after receiving a referral from a physician

(Wolff et al. 2017; Wong et al. 2009).

Barriers

Barriers are the actual or perceived obstacles that prevent victims from using formal

services. This concept reflects rational choice theory’s notion of perceived costs and is prominent

in medical sociological theory. For example, in the health belief model of health care utilization,

barriers indicate “a belief about the tangible and psychological costs of an advised action”

(Champion and Skinner 2008: 48). Barriers also refer to the variation in the perceived

accessibility of formal services, as violence victims must know about and be able to access a

formal service to use it.

Barriers can be tangible, psychological, or social. Tangible barriers generally refer to

impediments that limit access to formal services. Lack of time, resources (financial or otherwise),

or transportation limits violence victims’ ability to use formal services, such as the police

(Greenberg and Ruback 1992). In certain incidents, such as DV, offenders may also physically

prevent victims from using services by threatening harm (Fugate et al. 2005). Tangible barriers

are also linked to the availability of services. For instance, one study found that DV victims in

rural areas had greater service needs than DV victims in urban areas, but rural victims’ access to

services was reportedly more limited (Grossman et al. 2005). Some evidence suggests that rural

areas may also offer lower-quality care than urban areas (e.g., trauma care; Rogers et al. 1999).

Psychological barriers to help-seeking are rooted in the victims’ emotions, attitudes, and

beliefs (Komiya, Good, and Sherrod 2000). While fear can produce an emotional need for formal

services, fear can also be one of the most important psychological barriers that prevent victims

from seeking help. For instance, Felson and colleagues (2002) found that fear of retaliation

22

disincentivized victims from reporting to the police, particularly if they were attacked by an

intimate partner (instead of a stranger). Feelings of shame and guilt may also reduce victim help-

seeking. The fear of secondary traumatization, such as negative treatment by service providers

(Campbell 2013), can dissuade victims of sexual violence from reporting to the police or seeking

medical care (Overstreet and Quinn 2013). General attitudes regarding formal services may also

influence help-seeking. For example, a survey of victim service agencies across the United States

suggested that men do not use victim services because they do not believe that victim agencies

are set up to serve male victims (Tsui, Cheung, and Leung 2010).

Social barriers arise from external social influence or normative expectations. Using

multiple methods and datasets, Greenberg and Ruback’s (1992) research into victims’ crime

reporting decisions suggested that social influence affects how victims perceive crime and

whether they report to the police. For example, crime victims often follow the advice of others

when making a crime reporting decision (Ruback 1994). It seems likely that advice from one’s

social network may also influence whether victims use non-police services. Indeed, Pescosolido

(1992) and Andersen (1995) argue that social networks are critical resources that can enable

people to use health services. On the other hand, perceptions regarding social norms and

expectations may also impede victims from using formal services. One of the most frequent

findings in the help-seeking literature is that females are more likely than males to use police,

medical, and psychological services (McCart, Smith, and Sawyer 2010). The consistent gender

difference in help-seeking is most often attributed to the normative expectation that women ought

to seek help, whereas men ought to help themselves (Addis and Mahalik 2003; Galdas, Cheater,

and Marshall 2005).

Figure 2-2 illustrates the basic relationships proposed by the needs-barriers framework

for violence victims’ use of formal services, which has three critical elements. First, violence

victims are more likely to use a formal service if they experience a physiological, safety-related,

23

social, or psychological need for the service. Second, violence victims are less likely to use a

formal service when they perceive physical, psychological, or social barriers. Third, the

relationship between need/barriers and help-seeking is reciprocal, in that using a formal service

can increase violence victims’ perceived need for further formal services and reduce the potential

barriers that impede their use of these services. Consequently, it is expected that victims who use

formal services are more likely to use formal services in the future.

In the following section, I revisit Gottfredson and Gottfredson's (1987) original findings

regarding victims’ crime reporting decisions and reframe their research from a needs-barriers

perspective. I argue that this approach lends deeper insight into two critical predictors of victims’

use of formal services: the harms of violence and the victim-offender relationship.

24

Harm, Victim-offender Relationship, and Formal Services

Gottfredson and Gottfredson (1987) found that crime severity and the victim-offender

relationship were the two consistent predictors of whether victims reported to the police. In

essence, greater harm to the victim and lower relational closeness between the victim and the

offender (e.g., strangers) were associated with an increased likelihood of crime reporting. The

authors argued that these factors influenced reporting because of their relevance to the rational

and justice-oriented goals of victim crime reporting (e.g., justice, retribution, safety, and solve a

crisis). I argue that these two factors are more relevant to victims’ general need for help and the

barriers they face to get it. Accordingly, they can be framed using a needs-barriers perspective to

explain victims’ use of formal services more generally—not just police. Figure 2-3 illustrates this

argument.

Need

• Physiological

• Safety

• Social

• Psychological

Barriers

• Physical

• Psychological

• Social

Formal services

+

Figure 2-2. Needs-barriers Framework for Victims’ Use of Formal Services

+

Predisposing factors

Situational factors

• Victim-offender

relationship

Violence harms

• Physical

• Emotional

• Social

Need

• Physiological

• Safety

• Social

• Psychological

Barriers

• Physical

• Psychological

• Social

Formal services

/

+

+

+

+

Pre-crime stage Crime stage Post-crime stage

Figure 2-3. Applying the Needs-barriers Framework

+

/+

+

+

A needs-barriers perspective posits that victims are predisposed to situational factors

(e.g., victim-offender relationship) and harms of violence (e.g., physical, emotional, social) that

determine their needs for and barriers to formal services. Predisposing factors exist before the

crime occurs (i.e., pre-crime stage) and include, but are not limited to, the victim’s demographics

(e.g., gender, age, and race), social or environmental characteristics (e.g., social network or

neighborhood characteristics), and the victim’s pre-existing beliefs or attitudes regarding help-

seeking. While predisposing factors are not the focus of the dissertation, they must be included in

the framework because variation in the type and severity of violence is not distributed evenly in

the population.

Violence Harms and Victim-offender Relationship

Victims’ need for formal services is primarily determined by the physical, emotional, and

social harms of violence that occur during and immediately preceding the crime (i.e., crime

stage). Gottfredson and Gottfredson (1987) argue that the key predictors of violence severity are

the situational factors that immediately precede harm, such as the victim-offender relationship.

Regarding this factor, they, and other criminologists, posit that victims attacked by strangers are

less likely than victims attacked by known offenders to report to the police because the latter is

considered a “less serious” offense according to societal norms (Black 1979; Rossi et al. 1974).

From the victim’s perspective, stranger violence may also be uniquely traumatizing. In studies of

sexual violence victims, stranger violence is more likely to invoke fear (Ullman and Siegel 1993)

that increases victim help-seeking. Additionally, the anonymity associated with stranger violence

may also increase offenders' willingness to injure victims, as they may be less sympathetic to the

victim’s pain or less concerned about getting caught and punished (Lantz 2018). Thus, one

expectation is that:

27

Hypothesis 1a: Relational closeness between the victim and the offender is negatively related to

the harms of violence.

Alternatively, other scholars argue that the harm of violence runs deeper for victims who

know their offenders well. Apel, Dugan, and Powers (2013) found that victims were most likely

to be injured if they were attacked by an intimate partner or family member, as opposed to an

acquaintance or stranger. Victims of DV (i.e., intimate or family offender) also have fears of

revictimization, which may lead them to seek help to secure personal safety (Felson et al. 2002).

Thus, the psychological impact of DV extends beyond immediate injury or distress and may have

a long-term impact on victims’ physical, emotional, and social health (Rivara et al. 2019). This

argument leads to a competing expectation:

Hypothesis 1b: Relational closeness between the victim and the offender is positively associated

with the harms of violence.

These hypotheses suggest that the victim-offender relationship has a main effect on the

harms of violence, but some researchers argue that the victim-offender relationship may also

moderate the effects of harm on help seeking. Black (1979) asserted that social conditions, such

as a close relationship between a victim and offender, can reduce the perceived harm of crime. In

a poignant example, he stated, “Even intentional homicide loses some of its “seriousness” when it

occurs under the right conditions” (Black, 1979: 23). While Black’s example referred to how

societies define the harms associated with crime, it may be the case that victims also

contextualize the harms they experience.

This idea is critical because it suggests that the link between harm and victims’ use of

formal services may depend on who caused the harm. For example, victims may be more likely to

28

“downplay” injuries caused by known offenders than injuries caused by strangers. As a result,

injuries may have less influence on violence victims’ help-seeking decisions when they know

their offender(s) well. One way to test this expectation would be to examine whether violence

injuries produce more/less psychological, social, and long-term harms across different victim-

offender relationships. Physical injuries occur prior to the psychological and social consequences

of violence, which helps disentangle issues related to the time ordering of violence harms. If

people perceive the harm of violence based on the victim-offender relationship, then:

Hypothesis 2: The anticipated positive association between physical injury and the

psychological, social, and long-term harms of violent victimization will become weaker as the

relational closeness between the victim and the offender increases.

Victims’ Need for Formal Services

The physical, emotional, and social harms of violence produce a unique set of needs that

affect whether and what type of formal services victims use. In general, experiencing any one of

these harms to a greater degree should motivate violence victims to use formal services (McCart

et al. 2010). However, research rarely examines how these various harms, together, motivate

violence victims’ use of formal services. Most often, studies focus only on how injury and

weapon use is associated with reporting to the police (Xie and Baumer 2019), using medical care

(Hullenaar and Frisco 2020; Resnick et al. 2000; Zinzow et al. 2012) or using counseling or

therapy services (McCart et al. 2010). If all harm motivates help-seeking, then it is expected that:

Hypothesis 3: The physical, emotional, and social harm of violence is positively related to

victims’ use of formal services (i.e., police, hospital, or victim service agencies).

29

However, victims may opt to use different services, depending on their needs. Criminal

justice organizations focus on enforcing the law and increasing victim safety, whereas hospitals

and social service agencies focus on treating victims’ physical, emotional, or social problems.

Accordingly, there may be instances where help-seeking victims choose to avoid the police and

only use medical or social services, and vice versa. For example, violence victims who

experience severe injury may prioritize medical care over the police because of urgent

physiological needs. If violent victimization causes emotional or social distress, victims may

prefer to use only the counseling or social services offered at hospitals and victim service

agencies. By contrast, victims who are attacked or threatened by a weapon or multiple offenders

may feel a mortal danger that threatens their safety, and thus they may prefer to report to the

police because medical and social services, by themselves, do not fully satisfy their need for

protection. In short, the indicators of physical, emotional, and social harm may predict how

victims activate formal help-seeking resources. These expectations lead to the following three

hypotheses:

Hypothesis 4a: Victims with severe physical injuries are more likely to use only medical or

social services than use police services.

Hypothesis 4b: Victims who are attacked by a weapon or multiple offenders are more likely to

use police services than only medical or social services.

Hypothesis 4c: Victims who report emotional or social distress are more likely to use only

medical/social services than police services.

Contextualizing Harm

If violence victims contextualize their harm based on their social relationship to the

offender, the link between the harms of violence and victim help-seeking may also be moderated

30

by victim-offender relationship. More specifically, the relationship between the physical, social,

and emotional harms of violence and victims’ use of formal services should weaken as the

relational closeness between victims and offenders increases.

In a study on victims’ use of medical services, Hullenaar and Frisco (2020) found that the

severity of injury generally increased the likelihood that victims received professional medical

care. Yet this association was weaker for DV victims than for victims of stranger violence. They

argued that DV presents such a substantial barrier to medical care for victims that it reduces the

importance of injury in victims’ health care use decisions. However, they never examined how

the other harms of violence were associated with victims’ health care use. Moreover, they never

considered the possibility that the interaction between injury severity and victim-offender

relationship may be explained by how victims interpret injuries by known and stranger offenders.

If victims, for instance, “downplay” injuries or harms caused by intimate partners or family

members (as opposed to strangers and acquaintances), then it is expected that:

Hypothesis 5: The positive relationship between physical, emotional, and social harms of

violence and victims’ use of formal services will decrease as the relational closeness between the

victim and the offender increases.

Barriers: Victim-offender Relationship and Sexual Violence

As argued by Hullenaar and Frisco (2020), the victim-offender relationship may present

social, physical, and emotional barriers to victims’ formal help-seeking. Indeed, Black argued that

victims face social barriers when reporting to the police because the law is less available to

victims who intimately know their offender (Black 2010). As compared to stranger violence,

intimate partner and family violence also use alternative forms of dispute resolution (Horowitzs

31

1990). In these cases, violence typically occurs “behind closed doors” and is unlikely to involve

any formal service intervention (Felson and Paré 2005; Straus, Gelles, and Steinmetz 2017).

Victims of DV (as opposed to acquaintance or stranger violence) may also face physical

or emotional barriers that dissuade them from accessing services. For example, an intimate

offender may physically prevent victims from calling the police, using medical care, or using a

victim service agency. Victims may also avoid services to maintain their relationships. Among

victims who love or care for the person who hurt them, obtaining medical care risks public

disclosure of the victimization. If the victimization becomes known, care providers, friends, and

family members may pressure the victim to end their relationship or may stigmatize the victim for

staying with their abuser (Overstreet and Quinn 2013). Victims who wish to avoid this pressure

and judgment may avoid seeking help altogether.

Hypothesis 6: Relational closeness between the victim and the offender is negatively associated

with victims’ use of formal services.

There is considerable overlap between victims of domestic violence and victims of sexual

violence, and thus sexual violence may also present victims with emotional or social barriers to

using services. For example, sexual violence victims may avoid reporting to the police or seeking

medical care to prevent secondary victimization (Patterson, Greeson, and Campbell, 2009), which

is defined as the negative reactions and ramifications of interacting with family, friends, police,

and health care providers after a crime (Campbell et al. 2001; Williams 1984). If sexual violence

victims use health care, they may face stigmatizing attitudes from police and doctors (Campbell

2008; Overstreet and Quinn 2013) and a highly invasive treatment process (Campbell, 2008).

After long waits for care that require victims to forgo eating, drinking, and urinating to maintain

physical evidence (Taylor 2002, cf. Campbell 2008), sexual assault victims may also be asked to

32

undergo exams that involve “plucking head and pubic hairs; collecting loose hair by combing the

head and pubis; [and] swabbing the vagina, rectum, and/or mouth to collect semen, blood or

saliva” (Campbell, 2008: 706). The trauma of these exams can be compounded when victims

perceive that care providers—some with only minimal training or experience in giving forensic

exams—are rude or callous during the procedure (Campbell 2005). When weighing the potential

benefits of using professional services with the costs of secondary victimization, violence victims

may understandably avoid seeking help.

Hypothesis 7: Sexual violence victims are less likely than non-sexual violence victims to use

formal services.

Conclusion

This chapter offered a “needs-barrier” framework of victims’ use of formal services that

builds on rational choice approaches to studying victims’ crime reporting behaviors. Victims’

formal help-seeking is a reciprocal process that is driven by a complex interplay between victims’

needs for formal service (i.e., physiological, safety, social, and psychology needs), the barriers

that prevent them from obtaining services (i.e., physical, psychological, and social barriers), and

their past experiences with help-seeking. Understanding this interplay is critical for explaining

when and how victims use formal services, including the police, medical care, and social service

agencies. In the next chapters, I present results from two studies that test the empirical

implications of the needs-barriers framework, as summarized in the hypotheses outlined above.

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33



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63(8):702–17.

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Medical, and Mental Health Systems. edited by D. Sisti, A. Caplan, and H. Rimon-

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Felson, Richard B., Steven F. Messner, Anthony W. Hoskin, and Glenn Deane. 2002. “Reasons for

Reporting and Not Reporting Domestic Violence to the Police.” Criminology 40(3):617–48.

Felson, Richard B. and Paul Philippe Paré. 2005. “The Reporting of Domestic Violence and Sexual

Assault by Nonstrangers to the Police.” Journal of Marriage and Family.

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Galvin, Miranda A. and Aaron Safer-Lichtenstein. 2018. “Same Question, Different Answers:

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Goudriaan, Heike, James P. Lynch, and Paul Nieuwbeerta. 2004. “Reporting to the Police in

Western Nations: A Theoretical Analysis of the Effects of Social Context.” Justice

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Greenberg, Martin S. and R. B. Ruback. 1992. After the Crime: Victim Decision Making. New York:

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Grossman, Susan F., Sarah Hinkley, Annie Kawalski, and Carolyn Margrave. 2005. “Rural versus

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Hechter, Michael and Satoshi Kanazawa. 1997. “Sociological Rational Choice Theory.” Annual

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Kaukinen, Catherine. 2002. “The Help-Seeking Decisions of Violent Crime Victims: An

Examination of the Direct and Conditional Effects of Gender and the Victim-Offender

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38

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Chapter 3

The National Crime Victimization Survey

This dissertation uses data provided by the National Crime Victimization Survey (NCVS)

to study the correlates and consequences of victim help-seeking behaviors. The NCVS is a

nationally representative survey on personal and household victimization in the United States, and

it is one of the leading measures of crimes in the nation. The NCVS provides detailed characteristics

on criminal victimization, including information about its consequences on the victim, the

characteristics of the offender(s), the characteristics of the crime, and victims’ behaviors during

and after the crime. In this chapter, I discuss information about the NCVS, including its history,

its contribution to the measurement of crime, its design, and its limitations and strengths for

studying the correlates and consequences of victim help-seeking.

A Brief History

In the latter half of the 20th century, the US experienced a precipitous increase in violent

and property offenses that motivated a federal response to the emergent crime problem (O’Brien

2003). In 1965, President Lyndon Johnson formed the Commission on Law Enforcement and

Administration of Justice to study the nature of crime and inform the development of criminal

justice policy. The Commission published its findings in The Challenge of Crime in a Free Society

(1967), which detailed patterns and trends in several areas, such as juvenile delinquency, organized

crime, policing, courts, corrections, firearms, narcotics, and drunkenness offenses.

At the time, the commission had relied primarily on crime data provided by the police—

namely, the Uniform Crime Reports (UCR). Researchers on the commission acknowledged that

their findings might have provided an “inaccurate” picture of crime in the US because of inherent

limitations in law enforcement data (Rand 2006). Most importantly, data provided by the police

40

measures only crime that has been (a) reported to the police and (b) registered by the police to the

FBI as a crime. Thus, the commission’s report failed to capture what is commonly referred to as

the “dark figure” of crime, or crime that is not made known to or by the police.

To address the inherent limitations of police data, the commission recommended that the

federal government implement a victimization survey to better capture the “dark figure” of crime.

This recommendation led to the eventual design and implementation of the National Crime Survey

(NCS) in 1972 (Langton, Planty, and Lynch 2017). The purpose of the NCS was to use a nationally

representative, self-report survey to:

1) Provide an accurate measure of crime victimization over time (e.g., measure the “dark

figure”),

2) Act as an index for the UCR,

3) Provide measures of police reporting

Because the NCS would act as a comparison measure to the UCR, scholars designed the

NCS to mimic some features of the UCR. Namely, how crime was defined in the NCS was exactly

matched to how crime was defined in the UCR, with the exception of homicide (which cannot be

measured by a self-report survey).

The NCS had unique advantages over the UCR. First, by using random sampling and

survey methodologies, the NCS could provide a national estimate of crime victimization that did

not rely on police agency participation. Second, the NCS provided unique information unavailable

in the UCR, such as the victim’s relationship to the offender, whether the victim reported to the

police or used medical care services, and the prevalence of repeat victimization of the same person.

Third, the NCS could adopt or change the survey’s methodology to respond to emerging issues

related to crime in the United States.

41

One such change occurred in 1992, when the NCS underwent an extensive redesign and

was renamed the National Crime Victimization Survey (Langton et al. 2017). Because the NCS

definitions of crime reflected those of the UCR, researchers noted that the survey’s measures were

too rigid and narrow. As a result, the survey tended to undercount incidents of domestic and sexual

violence. To address these limitations, the NCVS redesign changed how the survey measured

crime and introduced computer-assisted telephone interviewing to improve data collection

methods. The NCVS asked whether victims experienced certain behaviors from others (e.g., hitting,

punching, and using a weapon), addressed specific behaviors related to sexual violence to help

respondents acknowledge victimization, and asked respondents explicitly about whether they were

attacked by someone they knew and how they were related to that person (Bachman and Taylor

1994).

Since the 1992 redesign, the NCVS has made additional changes to respond to emerging

issues in victimization (James 2008; Langton et al. 2017). For example, in 1999, the survey began

asking respondents about whether they felt they were victims of hate crime, or crimes motivated

by their race, gender, disability, or religion. At the start of the new millennium, the survey also

began to measure occurrences of cybercrime and identity theft. Most important to the current

dissertation, the NCVS also added detailed measures about the physical, emotional, and social

consequences of victimization, including detailed measures about the extent victims sought help

from formal services after a crime.

Instrument and Sample

The NCVS uses in-person, phone, and computer-assisted interviews to collect detailed

victimization data from members in US households (Bureau of Justice Statistics 2016). A

victimization incident is recorded by the NCVS if, during the screening process, a member of a

selected household mentions s/he or her/his household was victimized by a crime in the six months

prior to the interview. The former represents “personal victimization,” whereas the latter represents

42

“household victimization.” The NCVS interviewer collects detailed information about

victimization incidents based on the respondent’s answers. In rare cases, household respondents

may act as a proxy for victims in the household and describe the personal victimization incident to

the best of their knowledge. In the 2018 NCVS, a little over 150,000 households were interviewed,

and roughly 250,000 personal interviews were conducted (Bureau of Justice Statistics 2020).

Not all US residents are eligible to take the NCVS. Only members who are 12 years or

older are eligible to participate in an NCVS interview. Because households are the lowest level

sampling unit, people living on military bases, incarcerated populations, and people who are

homeless are excluded from the sample. Moreover, people living in shelters, mental hospitals, soup

kitchens, food vans, and group quarters for natural disaster victims are also excluded.

The sample selection of households is conducted using a stratified, multi-stage cluster

design (Bureau of Justice Statistics 2016).4 The US Census provides a sampling frame of addresses

(in some cases, building permit data is used to identify additional households) in the United States

and selects the sample in two stages. At the first stage, counties, groups of bordering counties, and

large metropolitan areas are selected. These are the primary sampling units (PSU) of the design.

Some PSUs contain such a large number of households that they are always selected at the first

stage (e.g., the Los Angeles metropolitan area) and are considered self-representing. The other

PSUs are stratified (i.e., separated into subgroups based on) by the nine Census divisions and then

further grouped into a stratum with other PSUs that look similar to them (based on population size

and demographics). For each stratum, PSUs are selected using a probability proportionate to size

(PPS) technique (Groves et al. 2011). In short, a PSU is more likely to be selected within a stratum

if they have a larger population of households relative to other PSUs in the stratum. This sampling

4 Stratified, multi-stage cluster design is a type of equal probability of selection method (EPSEM)

that ensures all households in the United States have an equal likelihood of being selected to take

the NCVS.

43

technique ensures that households in larger PSUs have a probability of being selected that is equal

to that of households in smaller PSUs, which allows researchers to assume that every household in

the sampling frame has an equal probability of being selected.

At the second stage, each selected PSU is divided into four non-overlapping sampling

frames, and then clustered units of households are selected within these frames (around four units).

Selecting a cluster of households, rather than just singular household, reduces the financial cost of

the survey by limiting the amount of travel needed by the interviewers. There are four different

types of sampling frames that differ based on where the frame is obtained. Unit frames, GQ frames,

and block frames come from the decennial census, and permit frames come from the Building

Permit Survey (which includes households expected to be built). The simplest and most frequent

procedure involves unit sampling frames, where households in a list are ordered by their urbanicity,

county, tract, and street address and then chosen systematically by selecting every nth household

on the list.5

Once the households are selected into the sample, they are contacted by NCVS interviewers

to complete the survey. The NCVS uses a rotating panel design: selected household addresses that

respond to the NCVS remain in the study for three and a half years. The survey is administered

annually to a new sample of households each year while following up with previously selected

households every six months. Regardless of whether household members move out or into the

sampled addresses, the address remains a part of the NCVS until the end of the three-and-a-half-

year period.

Strengths and Limitations

The NCVS is the foremost national-level survey on victimization in the U.S. The survey’s

sampling design provides the largest sample of interviewed households of any crime-focused

5 For the purposes of parsimony, a detailed discussion about sample selection procedures for each frame is

omitted from the paper.

44

survey. Unlike the Uniform Crime Reports and the National Incident-Based Reporting System, it

collects more detailed information both on crimes that are known and crimes that are unknown to

the police. Additionally, because the NCVS administers consistent measurement tools, it can be

used to monitor and describe trends in victimization-related phenomenon, such as victims’ use of

police, medical, and victim services after a crime.

The NCVS provides the richest data on victims’ use of formal services. Since its inception

(i.e., the NCS), the survey has measured whether violence victims call the police or seek

professional medical care services, such as emergency room, hospital, or physician care. After its

redesign in 1993, the survey added measures regarding victims’ use of victim service agencies.

Starting in 2008, it also added measures about victims’ use of professional services months after a

crime, including professional help for physical and emotional problems associated with being a

crime victim. Using NCVS data, researchers can understand the myriad ways victims use formal

services immediately and even months after the crime.

Yet the strengths of the NCVS must be considered within its limitations. The biggest

limitation of the NCVS is that it does not include certain populations who are a high risk of

victimization, namely institutionalized (Wolff et al. 2007) and homeless populations (Fitzpatrick,

La Gory, and Ritchey 1993; Roy et al. 2014). Thus, the help-seeking behaviors of these high-risk

populations remain unknown.

The second limitation is that the NCVS relies on victims’ self-reported information about

a crime incident, which can be inaccurate due to recall biases (e.g., victim cannot remember details

of the incident) and issues of telescoping. Telescoping occurs when a victim recalls a crime that

occurred before the six-month time window mentioned by the NCVS interviewer (e.g., recalling a

crime that occurred two years ago). The NCVS attempts to reduce instances of telescoping by first

conducting a bounding interview that does not ask about victimization. This bounding interview

serves as an anchor for NCVS respondents, in that NCVS interviewers can ask respondents—who

45

are now being interviewed a second time—whether they have been victims of a crime since their

bounding interview. Telescoping can still be problematic, however, if new respondents move into

the household after the initial bounding interview because only one bounding interview is given

per household (Addington 2005).

The third limitation of the NCVS is that it does not measure whether victims seek help

from informal networks, such as friends and family. Prior research indicates that talking with

friends and family about a victimization is usually the first step in victims’ help-seeking behaviors

(Greenberg and Ruback 1992). For example, victims will often listen to the advice of others

regarding whether to report to the police. Understanding the dynamics of this informal help-

seeking, such as the victim’s relationship with their advice giver (Knoth and Ruback 2019) and the

nature of the advice, is likely critical for understanding victims’ formal help-seeking behaviors

(Ruback, Greenberg, and Westcott 1984).

Conclusion

The NCVS provides detailed, nationally-representative information on violent

victimizations in the US. For the past four decades, the survey has undergone substantial changes,

including the development of survey items that measure victims’ use of formal services in addition

to measuring police reporting behaviors. These changes enabled the NCVS to provide a richer

description of victims’ formal help-seeking behaviors after a crime. Even though the survey has its

limitations (e.g., omitting populations with high risks of victimization), it is well-suited to study

the correlates and consequences of these behaviors.

References

Addington, Lynn A. 2005. “Disentangling the Effects of Bounding and Mobility on Reports of

Criminal Victimization.” Journal of Quantitative Criminology 21(3):321–43.

Bachman, Ronet and Bruce H. Taylor. 1994. “The Measurement of Family Violence and Rape by

46

the Redesigned National Crime Victimization Survey.” Justice Quarterly 11(3):499–512.

Bureau of Justice Statistics. 2016. National Crime Victimization Survey Technical

Documentation, 2016. Washington, DC.

Bureau of Justice Statistics. 2020. “Data Collection: National Crime Victimization Survey

(NCVS).” Data Collection Detail. Retrieved September 28, 2020

(https://www.bjs.gov/index.cfm?ty=dcdetail&iid=245).

Commission. 1967. The Challenge of Crime in a Free Society. Washington, DC: US Goverment

Printing Office.

Fitzpatrick, Kevin M., Mark E. La Gory, and Ferris J. Ritchey. 1993. “Criminal Victimization

among the Homeless.” Justice Quarterly 10(3):353–68.

Greenberg, Martin S. and R. B. Ruback. 1992. After the Crime: Victim Decision Making. New

York: Springer Science+Business Media.

Groves, Robert M., Floyd J. Fowler Jr, Mick P. Couper, James M. Lepkowski, Eleanor Singer,

and Roger Tourangeau. 2011. Survey Methodology. Vol. 561. John Wiley & Sons.

James, Nathan. 2008. How Crime in the United States Is Measured. Washington, DC.

Knoth, Lauren K. and R. Barry Ruback. 2019. “Reporting Crimes to the Police Depends on

Relationship Networks: Effects of Ties among Victims, Advisors, and Offenders.” Journal

of Interpersonal Violence 34(13):2749–73.

Langton, Lynn, Michael Planty, and James P. Lynch. 2017. “Second Major Redesign of the

National Crime Victimization Survey (NCVS).” Criminology and Public Policy

16(4):1049–74.

O’Brien, Robert M. 2003. “UCR Violent Crime Rates, 1958--2000: Recorded and Offender-

Generated Trends.” Social Science Research 32(3):499–518.

Rand, Michael. 2006. “The National Crime Victimization Survey: 34 Years of Measuring Crime

in the United States.” Statistical Journal of the United Nations Economic Commission for

47

Europe 23(4):289–301.

Roy, Laurence, Anne G. Crocker, Tonia L. Nicholls, Eric A. Latimer, and Andrea Reyes Ayllon.

2014. “Criminal Behavior and Victimization among Homeless Individuals with Severe

Mental Illness: A Systematic Review.” Psychiatric Services 65(6):739–50.

Ruback, R. Barry, Martin S. Greenberg, and David R. Westcott. 1984. “Social Influence and

Crime-Victim Decision Making.” Journal of Social Issues 40(1):51–76.

Wolff, Nancy, Cynthia L. Blitz, Jing Shi, Jane Siegel, and Ronet Bachman. 2007. “Physical

Violence inside Prisons: Rates of Victimization.” Criminal Justice and Behavior 34(5):588–

99.

Chapter 4

Contextualizing the Harms of Violence

This study uses the National Crime Victimization Survey (NCVS) to examine the

physical, emotional, and social harms victims reported after a violent crime. First, it examines the

prevalence of these harms among violent victimizations in the U.S., with a particular focus on

examining the relationship between physical injury and the emotional, social, and long-term

sequelae of violence. Second, it investigates the key predictors of these harms, including

predisposing and situational factors of violent victimization. More specifically, it tests whether

the relational closeness between the victim and the offender is negatively (hypothesis 1a) or

positively (hypothesis 1b) associated with the harms of violence. Third, following the argument

that stranger violence is typically considered more serious than violence by known offenders

(Black 1979; Gottfredson and Gottfredson 1987; Rossi et al. 1974), it tests whether the expected

link between physical injury and the sequelae of violence (i.e., emotional, social, and long-term

harm) may be conditioned by the victim’s relationship to the offender (hypothesis 2). These

results inform whether victims contextualize the harm of violence based on who attacked them. In

the conclusion, I summarize the key highlights from the study and their implications for victims’

help-seeking outcomes.

Data

This study used data collected by the NCVS from 2008 to 2018. The sample was limited

to these years because the NCVS began measuring the long-term emotional and social problems

associated with violent victimization in 2008 and the latest year of available data was 2018. The

unit of analysis is a reported violent victimization. The main analytic sample included 12,493

respondents who reported 16,723 violent victimizations: 10,712 simple assaults, 3,079 aggravated

49

assaults (i.e., assaults involving a weapon or serious injury to victim), 1,838 robberies, and 1,094

rape and sexual assaults. All victimizations occurred in the United States. Complete descriptive

statistics of the study sample (including measures used in Chapter 5) are available in Appendix A.

Overall, 39% of cases had missing data on at least one measure in the study. Most of this

missingness was attributed to measures of the victim’s emotional and social distress (14.3%

missing), offender characteristics (12.5% missing), and the victim’s household income (12.5%

missing). Given that the NCVS provides detailed information about the victim and crime

characteristics and reported a relatively low proportion of missing data, multiple imputation is a

valuable approach to deal with missing data problems. I specifically used multiple imputation

with chained equations (MICE) to deal with missing data. MICE is a set of linear and general

linear models that substitute missing data values for plausible values using the observed data and

an iterative stochastic approach. MICE assumes that the data is conditionally missing at random,

meaning that missing data is attributed to a stochastic process once the observed data is accounted

for in the imputation model. I specified the equations for each imputed variable based on its level

of measurement. Logistic regression models were used for binary variables (e.g., formal service

use, emotional distress, and social distress), multinomial logistic regression models were used for

variables with multiple categories (e.g., victim-offender relationship, injury severity), and linear

regression was used to impute continuous variables (e.g., financial loss reported by victim). For

each equation, I included all variables used in the final analyses. I used 50 imputations to estimate

plausible values from the chained equations.

In analyses of the long-term physical and emotional problems reported by violence

victims, the sample is limited to 8,675 violent victimizations because of natural skips in the

NCVS. Questions about long-term physical and emotional consequences are asked only of

violence victims who reported emotional or social distress. Note that these victimizations were,

50

on average, more harmful than victimizations in the general sample in terms of injury severity

and financial loss (see Table 4-1).

Measures

Outcomes

To measure the scope of harm caused by violence, the study analyzed five different

outcomes: injury severity, emotional distress, social distress, long-term physical problems, and

long-term emotional problems.

Following Hullenaar and Frisco (2020), injury severity was coded into three categories:

no injury (reference), minor injury, and serious injury. Minor injuries indicated that the victim

experienced only cuts, bruises, swelling, or chipped teeth. In the NCVS, these injury types are all

coded as one category. Serious injuries indicated that that victim experienced a gunshot wound,

stab wound, internal injuries, unconsciousness, broken bones or teeth, and/or rape and sexual

assault injuries.6 The types of injuries reported in the serious injury category are available in

Appendix B. In 1.3% of cases, the NCVS recorded a victim injury as only an “other” injury.

Because this category provided no information about severity, I treated “other” injuries as a

separate category.

The aforementioned categorization of injury severity is subjective and somewhat vague

because injuries are reported by the victim and not medically evaluated. Thus, some injuries in

the minor category may be more medically serious than those in the serious injury category. As a

criterion-related validity check, I examine the bivariate relationships between injury severity and

the other harms of violence. It is expected that victims will be more likely to report other harms,

and to a greater degree, as the severity of their injuries increase.

6 The NCVS always codes victims as being injured if they report a completed rape (i.e., completed rape

injury). Among victims in the serious injury category, 29% reported only a completed rape injury. In my

analysis, I control for whether the victimization was sexual violence. Additionally, in sensitivity analyses, I

removed rape/sexual assault incidents and found that the estimates were not statistically different.

51

Emotional distress was measured based on how distressing the violence was to the victim

(1 = not at all distressing and 4 = severely distressing). I dichotomized this measure based on

whether the victim reported moderate to severe distress (=1) or no to mild distress for empirical

reasons (=0). I found that there were no significant differences in the outcomes between

victimizations that were not distressing and mildly distressing or between victimizations that were

moderately distressing and severely distressing. Social distress measured whether the violence

contributed to victims’ problems at school, problems in professional relationships7, or problems

with social relationships8 (= 1).

Long-term physical problems captures the number of physical problems violence victims

experienced for a month or more after their victimization. Physical problems included

experiencing headaches, trouble sleeping, changes in eating or drinking habits, stomach aches,

fatigue, high blood pressure, muscle tension/back pain, and “some other physical problem.” For

each problem, victims reported either yes or no. The number of yes responses were summed to

obtain a scale of physical problems. The maximum number of physical problems the victim could

have reported was 8.

Long-term emotional problems reflects the number of emotional problems violence

victims experienced for a month or more after their victimization. Emotional problems included

whether the victim felt worried/anxious, angry, sad/depressed, vulnerable, violated, distrust in

people, unsafe, and “some other way.” Similar to long-term physical responses, the number of yes

responses to these problems were summed to obtain a scale of emotional problems. The

maximum number of emotional problems the victim could have reported was 8.

7 The question about problems at school and professional relationship was as follows: “Did being a victim

of this crime lead you to have significant problems with your job or schoolwork, or trouble with your boss,

coworkers, or peers?” 8 The question about problems with social relationships was as follows: “Did being a victim of this crime

lead you to have significant problems with family members or friends, including getting into more

arguments or fights than you did before, not feeling you could trust them as much, or not feeling as close to

them as you did before?”

52

Predictors

The study included predictors that indicated predisposing factors of violence harms and

the situational factors of the violent incident. Predisposing factors included the victim’s personal

and household characteristics, including the victim’s gender (1 = female), their age (continuous),

their race and ethnicity (non-Hispanic White [reference], non-Hispanic Black, non-Hispanic

other/mixed race, and Hispanic), their education (less than high school [reference], high school,

some college, and Bachelor’s degree or more), marital status (1=married), urbanicity of their area

(rural [reference], suburban, and urban), and their household’s region of residence (Northeast

[reference], Midwest, South, and West). Using STATA’s factor package, I also estimated a factor

variable that measured the victim’s household economic status. Three items were loaded on the

economic status factor: household income, whether the house was owned or rented, and how

many cars owned by members of the household. These items were significantly correlated (r >=

.35) and the eigenvalue of the factor was above the typical “cut-off” point of 1 (Yong et al. 2013;

eigenvalue = 1.88). The factor was derived from the weighted contribution of each item to

economic status based on the factor analysis and then standardized to z scores (mean= 0, standard

deviation = 1).

Situational factors included the characteristics of the violent crime. Weapon use and the

presence of multiple offenders were treated as situational factors that increased the threat of

violence. Weapon use indicated whether and what type of weapon was used during the violent

crime: no weapon (reference), knife, firearm, other/unknown weapon. Multiple offenders

measured whether the incident involved two or more offenders (=1). Financial loss was measured

as the total financial losses that the victim incurred because of stolen cash, stolen property,

damaged goods, and medical care costs. Estimated losses were based on victims’ self-reports and

not validated by a separate source. This measure should be interpreted with some caution because

victims may over- or under-estimate their losses. Victimizations were coded as incurring zero

53

financial loss if they reported no losses or if the victim did not experience stolen cash/property,

did not experience vandalism, or did not seek professional health care services.

The regression models described below also included situational factors that could

present barriers to victims use of formal services. The victim’s relationship to the offender was

coded into three categories: strangers (reference), friends/acquaintances, and family

members/intimate partners (i.e., family/IP violence). Some victimizations involve multiple

offenders, and for these incidents, I coded the relationship based on the offender who had the

closest relationship with the victim. For example, if the victim was attacked by a family member

and a stranger, the incident was coded as family/intimate partner. This coding strategy was also

the motivating factor for coding family and intimate partner violence as the same category, as it is

difficult to discern “closeness” between intimates and family members.

Situational factors also indicated whether the violence was sexual, it was part of a series

of attacks, a third-party was present during the violence, the victim physically retaliated against

the offender during the crime, and it occurred at a work/school site. Sexual violence was coded as

a completed/attempted rape and or a completed/attempted sexual assault (=1). The models did not

include dummy variables of nonsexual violence types (i.e., robbery, aggravated, or simple

assault) because the measures most often used to determine these crime types were already

included in the analyses (e.g., financial loss, injury severity, and weapon use). Repeat

victimization measured whether the victimization was part of a series of attacks (=1; e.g., multiple

violent incidents by the same offender). Presence of a third party measured whether someone

else besides the victim and the offender were present during the violent crime (=1). Location

measured the physical location of the violence and whether the location was where the respondent

worked. I coded location based on whether it was a private residence (reference), a public area

(e.g., park, bus stop, etc.), a semi-public area (e.g., private park in apartment complex, bank, gas

station, other), and for whether the violence occurred at the victim’s school or a work site that

54

was not at a household residence. To identify whether the violence occurred at the victim’s work

site, I used a separate measure (i.e., “Did the incident occur at your work site?”) that was different

from the general location measure (i.e., “Where did the incident happen?”). Finally, the models

included two measures of the offender’s demographic characteristics. Specifically, the study

incorporated offender gender (only male [reference], only female, and mixed-sex group) and age

(only juveniles [reference], juveniles and adults, and adults only).

Analytic Strategy

This chapter examines predictors of five outcomes that capture different harms of

violence: injury severity, emotional distress, social distress, long-term physical problems, and

long-term emotional problems. Each outcome varies in its measurement, which necessitates

different empirical approaches. This section describes these approaches.

Three outcomes—injury severity, emotional distress, and social distress—were

categorical measures. For injury severity, I used a multinomial logistic regression model, as it

contained three categories (no injury, minor injury, and serious injury). Multinomial logistic

regression simultaneously estimates a series of binomial logistic regression models on each

category, treating one category as the reference group. I present results for the following

comparisons: no injury vs. minor injury; no injury vs. serious injury; minor injury vs. serious

injury. The measures of emotional and social distress, by contrast, encompass just two response

options, which indicated the presence or absence of distress. For these outcomes, I estimated

logistic regression models, treating the absence of distress as the reference category.

Logistic regression models (binomial and multinomial) estimate the absolute difference

between the log of the odds that a victimization falls under one category and the log of the odds

that a victimization falls under reference category. As an estimate, the absolute difference

between log odds provides limited information regarding effect sizes. Thus, I exponentiated the

models’ coefficients to report odds ratios, which indicate a relative (i.e., multiplicative) difference

55

in the odds of a victimization falling under one category instead of the reference category. For

example, when estimating the association between victim’s gender and emotional distress, odds

ratios indicate the relative difference between the odds of a female victim and the odds of a male

victim reporting emotional distress (as opposed to no distress).

Long-term physical and emotional problems indicated the number of symptoms victims

experienced for a month or more. Count models, such as Poisson regression, are thus most

appropriate. Poisson regression assumes equidispersion in the outcome, which refers to equality

between the mean and the variance. Violations of this assumption produce downwardly biased

standard errors. There was significant evidence of overdispersion in the measures of long-term

physical and emotional problems—i.e., the variance exceeded the mean—according to a

likelihood ratio chi-square test of the overdispersion parameter in the model.9 Accordingly, a

negative binomial model is preferred over the Poisson regression model. Negative binomial

models estimate the log of the expected count in the dependent variable (e.g., log of the expected

count of the number of long-term physical problems). Similar to logistic regression models, log

expected counts are somewhat difficult to substantively interpret. Thus, I exponentiated the

coefficients estimated by the negative binomial model to derive incident-rate ratios. Incident-rate

ratios estimate the relative (i.e., multiplicative) change in the expected count of the dependent

variable based on a one-unit change in the predictor variable.

In the NCVS sample, one victim can be represented multiple times in the data if they

report separate violent incidents. This characteristic of the NCVS data violates the assumption of

independence across units. To account for this issue, I clustered the standard errors on the

victim’s identification number provided by the NCVS.

9 Since I used multiply imputed data, a singular estimate of this chi-square test was unavailable. To address

this limitation, I separately conducted a negative binomial regression model for each imputed data set,

recorded the test result, and then examined the distribution of the results across the fifty imputed datasets. I

found evidence of overdispersion in each imputed dataset.

56

Results

Prevalence of Harm

Table 4-1 presents descriptive statistics on the primary harm outcomes: injury severity,

financial loss, emotional and social distress, and long-term physical and emotional problems. At

the top, Panel A describes these outcomes for the entire sample (n = 16,723). At the bottom,

Panel B describes these outcomes for the selected sample of victims with emotional and social

distress (n = 8,675). Recall that only these victims were asked questions about long-term physical

and emotional problems caused by the violent incident.

57

Table 4-1. Selected descriptive statistics: Harms of violence

Panel A. Total sample (n = 16,723)

Type of harm Pr Med (M)

Injury severity

No injury .74

Minor injury .18

Serious injury .06

Other injury .01

Financial loss .17 $518 ($2,321)

Emotional distress .54

Social distress .28

Panel B. Victims with emotional or social distress (n = 8,675)

Type of harm Pr (M) Med (M)

Injury severity

No injury .64

Minor injury .24

Serious injury .10

Other injury .02

Financial loss .23 $664 ($2,655)

Long-term physical symptomsa .60 (2.19)

Long-term emotional symptomsa .91 (4.53)

Note: Pr = probability; M = mean; Med = Median a Long-term emotional and physical symptoms are reported only when violence victims report

experiencing emotional or social distress after the crime.

In the total sample (Panel A), 25% of victimizations involved some level of injury. Minor

injuries were the most commonly reported (18%), followed by serious injuries (6%), then “other”

injuries (1%). Around 17% of victimization involved financial loss to the victim, either through

stolen property, damaged property, or medical costs. Among victimizations involving financial

loss, the median cost was $518, whereas the average cost was around $2,655. Victims reported

feeling emotional distress in a little over half of the victimizations (54%), whereas social distress

was reported in more than a quarter of victimizations (28%).

Overall, victims who reported emotional or social distress also reported more injuries and

greater financial loss (Panel B). In this sample, 36% reported some type of injury, with minor

injuries being the most common (24%) and serious or other injuries being the least common (10%

and 2%, respectively). In these victimizations, a quarter of respondents indicated financial loss,

58

with a median cost of $664 and an average of $2,655. Long-term physical and emotional

problems were common. In 60% of victimizations involving emotional or social distress, the

victim reported experiencing one or more long-term physical problems (mean = 2.2). Long-term

emotional problems were even more prevalent, in that 91% of these victimizations involved one

or more long-term emotional problems (mean = 4.5).

Table 4-2 summarizes the bivariate relationships between injury severity and the other

sequelae of victimization. On average, victims who reported injuries sustained higher financial

losses, partly due to the cost of medical care. Financial loss was particularly high for victims with

serious injuries. Around 60% of victimizations with serious injury involved some type of

financial cost. The median value for costs associated with serious injury ($2,667) was 10 times

higher than victimizations involving no injury ($266) and 5 times higher than victimizations

involving only minor injuries ($500), respectively. Injury severity was also positively related to

emotional distress and social distress. Victims who experienced serious injuries had a probability

of emotional distress that was 33 points higher than victims who experienced no injuries (serious

injuries = 81% vs. no injuries = 48%). The probability of social distress was also 32 points higher

for victims with serious injuries than victims with no injuries (serious injuries = 55% vs. no

injuries = 23%). For both these outcomes, victims with minor injuries fell in-between these

groups.

59

Table 4-2. Injury Severity and the Other Sequelae of Violence

No injury Minor injury Serious injury

Type of harm Pr Med (M)b Pr Med (M)b Pr Med (M)b

Financial loss .09

$266

($1,267) .33

$500

($1,649) .60

$2,667

($5,104)

Emotional distress .48 .65 .81

Social distress .23 .37 .55

LT emotional

problemsa .89 4.71 .93 5.06 .98 5.68

LT physical

problemsa .51 3.46 .66 3.55 .85 4.14

Sample size 12,597 2,848 1,061

Note: Pr = proportion; Med = median; M = mean; LT = long-term a Long-term emotional and physical symptoms are measured only when violence victims report

experiencing emotional or social distress. b Medians and means were measured using only the victimizations experiencing the relevant

condition. For example, the mean for financial loss is the average only for victimizations involving

financial loss.

Regarding long-term issues, 98% and 85% of victimizations involving severe injury

reported experiencing emotional and physical problems, respectively, a month or more after the

crime. Recall that long-term problems were measured only for victimizations involving social or

emotional distress. These proportions were respectively higher than both violence involving no

injury (89% emotional problems and 51% physical problems) and violence involving only minor

injuries (93% emotional problems and 66% physical problems). The average number of problems

reported were also higher for violence involving serious injury than violence involving no or

minor injury. The prevalence and level of emotional problems generally were high for all three

groups, as around 9 out of 10 victims reported some type of emotional problems and the average

number of problems reported ranged from 4.7 to 5.7 (depending on injury severity).

In sum, injury is a potential risk factor for the emotional and social harms associated with

violence victimization, including its long-term consequences. These results provide a criterion-

related validity check for the graded measure of injury severity used in the current study, as

victims reported a greater degree of emotional, social, and long-term harms from victimization as

their level of injury increased.

60

Injury Severity

Because violence injury could lead to other types of harm experienced by victims, it is

important to understand the risk factors for injury. Table 4-3 summarizes the results of a

multinomial logit model that predicts injury severity (no injury, minor injury, serious injury)

based on the situational factors of violence and the victim’s predisposing factors. I focus

primarily on the association between victim-offender relationship and injury severity. From a

social norms perspectives, both Black (1979) and Gottfredson and Gottfredson (1987) argued that

victim-offender relationship is negatively associated with violence severity (hypothesis 1a). From

a victim’s perspective, however, others have suggested that victim-offender relationship may be

negatively related to severity (hypothesis 1b), at least with regard to injury risk (Apel, Dugan, and

Powers 2013).

61

Table 4-3. Multinomial logit model of injury severity

Independent variables

Minor injury

(vs. no injury)

Serious injury

(vs. no injury)

Serious injury

(vs. minor injury)

OR [LL,UL] OR [LL,UL] OR [LL,UL]

Victim-offender relationship

Acquaintance/friend 0.360*** [0.308,0.420] 0.491*** [0.384,0.629] 1.365* [1.043,1.787]

Stranger 0.267*** [0.227,0.314] 0.345*** [0.265,0.448] 1.291+ [0.969,1.720]

Other situational factors

Weapon

Knife 0.598*** [0.460,0.777] 3.525*** [2.683,4.630] 5.898*** [4.179,8.324]

Firearm 0.569*** [0.458,0.706] 0.945 [0.678,1.317] 1.661** [1.135,2.431]

Other weapon 1.771*** [1.497,2.097] 2.931*** [2.243,3.829] 1.654*** [1.240,2.207]

Multiple offenders 1.862*** [1.570,2.209] 2.681*** [2.020,3.559] 1.440* [1.050,1.974]

Offender age

Juveniles and adults 0.834 [0.550,1.264] 1.465 [0.715,3.002] 1.757 [0.836,3.691]

Adult(s) only 0.932 [0.760,1.142] 1.670* [1.126,2.477] 1.792** [1.199,2.680]

Offender sex

Female(s) only 0.976 [0.850,1.121] 0.804 [0.616,1.050] 0.824 [0.623,1.091]

Mixed sex 0.622** [0.461,0.839] 0.586* [0.368,0.935] 0.942 [0.561,1.583]

Sexual violence 0.174*** [0.111,0.273] 15.83*** [12.54,19.98] 91.11*** [56.90,145.88]

Repeat victimization 0.677*** [0.583,0.786] 0.448*** [0.357,0.563] 0.662** [0.514,0.853]

Third party present 0.996 [0.887,1.117] 0.743*** [0.623,0.886] 0.746** [0.614,0.907]

Location

School/work site 0.745*** [0.628,0.884] 0.499*** [0.350,0.710] 0.670* [0.457,0.981]

Public 1.189* [1.005,1.406] 1.029 [0.787,1.345] 0.865 [0.645,1.162]

Semi-public 0.927 [0.780,1.101] 1.041 [0.800,1.354] 1.123 [0.836,1.509]


Female 1.087 [0.968,1.220] 0.823+ [0.677,1.000] 0.757** [0.613,0.935]

Race/ethnicity

NH Black 0.921 [0.774,1.095] 1.280+ [0.987,1.660] 1.390* [1.042,1.854]

NH other/mixed 1.172 [0.948,1.449] 1.327+ [0.961,1.833] 1.133 [0.795,1.613]

Hispanic 0.986 [0.840,1.157] 1.082 [0.840,1.394] 1.098 [0.831,1.450]

Age 0.994** [0.990,0.998] 0.999 [0.993,1.004] 1.005 [0.998,1.011]

Education

High school 1.048 [0.870,1.261] 0.929 [0.720,1.199] 0.887 [0.664,1.185]

Some college 0.964 [0.807,1.153] 0.679** [0.528,0.874] 0.704* [0.530,0.936]

Bachelor's or more 0.882 [0.708,1.100] 0.540*** [0.398,0.734] 0.612** [0.434,0.865]

Economic status 0.884*** [0.824,0.949] 0.912 [0.817,1.018] 1.032 [0.912,1.167]

Married 0.725*** [0.622,0.846] 0.686** [0.544,0.867] 0.946 [0.728,1.230]

Urbanicity

Suburban 0.989 [0.820,1.192] 1.020 [0.780,1.334] 1.031 [0.764,1.392]

Urban 1.007 [0.833,1.219] 0.882 [0.668,1.165] 0.876 [0.642,1.195]

Region

Midwest 0.934 [0.773,1.128] 1.211 [0.904,1.622] 1.297 [0.942,1.785]

South 0.957 [0.799,1.147] 1.095 [0.823,1.456] 1.144 [0.839,1.559]

West 0.885 [0.732,1.071] 1.045 [0.777,1.407] 1.181 [0.852,1.636]

Year fixed effects X X X

Clustered errors X X X

Survey weights X X X

Sample 16,723

Note: Multinomial logit analyses did include “other injury” category, but it is omitted from these results. All

models included year fixed effects, clustered standard errors, and survey weights.

62

The victim’s relationship to the offender was a strong predictor of violence injury

severity. As noted in column 1, Stranger and acquaintance violence victims had 73% and 64%

lower odds, respectively, than family/IP violence victims of experiencing a minor injury than no

injury (stranger: OR = 0.267, 95% CI: 0.227, 0.314; acquaintance: OR = 0.360, 95% CI: 0.308,

0.420). Additionally, column 2 shows that stranger and acquaintance violence victims had 52%

and 66% lower odds, respectively, than family/IP victims of reporting a serious injury than no

injury (stranger: OR = 0.345, 95% CI: 0.265, 0.448; acquaintance: OR = 0.491, 95% CI: 0.384,

0.629). Yet for victims who reported injuries, stranger and acquaintance violence (vs. family/IP

violence) was associated with an increased likelihood of severe injury (column 3). Thus, although

family/IP incidents are more likely than other violence to involve injuries, the injuries that stem

from family/IP violence tend to be less severe than injuries perpetrated by strangers and

acquaintances.

Figure 4-1 provides a more intuitive illustration of these results by summarizing the

predicted probabilities of minor injury and serious injury by victim-offender relationship. Using

STATA and a margins package, I (i.e., margins) calculated predicted probabilities using the logit

coefficients presented in Table 4-3. To estimate predicted probabilities in each condition (e.g., no

injury, minor injury, and serious injury), I set all cases in the data to take the value associated

with a condition (e.g., no injury) and kept all other covariates at their observed values. Then, I

calculated the predicted probability using the estimated odds, based on the logistic regression

estimates.10

10 Calculating predicted probabilities from logistic regression equations occurs in three steps: (1) estimate

the predicted log-odds (without transformation) based on the values set for the independent variables and

the coefficients estimated by the logistic regression model, (2) exponentiate this predicted log-odds to

obtain the predicted odds, and (3) calculate the predicted probability using the following formula :

predicted probability = predicted odds / (1 + predicted odds).

63

Consistent with hypothesis 1b, relational closeness was positively related to injury severity. The

probability that a victim sustained a minor injury was highest among family/IP violence victims

(32%) and lowest among stranger violence victims (13%), with acquaintance violence victims

falling in-between (16%). This same pattern was also true of the probability that victims sustained

a serious injury (family/IP: 9%; stranger violence: 5%; acquaintance violence: 6%). All

differences within injury type were significantly different at the 95% confidence level.

Conflicting with Gottfredson and Gottfredson (1987) and Black’s (1979) position, these results

suggest that—in terms of general injury risk—family/IP violence may be more serious than

stranger violence. However, they are consistent with more recent studies on risk factors of

violence injury (Apel et al. 2013).

64

Of course, situational factors traditionally associated with the severity of violence were

also highly predictive of injury severity (Gottfredson and Gottfredson 1987; Wolfgang 1985). For

instance, the presence of a weapon was generally associated with a decreased likelihood of minor

injury (vs. no injury) but an increased likelihood of serious injury (vs. no injury). However, these

relationships varied by the type of weapon. For example, violence involving a knife or firearm

(vs. no weapon) had lower odds of the victim reporting a minor injury as opposed to no injury

(knife: OR = 0.598, 95% CI: 0.460, 0.777, firearm: OR = 0.569, 95% CI: 0.458, 0.706). By

contrast, the presence of an “other” or unknown weapon increased the likelihood the victim

reported a minor injury (vs. no injury; OR = 1.771, 95% CI: 1.497, 2.097). In violence involving

some form of injury, incidents involving a knife (vs. no weapon) had 5.9 times higher odds of

serious injury (vs. minor injury; OR = 5.898, 95% CI: 4.179, 8.324). Interestingly, compared to

firearm violence, violence involving a knife had higher odds of serious injury. When discharged,

.32

.09

.16

.06

.13

.05

.00

.05

.10

.15

.20

.25

.30

.35

.40

Minor injury Serious injury

Pre

dic

ted

pro

bab

ilit

y

Domestic Violence

Friend/acquaintance

Stranger

Note: 95% confidence intervals presented. Significant differences were observed between all victim-

offender relationship categories within each injury subgroup.

Figure 4-1. Predicted Probabilities of Minor Injury and Serious Injury by Victim-Offender Relationship

65

firearms are usually deadlier than knives (Braga et al. 2020). However, the lethal injuries caused

by firearms are absent in the data because the NCVS does not include homicide. For non-lethal

violence, knives may have a greater propensity to produce injury because offenders use them to

physically attack victims, whereas offenders with a gun may be more likely to merely threaten the

victim.11

Other factors that typically increase the threat of violence also predicted injury severity.

The presence of multiple offenders (vs. a single offender) increased the likelihood of injury and

increased the severity of injuries. The characteristics of the offenders also mattered, as violence

involving only adults (as opposed to only juveniles) was more likely to involve serious injury

than no injury and more likely to involve serious injury than minor injury.

Several predisposing factors significantly predicted injury severity, and although I did not

hypothesize these relationships, I review them here. The victim’s gender, race/ethnicity, age,

educational background, economic status, and marital status were significantly related to violence

injury. Female victims were less likely than male victims to experience serious injuries than no

injury at all (OR = 0.823, 95% CI: 0.677, 1.000), and among injured victims, females were also

less likely than males to report serious injuries than minor injuries (OR = 0.757, 95% CI: 0.613,

0.935).12 Non-Hispanic Black victims were more likely than non-Hispanic White victims to

report serious injuries than no injuries (OR = 1.280, 95% CI: 0.987, 1.660) or minor injuries (OR

= 1.390, 95% CI: 1.042, 1.854). Regarding age, victims who were older were, on average, more

likely to report a minor injury than no injury (OR = 1.280, 95% CI: 0.987, 1.660

11 In sensitivity analyses, I found that the offender attacked the victim in 34% of knife violence incidents,

and in 57% of incidents where the victim was attacked by a knife, the victim also reported being stabbed.

By contrast, the offender physically attacked the victim in 22% of firearm violence, and in only 13% of

incidents where the victim was attacked by a firearm, did the victim also report being shot. 12 These gendered patterns in serious injuries occurred only after controlling for sexual violence. In the

current analyses, sexual violence injuries are treated as serious. In models where sexual violence is not a

covariate, female victims have a greater likelihood than male victims to report a serious injury (vs. no

injury).

66

Educational status was a strong protective factor for serious violence injuries. If victims

had any type of college education (even some college), they were less likely to report serious

injuries (as opposed to no injury or minor injury). For example, victims who reported having a

bachelor’s degree had 46% lower odds of reporting a serious injury than no injury (OR = 0.848,

95% CI: 0.737, 0.975) and 39% lower odds of reporting a serious injury than a minor injury (OR

= 0.848, 95% CI: 0.737, 0.975). Economic status was also a protective factor, but only for minor

injuries. For everyone one-unit increase in the standard deviation of economic status, victims had

11.6% lower odds of reporting a minor injury (vs. no injury; OR = 0.848, 95% CI: 0.737, 0.975).

Emotional Distress and Social Distress

Table 4-4 summarizes the logistic regression models of emotional distress and social

distress. For the sake of brevity, I focus on discussing results regarding the victim-offender

relationship and injury severity because they are the most relevant to my hypotheses.

Furthermore, many of the findings associated with the other factors were consistent with the

relationships observed in the multinomial model of injury severity, in that the same factors that

predicted injury severity similarly predicted emotional and social distress as well. Full models are

available in Appendix C.

67

Table 4-4. Logistic regression models of emotional distress and social distress

Emotional distress

(vs. no distress)

Social distress

(vs. no distress)

Independent variables OR 95% [LL,UL] OR 95% [LL,UL]

Injury severity

Minor injury 1.734*** [1.536,1.957] 1.479*** [1.307,1.673]

Serious injury 2.728*** [2.145,3.468] 2.573*** [2.083,3.179]

Other injury 1.549* [1.095,2.192] 1.583* [1.108,2.262]


Acquaintance/friend 0.678*** [0.582,0.789] 0.542*** [0.469,0.626]

Stranger 0.460*** [0.396,0.535] 0.225*** [0.192,0.263]

Control variables X X

Year fixed effects X X

Clustered errors X X

Survey weights X X

Sample 16,723

Note: OR = odds ratio; LL = lower limit, UL = upper limit. All models included control

variables listed in Table 4-3. Complete models are available in Appendix C.

Similar to the bivariate relationships presented on Table 4-2, injury severity was strongly

and positively associated with both emotional and social distress among victims of violence, even

after controlling for other factors. The degree of injury also mattered. The likelihoods of

emotional and social distress were significantly higher among victims who sustained serious

injuries than victims who sustained no injury, minor injury, or other injury. Additionally, the

odds of emotional and social distress were higher among victims with minor injuries than victims

with no injuries (emotional distress: OR = 1.734, 95% CI: 1.536, 1.957). In short, the degree of

violence injury is a key risk factor for the emotional and social harms of violence.

Even after controlling for the level of injury and other factors, the victim-offender

relationship also had a strong association with emotional and social distress. Family/IP violence

victims had the highest likelihood of reporting emotional and social distress. Compared to

family/IP violence, stranger and acquaintance violence had 32% and 54% lower odds,

respectively of involving emotional distress to victims (stranger: OR = 0.678, 95% CI: 0.582,

68

0.789; acquaintance: OR = 0.460, 95% CI: 0.396, 0.535). Additionally, stranger and acquaintance

violence had 46% and 77% lower odds, respectively, of reporting social distress (stranger: OR =

0.542, 95% CI: 0.469, 0.626; acquaintance: OR = 0.225, 95% CI: 0.192, 0.263).

Figure 4-2 summarizes the predicted probabilities of victims reporting emotional and

social distress by victim-offender relationship using the same process as described on page 15

(holding all covariates at their observed values). Again, consistent with hypothesis 1b, the

relational closeness between the victim and the offender was positively related to emotional and

social distress. These patterns reflect those observed in the analyses of injury severity. The

probability that a victim reported emotional distress was highest in family/IP violence (64%) and

lowest in stranger violence (47%), with acquaintance violence falling in-between (55%).

Additionally, victims were far more likely to report social distress in family/IP (44%), as opposed

to acquaintance violence (31%) or stranger violence.

69

Long-term Physical and Emotional Problems

Table 4-4 summarizes the models of long-term emotional and physical problems that

violence victims reported experiencing for a month or more. As with the previous section, I limit

my discussion to results regarding the two key predictors of harm: injury severity and victim-

offender relationship. A more detailed discussion of the other predictors of long-term problems is

available in Appendix D.

.64

.44

.55

.31

.47

.16

.00

.10

.20

.30

.40

.50

.60

.70

.80

Emotonal distress Social distress

Pre

dic

ted

pro

bab

ilit

y

Domestic Violence

Friend/acquaintance

Stranger

Figure 4-2. Predicted probabilities of emotional distress and social distress by victim-offender

relationship

Note: Predicted probabilities calculated from the model coefficients presented in Table 4-3. 95%

confidence intervals presented. Significant differences were observed between all victim-offender

relationship categories within each injury subgroup.

70

Table 4-4. Negative binomial models of the long-term harms of violence

Independent variables Long-term physical problems Long-term emotional problems

IRR [LL,UL] IRR [LL,UL]

Injury severity

Minor injury 1.275*** [1.185,1.371] 1.100*** [1.066,1.137]

Serious injury 1.755*** [1.596,1.931] 1.160*** [1.114,1.208]

Other injury 1.458*** [1.192,1.784] 1.131** [1.043,1.227]


Acquaintance/friend 0.905* [0.832,0.985] 0.973 [0.937,1.010]

Stranger 0.674*** [0.613,0.740] 0.902*** [0.867,0.939]

Control variables X X


Clustered standard errors X X

Survey weights X X

Sample 8,675

Note: IRR = incident rate ratio

As expected, injury severity was strongly and positively associated with the number of

long-term physical and emotional problems violence victims reported a month (or more) after the

crime. Violence involving serious injury to the victim was associated with a 76% higher count of

long-term physical problems (IRR = 1.755, 95% CI: 1.596, 1.931) and a 16% higher count of

long-term emotional problems (IRR = 1.160, 95% CI: 1.114, 1.208), compared to violence

involving no victim injury. Violence involving only a minor injury to the victim was associated

with a 28% higher count of long-term physical problems and a 10% higher count of long-term

emotional problems. The degree of injury also mattered for violence victims’ long-term

outcomes, as violence victims who experienced serious injury reported a higher number of both

physical problems and emotional problems than violence victims who experience only a minor

injury (p < 0.05).

Regarding victim-offender relationship, family/IP violence victims reported the highest

number of long-term physical and emotional problems compared to other relationship types.

Victims of stranger violence and acquaintance violence reported 33% fewer and 10% fewer

physical problems, respectively, than family/IP victims (stranger: IRR = 0.674, 95% CI: 0.613,

0.740; acquaintance: IRR = 0.905, 95% CI: 0.907, 0.985). Further, victims of stranger violence

71

reported 10% fewer emotional problems than family/IP victims (IRR = 0.902 95% CI: 0.867,

0.939). There was no significant difference between the expected counts of emotion problems

between family/IP victims and victims of acquaintance violence.

Figure 4-3 summarizes the expected counts of long-term emotional problems and long-

term physical problems reported by victims one month (or more) after the crime. These estimates

were derived from the negative binomial models presented in Table 4-4. Consistent with

hypothesis 1b, victims who had a closer relationship with their offender(s) tended to report a

higher number of long-term physical and emotional problems a month or more after the crime.

Family/IP victims reported the highest number of problems (physical: 2.45, emotional: 4.65),

acquaintance violence victims reported the second-most number problems (physical 2.22,

emotional: 4.52), and strangers reported the lowest number of problems (physical: 1.64,

emotional: 4.18). Note that there were no significant differences in the expected count of long-

term emotional problems between family/IP and acquaintance violence.

72

Conditioning Harm by Victim-offender Relationship

Up to this point, the evidence presented in the current study suggests that injury severity

and the relational closeness between the victim and the offender are consistent risk factors for the

sequelae of violent victimization (as described in Table 4-3 and Figures 4-1 to 4-3). However, I

argue that these two factors also interact to influence violence harms, in that injuries have

different consequences for victims based on who attacked the victim. Consistent with Gottfredson

and Gottfredson (1987) and Black (1979), I expect that the link between injury severity and these

other harms of violence attenuate as the relational closeness between the victim and the offender

narrows.

2.45

4.65

2.22

4.52

1.64

4.18

.00

1.00

2.00

3.00

4.00

5.00

6.00

Long-term physical problems Long-term emotional

problems

Ex

pec

ted

co

un

t

Domestic Violence

Friend/acquaintance

Stranger

Figure 4-3. Expected count of long-term physical problems and long-term emotional problems

Note: Long-term problems are defined as symptoms victims reported experiencing a month or more

after the crime. Expected counts calculated from the model coefficients presented in Table 4-3. 95%

confidence intervals presented. Significant differences were observed between all victim-offender

relationship categories within each injury subgroup.

73

I tested this hypothesis by extending the models of emotional distress, social distress,

long-term physical problems, and long-term emotional problems by including an interaction term

between injury severity and victim-offender relationship (i.e., injury severity x victim-offender

relationship). I then used these models to estimate the marginal effects of injury severity on the

probability of each harm outcome across victim-offender relationship types. I then used a

pairwise comparison test (95% confidence level) to determine whether these associations

significantly differed between victim-offender relationship types.13 Similar to previous estimates

of predicted probabilities, all covariates were treated as their observed values in the data. Figures

4-4 to 4-7 summarize the results of these tests. Whether two estimates significantly differed is

indicated by a subscripts in the figures. Estimates that share a subscript (e.g., a, b, c) did not

significantly differ at the 95% confidence level.

Figure 4-4 summarizes the conditional association between injury severity and emotional

distress by victim-offender relationship. The association between minor injury and emotional

distress did not significantly differ between victims of family/IP violence and victims of stranger

violence or victims of acquaintance violence. However, consistent with my expectations this

association was significantly weaker for acquaintance violence victims, compared to stranger

violence victims. The probability of emotional distress was 14.2 points higher when victims of

stranger violence reported a minor injury (vs. no injury; Δ = 8.50, 95% CI: 4.80, 12.22) and only

8.5 points higher when victims of acquaintance violence reported a minor injury (vs. no injury; Δ

= 14.18, 95% CI: 10.84, 17.51). These effect sizes were significantly different according to

pairwise tests (τ = 5.67, 95% CI: 0.711, 10.63). The results were different for serious injury (vs.

13 Statistical tests of marginal effects follows procedures outlined in Williams (2012). In the margins

package of STATA, margins is used to estimate the absolute differences in predicted probabilities of two

injury categories (e.g., no injury - serious injury) across victim-offender relationship categories using the

dydx() option, then a pairwise comparison is specified (i.e., pwcompare) to test whether these differences

are statistically different at a 95% confidence level. This estimate is analogous to “average discrete change”

estimate discussed in Long and Mustillo (2018).

74

no injury), but consistent with my expectations. The probability of emotional distress was 25.4

points higher when victims of stranger violence reported a serious injury (vs. no injury; Δ =

25.40, 95% CI: 19.63, 31.26) and only 13.9 percentage points higher when family/IP victims

reported a serious injury (vs. no injury; Δ = 13.93, 95% CI: 7.48, 20.39), and the difference

between these effects was significant at the 95% confidence level (τ = 11.51, 95% CI: 2.97,

20.05). The association between serious injury and emotional distress did not differ between

victims of acquaintance/friend violence and victims of family/IP. In short, the association

between injury and emotional distress was generally stronger for victims of stranger violence, but

in some cases, this association was not significantly different from victims who had closer

relationships to their offenders.

75

Figure 4-5 examines the relationships between injury severity and social distress by

victim-offender relationship. The findings were generally similar to the model of emotional

distress, with some exceptions. The positive relationship between minor injury (vs. no injury) and

emotional distress was significantly stronger for stranger violence victims compared to family/IP

victims (τ = 5.26, CI: 0.531, 10.01). This relationship did not differ between acquaintance

violence victims and family/IP victims. Further, the positive relationship between serious injury

+.117

+.085

+.142

-.05

.00

.05

.10

.15

.20

.25

.30

.35

Family/IP Friend Stranger

Chan

ge

in p

r(em

oti

onal

dis

tres

s)

Minor injury (vs. no injury)

bab a

+.139

+.198

+.254

-.05

.00

.05

.10

.15

.20

.25

.30

.35


Chan

ge

in p

r(em

oti

on

al d

istr

ess)

Serious injury (vs. no injury)

Figure 4-4. Conditional association of injury severity and emotional distress by victim-offender

relationship

Note. The estimates above present the percentage point change in the probability a victim reported

emotional distress when they experienced minor injuries (vs. no injuries) and when they

experienced serious injuries (vs. no injuries). + indicates a positive change in the probability. This

figure compares this effect across different victim-offender relationship categories (i.e., family/IP

[DV], acquaintance/friend [Friend], and stranger). Categories within each panel that do not share a

subscript are significantly different at the 95% confidence level according to pairwise comparison t-

tests. Estimates are based on logit models of formal service use that interacted relationship with

injury severity. All covariates were held at their mean values.

a ac c

76

(vs. no injury) and social distress was stronger for victims of stranger violence (τ = 14.91, CI:

6.48, 23.35) and victims of friend/acquaintance violence (τ = 10.91, CI: 2.44, 19.38) than for

family/IP victims.

I found further evidence of attenuated injury associations in models of long-term physical

problems (Figure 4-6) and long-term emotional problems (Figure 4-7). A minor injury (vs. no

injury) was associated with a 0.84 increase (95% CI: 0.56, 1.17) in the expected count of physical

+.044

+.079+.097

-.05

.05

.15

.25

.35


Chan

ge

in p

r(so

cial

dis

tres

s)


+.095

+.204

+.244

-.05

.05

.15

.25

.35


Chan

ge

in p

r(so

cial

dis

tres

s)


Figure 4-5. Conditional association of injury severity and social distress by victim-

offender relationship

Note. The estimates above present the percentage point change in the probability a victim reported social

distress when they experienced minor injuries (vs. no injuries) and when they experienced serious injuries (vs.

no injuries). + indicates a positive change in the probability. This figure compares this effect across different

victim-offender relationship categories (i.e., family/IP [DV], acquaintance/friend [Friend], and stranger).

Categories within each panel that do not share a subscript are significantly different at the 95% confidence

level according to pairwise comparison t-tests. Estimates are based on logit models of social distress that

interacted relationship with injury severity.

a ab b a a b

77

problems for victims of stranger violence. According to pairwise comparison tests at the 95%

confidence level, the strength of this association was stronger than both acquaintance violence (τ

= 0.29; 95% CI: -0.02, 0.60) and family/IP (τ = 0.33; 95% CI: 0.09, 0.58). Similar findings were

observed for serious injury. The relationship between serious injury (vs. no injury) and the

expected count of long-term physical problems was strongest for stranger violence (τ = 1.84; 95%

CI: 1.42, 2.56) than for acquaintance violence (τ = 1.25; 95% CI: 0.09, 0.58) and family/IP (τ =

0.33; 95% CI: 0.09, 0.58).

78

A similar interaction effect between injury severity and victim-offender relationship was

observed in the model of long-term emotional problems, but there were some differences (Figure

4-7). Based on pairwise comparison tests, the presence of injury—whether minor or severe—was

more strongly associated with long-term emotional problems from stranger violence than for

family/IP. However, when comparing between acquaintance violence and stranger violence, the

association between injury and long-term emotional problems was only stronger for stranger

violence when the victim reported a minor injury. There was no significant difference between

+0.33 +0.29

+0.84

-0.05

0.45

0.95

1.45

1.95

2.45

2.95


Chan

ge

in e

xp

ecte

d c

ount

of

physi

cal

pro

ble

ms


+0.82

+1.26

+1.84

-0.05

0.45

0.95

1.45

1.95

2.45

2.95


Chan

ge

in e

xp

ecte

ed c

ount

of

physi

cal

pro

ble

ms


Figure 4-6. Conditional association of injury severity and long-term physical problems by

victim-offender relationship

Note. The estimates above present the change in the count of physical problems when victims

experienced minor injuries (vs. no injuries) and when they experienced serious injuries (vs. no

injuries). + indicates a positive change in the count. This figure compares this effect across different

victim-offender relationship categories (i.e., family/IP [DV], acquaintance/friend [Friend], and

stranger). Categories within each panel that do not share a subscript are significantly different at the

95% confidence level according to pairwise comparison t-tests. Estimates are based on negative

binomial regression models of physical problems that interacted relationship with injury severity.

a ab b a a b

79

stranger violence and acquaintance violence in the association between serious injury (vs. no

injury) and long-term emotional problems.

Conclusion

This study investigated the physical, emotional, social, and long-term harms victims

report in the aftermath of violence. Some of the results were expected based on prior research,

whereas other results were surprising. This section does not delve deeply into the theoretical or

policy implications of these findings, as the concluding chapter (Chapter 6) addresses these issues

+.442

+.067

+.740

-0.25

0.05

0.35

0.65

0.95

1.25


Ch

ange

in e

xp

ecte

d c

ou

nt

of

emo

tio

nal

pro

ble

ms


+.434

+.670

+.960

-0.25

0.05

0.35

0.65

0.95

1.25


Ch

ange

in e

xp

ecte

d c

ou

nt

of

emo

tio

nal

pro

ble

ms


Figure 4-7. Conditional association of injury severity and long-term emotional problems by

victim-offender relationship

Note. The estimates above present the change in the expected count of emotional problems when victims

experienced minor injuries (vs. no injuries) and when they experienced serious injuries (vs. no injuries). +

indicates a positive change in the count. This figure compares this effect across different victim-offender

relationship categories (i.e., family/IP [DV], acquaintance/friend [Friend], and stranger). Categories within

each panel that do not share a subscript are significantly different at the 95% confidence level according to

pairwise comparison t-tests. Estimates are based on negative binomial regression models of physical problems

that interacted victim-offender relationship with injury severity.

a ab b a b c

80

in greater detail. Instead, it focuses on how these findings inform and update expectations

regarding victims’ use of formal services, which is examined in the following chapter (Chapter

5).

Injury severity and victim-offender relationship were key risk factors for victims’ social,

emotional, and long-term outcomes after violence. Overall, experiencing serious injury or

knowing the offender were associated with worse outcomes for victims. This finding is not

surprising from a medical perspective, as the health and psychological literature has linked the

severity of physical trauma to acute and chronic post-traumatic symptoms and poor physical

health (Campbell et al. 2002; Malinosky-Rummell and Hansen 1993; Mayou, Bryant, and Duthie

1993). However, one of the more interesting findings is how the relational closeness between the

victim and the offender was a consistent and positive predictor of violence harms. Survey

research and criminological theory on perceptions of crime severity has assumed that, in general,

people consider stranger violence to be more severe than violence committed by a known

offender (Black 1979; Gottfredson and Gottfredson 1987; Gottfredson and Hindelang 1979; Rossi

et al. 1974). From a victim’s perspective, however, it seems these assumptions are incorrect.

Many studies have found that relational closeness positively predicts the occurrence of injury

during violence (Apel et al. 2013; Bachman et al. 2002; Weaver et al. 2004). This study furthers

this prior research and suggests that victims who know their offender also experience greater

emotional distress, worse social outcomes (e.g., problems with relationships, work, or school),

and are at greater risk for long-term physical and emotional problems.

According to Gottfredson and Gottfredson (1987) and other scholars (Black 1979; Block

1973), one reason victims are less likely to report known offenders (vs. stranger offenders) to the

police is because violence by known offenders is considered to be less serious. The findings from

the current study shed doubt on this claim, and they suggest that these victims may be more likely

to report to the police and even seek help from other formal services because violence by known

81

offenders is more serious. Even if victims of known offenders face barriers to formal services,

such as the limited availability of the law (Black 2010) or stigmatization (Hullenaar and Frisco

2020; Overstreet and Quinn 2013), they may be more likely to seek services because they need

them. This expectation leads to an alternative expectation to Hypothesis 6 presented in Chapter 2:

Hypothesis 6a: Relational closeness is positive related to victims’ use of formal services.

In general, victims who reported more serious injuries had worse emotional, social, and

long-term outcomes, but these associations depended on the victim’s relationship with the

offender. More specifically, injury severity had weaker associations with the emotional, social,

and long-term harms of violence when the victim knew the offender, particularly when the

offender was an intimate partner or family member. If physical injury is a strong predictor of

victims’ need for formal services, it is expected the influence of physical injury on victims’ help-

seeking may also depend on the victim’s relationship to the offender. This expectation is

consistent with prior research on victims use of medical care (Hullenaar and Frisco 2020), but has

not been examined on victims’ use of formal services more generally.

The following chapter test these expectations by examining victims’ use of formal

services.

References

Apel, Robert, Laura Dugan, and Ráchael Powers. 2013. “Gender and Injury Risk in Incidents of

Assaultive Violence.” Justice Quarterly 30(4):561–93.

Bachman, Ronet, Linda E. Saltzman, Martie P. Thompson, and Dianne C. Carmody. 2002.

“Disentangling the Effects of Self-Protective Behaviors on the Risk of Injury in Assaults

against Women.” Journal of Quantitative Criminology 18(2):135–57.


18–27.


82

Block, Richard. 1973. “Why Notify the Police-The Victim’s Decision to Notify the Police of an

Assault.” Criminology 11:555.

Braga, Anthony A., Elizabeth Griffiths, Keller Sheppard, and Stephen Douglas. 2020. “Firearm

Instrumentality: Do Guns Make Violent Situations More Lethal?” Annual Review of

Criminology 4.

Campbell, Jacquelyn, Alison Snow Jones, Jacqueline Dienemann, Joan Kub, Janet

Schollenberger, Patricia O’Campo, Andrea Carlson Gielen, and Clifford Wynne. 2002.

“Intimate Partner Violence and Physical Health Consequences.” Archives of Internal

Medicine 162(10):1157–63.







Long, J. Scott and Sarah A. Mustillo. 2018. “Using Predictions and Marginal Effects to Compare

Groups in Regression Models for Binary Outcomes.” Sociological Methods & Research

0049124118799374.

Malinosky-Rummell, Robin and David J. Hansen. 1993. “Long-Term Consequences of

Childhood Physical Abuse.” Psychological Bulletin 114(1):68.

Mayou, Richard, Bridget Bryant, and Robert Duthie. 1993. “Psychiatric Consequences of Road

Traffic Accidents.” British Medical Journal 307(6905):647–51.




83


224–37.

Weaver, Greg S., Janice E. Clifford Wittekind, Lin Huff-Corzine, Jay Corzine, Thomas A. Petee,

and John P. Jarvis. 2004. “Violent Encounters: A Criminal Event Analysis of Lethal and

Nonlethal Outcomes.” Journal of Contemporary Criminal Justice 20(4):348–68.

Williams, Richard. 2012. “Using the Margins Command to Estimate and Interpret Adjusted

Predictions and Marginal Effects.” The Stata Journal 12(2):308–31.

Wolfgang, Marvin Eugene. 1985. The National Survey of Crime Severity. US Department of

Justice, Bureau of Justice Statistics.

Yong, An Gie, Sean Pearce, and others. 2013. “A Beginner’s Guide to Factor Analysis: Focusing

on Exploratory Factor Analysis.” Tutorials in Quantitative Methods for Psychology

9(2):79–94.

Chapter 5

Victims’ Use of Formal Services After Violence

This study examines violence victims’ use of formal services after the crime, including

police, health care, and social services. Table 5-1 provides a brief review of the hypotheses,

presented in Chapter 2, that are examined in the current chapter:

Table 5-1. Hypotheses regarding victims’ use of formal services

Hypotheses Description

Hypothesis 3 The physical, emotional, and social harms of violence are positively

related to victims’ use of formal services (i.e., police, hospital, or victim

service agencies).

Hypothesis 4a Victims with severe physical injuries are more likely to use only medical

or social services than use police services.

Hypothesis 4b Victims who are attacked by a weapon or multiple offenders are more

likely to use police services than only medical or social services.

Hypothesis 4c Victims who report emotional or social distress are more likely to use

only medical/social services than police services.

Hypothesis 5 The positive relationship between physical, emotional, and social harms

of violence and victims’ use of formal services will decrease as the

relational closeness between the victim and the offender increases.

Hypothesis 6 Relational closeness between the victim and the offender is

negatively/positively associated with victims’ use of formal services.

Hypothesis 6a Relational closeness between the victim and the offender is positively

associated with victims’ use of formal services.

Hypothesis 7 Sexual violence victims are less likely than nonsexual violence victims

to use formal services.

85

The chapter is organized as follows. The first section discusses the prevalence and trends

in victims’ crime reporting behavior, health care utilization, and use of victim services for the last

25 years (1994 to 2018). The second section presents statistical models of victims’ use of formal

services, including whether victims use formal services and what types of formal services they

use. The models specifically test empirical expectations laid out by the needs-barriers framework

discussed in Chapter 2, focusing on how violence harms, victim-offender relationship, and sexual

violence predicts these help-seeking outcomes (hypotheses 3, 4a-c, 6, and 7). This section also

extends prior work by examining victims’ long-term help-seeking outcomes; more specifically,

their use of follow-up medical care in the months after the crime occurred. The third section tests

whether the influence of injury severity on victims’ use of formal services is conditional on the

victim’s relationship to the offender(s) (hypothesis 5). The fourth section—the conclusion—

summarizes the major findings of the study.

Data

This study analyzed violent victimizations collected by the NCVS but used a more

extended period (1994 to 2018) than the data analyzed in Chapter 4 (2008 to 2018). The purpose

of using a longer study period in this chapter was to examine the temporal trends in victims’ use

of police, medical care, and victim service agencies. After analyzing these trends, I limited the

sample to only violent victimizations that occurred from 2008 to 2018 because the NCVS began

measuring the emotional and social consequences of violent victimization and victims’ use of

formal follow-up services for the first time in 2008.

The primary sample included 12,573 respondents who reported 16,723 violent

victimizations: 10,754 simple assaults, 3,106 aggravated assaults (i.e., assaults involving a

weapon or serious injury to victim), 1,864 robberies, and 1,104 rape and sexual assaults. Analyses

of victims’ use of follow-up services for treating long-term emotional or physical problems (i.e.,

problems that lasted for more than a month) was based on sub-sets of this sample. Specifically,

86

the NCVS measures follow-up services only when victims indicated long-term issues. Thus, the

samples were smaller in analyses of victims’ use of follow-up care for long-term emotional

problems (n = 7,947) and long-term physical problems (n = 5,175).

As with the data presented in chapter 4, 39% of cases had missing data on at least one

measure in the study. Similar to the previous analyses, I used multiple imputation using chained

equations (imputations = 50) to handle missing data (see Chapter 4, page 49 for details).

Measures

Outcomes

The primary dependent variable in the study was whether a violence victim used any

formal service after a crime.14 Formal service use is operationalized as victimizations that were

reported to the police, involved victims using professional medical services (i.e., a doctor’s office,

medical clinic, emergency room, or hospital) 15, or involved the victim using a victim service

agency. Violence victims who did not use any of these services were treated as the reference

category.

In further analyses, this study distinguished between the types of formal services that

violence victims used. Type of formal service contains three categories: no formal service use,

victims used only non-police services (i.e., professional medical services or victim service

agency, or victims used police services), and victims used police services. The last category—

victims used police services—includes all victimizations that involved any police services,

including those that involved professional medical care or victim service agencies. Additionally,

the study also examined whether victims’ used formal follow-up care for emotional and physical

14 Note that this outcome does not incorporate information about whether victims used formal services to

treat long-term physical or emotional problems, as this information was asked only for victims who

reported long-term physical or emotional problems. 15 NCVS asks whether victims used professional medical services after a violent crime only when victims

report injuries that needed some type of medical care (including non-professional care or self-care). It is

possible that some victims visited a health care professional, even if they did not report a physical injury.

However, this would likely be a rare occurrence.

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problems they experienced for a month or more (see page 51 for measurement description).

Follow-up care included counseling, therapy, doctors, nurses, emergency rooms, hospitals, and

clinics. Victims who did not use follow-up care were treated as the reference category.

Predictors

All predictors described in Chapter 4 were used in the analyses.16 Appendix A provides a

detailed description of these measures.

Analytic Strategy

To examine patterns and trends in formal service use, I present descriptive statistics and

linear time trends of police, medical, and victim service use. To estimate time trends, I used

logistic regression models and regressed whether violence victims used police, medical, or victim

services on a continuous measure of the year of the NCVS interview (and its non-linear

transformations), including all covariates. For each model, I determined whether to include a

higher-order term (e.g., year2 and year3) based on their statistical significance. These models were

then used to generate predicted probabilities of police, medical, and victim service use over

time—accounting for any changes in predisposing and situational factors across years.

Following these analyses, I estimated two logistic regression models of whether victims

used any of these formal services (vs. no services) and what types of services they used. Similar

to previous analyses, I exponentiated the estimated coefficients in the logistic regression models

to derive odds-ratios. Odds-ratios provide the relative (i.e., multiplicative) difference in the odds

given a one-unit change in an independent variable. To predict what type of services victims

used, I used a multinomial logistic regression model to estimate whether a victim used police

services, only medical and victim services, or no services after a crime. I used a multinomial

16 Financial loss was recoded for the analyses of victims’ use of formal services. Specifically, financial loss excludes

medical costs because these costs are determined by the outcome (i.e., using professional medical services).

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logistic regression model to specifically compare the odds that victims used only medical or

victim services to the odds that they used services involving the police.17

To analyze follow-up care, I estimated two separate logistic regression models. The first

model estimated whether victims used follow-up care to treat long-term emotional problems

(follow-up emotional care). The second model estimated whether victims used follow-up care to

treat long-term physical problems (follow-up physical care). The sample in these analyses

represented a subset of the analytic sample, as follow-up care outcomes were measured for only

victims who reported long-term emotional or physical problems.

The final set of models tested whether the associations between need factors (i.e., injury

severity, emotional distress, social distress, long-term physical problems, and long-term

emotional problems) and victims’ help-seeking outcomes differed by victim-offender

relationship. I re-estimated all help-seeking models and included terms that estimated the

interaction effects between the victim’s relationship to the offender and their injury severity

(relationship x injury severity), emotional distress (relationship x emotional distress), social

distress (relationship x social distress), long-term emotional problems (relationship x long-term

emotional problems), and long-term physical problems (relationship x long-term physical

problems). I then used the estimates from these models to calculate predicted probabilities to test

whether the associations between these need factors and victims’ formal service use (including

follow-up care) attenuated as the relational closeness between the victim and the offender

narrowed. I used pairwise comparisons at the 95% confidence level to test for differences.

All models were estimated using weighted and imputed NCVS data.18

17 It is also possible to estimate a binomial model of non-police service use (vs. police service use) using

the sample of victimizations involving victims who used formal services at all. However, for models using

imputed data, this would result in samples that vary across datasets, as the estimated values of whether

victims used formal services vary across imputations. 18 The weight used in these analyses (i.e., victimization weight) does not give greater weight to series

victimizations, i.e., victimizations that occurred multiple times (i.e., up to ten) to the extent that victims

cannot recall details that distinguish the incidents, nor does it downweight violent incidents involving

89

Results

Patterns and Trends in Formal Service Use

Table 5-2 summarizes the proportion of violent victimizations involving police, medical,

and victim services. Panel A describes the analytic sample, whereas Panel B describes a select

sample of victimizations that involved serious injury.19 I examined serious injuries separately

because these victims are at a higher risk for adverse health outcomes (see Chapter 4 results).

Thus, from a theoretical and practical standpoint, these victims’ help-seeking patterns are critical

to understand. In the total sample, victims used one or more formal services in roughly half of the

violent victimizations. Not surprisingly, police services were—by far—the most common (48%

of violent victimizations), followed by the relatively low utilization rates of victim service

agencies (8%) and medical care (6%). When victims used formal services after the crime, the

police were involved in almost all cases (94%; analysis not presented). Victims who received

formal help most often used only one service. Among violence victims who used two different

services, the vast majority used either the police and victim service agencies (54%) or the police

and medical care (45%). Violence victims rarely received all three services (1%).

Compared to the general sample, victims more often used formal services if they

experienced serious injury (74% used formal services after violent victimizations with serious

injury). Again, police services were most common (63%), but medical services were much more

prevalent than in the general sample (50% serious injury vs. 6% in the total sample). Still, even

when victims experienced serious injuries, they rarely utilized victim services, and the

multiple NCVS victims. This choice was motivated by conceptual and methodological reasons. Series

victimization weights allow for a more accurate estimate of victimization counts, but they assume—

perhaps incorrectly—that series victims who used formal services did so for every victimization they

reported in the series (e.g., they went to the hospital for every victimization). Methodologically, using

series weights also presents an issue for estimating the influence of repeat victimization on formal service

use, as repeat victims will be weighted more heavily than non-repeat victims. In general, the choice and

inclusion of weights had a negligible influence on the results. 19 Descriptive statistics of help-seeking outcomes from 1994-2018 are not presented.

90

involvement of victim services was relatively rare in both samples (19% serious injury; 8% total

sample).

Table 5-2. Selected descriptive statistics: Victims’ use of formal services, 2008-2018

Panel A. Total sample (n = 16,723)

Formal service Pr

Police .48

Medical care .06

Victim service agency .08

Number of services

None .49

One .41

Two .08

Three .01

Panel B. Violence with serious injury (n = 1,033)

Formal service Pr

Police .63

Medical care .50

Victim service agency .19

Number of services

None .26

One .28

Two .36

Three .11 Note: Pr = proportion. Percentages of formal service may not sum to 100 because the categories are not

mutually exclusive. Victims may use one or more formal services. These estimates do not include victims’

follow-up medical care for long-term physical or emotional problems, as this information is asked only for

victims who report these problems.

After examining the prevalence of formal service use in the pooled sample, I then

examined temporal trends to better understand how the utilization of formal service has changed

over time. Figure 5-1 illustrates estimated linear time trends (1994-2018) in victims’ use of

police, medical, and victim services after experiencing a serious injury. These estimates do not

account for any other covariates. I focus only on violence that resulted in serious injury because

these victimizations provide a more relevant picture of formal service use. Victims with no

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injuries or minor injuries make up the vast majority of violent incidents, and they rarely seek

services outside of the police. As a result, there has been no statistically significant change in

their utilization of health care or victim service agencies over time.

For victims who reported serious injuries, the use of police and medical services

demonstrated a curvilinear trend over the study period, whereas the use of victim services

remained low and stable (p > .1). Rates of reporting to the police for violence involving serious

injuries increased from 57% reported in 1994 to 69% reported in 2008, a 21% increase. However,

this rate subsequently decreased back to 56% in 2018. Rates of using medical services for

violence involving serious injuries demonstrated a similar pattern, as they increased from 47% in

1994 to around 59% in 2004. Yet, similar to police reporting, the rate of medical service

utilization then declined dramatically to an all-time low of 39% in 2018. The rate of victim

services for violence involving serious injuries remained constant at about 20% from 1994 to

2018.

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I isolated my analyses to 2009 to 2018 to examine whether the declines in police and

medical service use during this period was attributed to changes in victims’ predisposing,

situational, and need factors related to their victimization (Figure 5-2; see Appendix A for list of

these factors). I chose this period because, according to two-year rolling average estimates,

declines in police and medical service use began around 2009. These models were based on

multiply imputed values, as they included all covariates from the study.

Figure 5-1. Trends in police, medical, and victim service use for violent victimizations

involving serious injury (1994-2018)

Note. The estimates above present the predicted probabilities of violence victims’ use of

police, medical, and victim services after sustaining a serious injury. The second label on each

trend line reflects that peak of that respective trend. Victims’ use of police and medical

services demonstrated significant curvilinear trends (year and year2, p < .05), whereas their

use of victim services has remained stable over time (p > .10).

.21 .20 .19

.47

.59

.39

.57

.69

.56

.0

.1

.2

.3

.4

.5

.6

.7

.8

1994 1998 2002 2006 2010 2014 2018

Pre

dic

ted p

robab

ilit

y

Estimated trend

Two-year rolling average

93

These models uncovered two important findings. First, temporal changes in victims’ use

of police services were almost entirely attributed to changes in observable factors related to the

violence. In analyses not presented, I found that up-ticks in the proportion of sexual violence

during this period entirely accounted for the decline in police reporting. After introducing sexual

violence into the model, the relationship between year and police notification was not statistically

significant (p > .10). Second, the ten-year decline of victims’ utilization of medical care was

observed even after accounting for the predisposing, situational, and need factors related to the

.69 .68

.60

.37

.15 .14

.0

.2

.4

.6

.8

1.0

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Pr(

Ser

vic

e use

)Figure 5-2. The decline in medical service use after accounting for covariates (2009-

2018)

Note. The estimates above present the predicted probabilities of violence victims’ use of police,

medical, and victim services after sustaining a serious injury. Estimates are based on separate

logit models of formal service use and the coefficients of the year the NCVS interview was

completed. These estimates account for predisposing, situational, and need factors related to

violent victimization. Only the use of medical services significantly changed over time (p <

0.05), and the higher order terms (i.e., year2 and year3) were not statistically significant. Each

outcome had some missing data: police (2.6% missing), medical (1.5% missing), and victim

services (0.7% missing). All covariates were held at their mean values.

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victimization. Even though medical care and police reporting were highly correlated (r = .45), the

decline in victims’ healthcare utilization was unique and unexplained by the factors observed in

this study. In further analyses, I also included dummy variables for each category of serious

injury (see Appendix B), and again, the time trend remained. The next section addresses the key

predictors of victims’ use of formal services.

Models of Formal Service Use

Table 5-3 summarizes logistic regression models that estimated whether violence victims

used formal services (Model 1) and what type of formal services they used (Model 2). Starting

with Model 1, need factors had a strong, positive impact on whether victims used formal services,

consistent with the needs-barrier framework. Victims were far more likely to use formal services

if they experienced any injury. For instance, victims who reported a minor or serious injury had

1.9 (OR = 1.876, 95% CI: 1.657, 2.124) and 3.5 (OR = 3.500, 95% CI: 2.856, 4.289) times higher

odds, respectively, of using formal services than victims with no injury. The level of injury also

mattered, as victims who reported serious injuries were more likely than victims who reported

minor or other injuries to receive formal services (p < .05).

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Table 5-3. Logistic regression models of victims’ use of formal services

Model 1

Formal service (vs. no service)

Model 2

Only medical/victim service (vs. police)

Independent variables OR 95% CI [LL,UL] OR 95% CI [LL,UL]

Need factors

Injury severity

Minor injury 1.876*** [1.657,2.124] 1.277 [0.953,1.711]

Serious injury 3.566*** [2.906,4.376] 2.864*** [1.930,4.250]

Other injury 1.885*** [1.333,2.666] 2.629** [1.311,5.273]

Financial loss 1.028** [1.011,1.046] 0.999 [0.992,1.006]

Financial loss2 0.999** [0.999,0.999] - -

Emotional distress 1.670*** [1.510,1.847] 0.965 [0.726,1.281]

Social distress 1.037 [0.930,1.157] 2.083*** [1.593,2.724]

Situational factors


Stranger 0.899 [0.779,1.038] 0.756 [0.520,1.097]

Acquaintance/friend 0.739*** [0.642,0.850] 1.071 [0.767,1.495]

Sexual violence 0.544*** [0.437,0.678] 2.058** [1.300,3.257]

Weapon

Knife 1.502*** [1.258,1.793] 0.451* [0.225,0.904]

Firearm 2.244*** [1.901,2.648] 0.659 [0.397,1.093]

Other/unknown weapon 1.498*** [1.294,1.734] 0.827 [0.541,1.264]

Multiple offenders 1.329*** [1.150,1.536] 0.601* [0.377,0.956]

Offender age

Juveniles and adults 1.812*** [1.291,2.543] 0.352+ [0.106,1.176]

Adult(s) only 1.306** [1.108,1.539] 0.389*** [0.264,0.573]

Offender sex

Female(s) only 0.997 [0.889,1.118] 1.009 [0.758,1.342]

Mixed sex 1.049 [0.817,1.346] 1.121 [0.533,2.357]

Repeat victimization 0.671*** [0.599,0.752] 1.710*** [1.328,2.202]

Third party present 1.629*** [1.483,1.791] 0.789+ [0.614,1.014]

Location

School/work site 0.726*** [0.637,0.827] 2.202*** [1.576,3.077]

Open area 0.614*** [0.536,0.703] 1.047 [0.675,1.623]

Other area 0.547*** [0.478,0.625] 1.639* [1.097,2.450]


Female 1.165** [1.055,1.285] 1.515** [1.153,1.991]

Race/ethnicity

NH Black 1.293*** [1.121,1.492] 0.971 [0.666,1.416]

NH other/mixed 0.749*** [0.631,0.888] 1.448+ [0.963,2.177]

Hispanic 1.065 [0.936,1.211] 1.183 [0.850,1.646]

Age 1.127*** [1.075,1.182] 0.964* [0.929,0.999]

Age2 0.998*** [0.997,0.999] 1.000* [1.000,1.001]

Age3 1.000*** [1.000,1.000] - -

Education

High school 0.936 [0.808,1.085] 0.853 [0.565,1.289]

Some college 0.920 [0.799,1.059] 1.050 [0.739,1.494]

Bachelor's or more 0.821* [0.696,0.969] 1.290 [0.841,1.978]

Economic status 1.016 [0.962,1.073] 1.050 [0.907,1.215]

Married 1.189** [1.060,1.333] 0.719* [0.528,0.980]

Urbanicity

Suburban 0.849* [0.731,0.987] 0.850 [0.599,1.206]

Urban 0.846* [0.725,0.988] 0.968 [0.682,1.375]

Region

Midwest 0.954 [0.821,1.108] 0.807 [0.540,1.206]

South 0.951 [0.823,1.100] 0.943 [0.640,1.391]

West 0.888 [0.766,1.030] 1.137 [0.771,1.676]

Sample size 16,723 8,501 + p < 0.10, * p < 0.05, ** p < 0.01, *** p < 0.001; OR = odds ratio, LL= lower limit; 95% confidence intervals in

brackets. All models include year fixed effects, robust standard errors, and survey weights

96

The influence of need factors also extended beyond physical injury. Victims who

reported greater financial losses were more likely to use formal services (OR = 1.028, 95% CI:

1.011, 1.046). However, this relationship diminished as reported losses increased (OR = 0.999,

95% CI: 0.999, 0.999). Additionally, victims who reported emotional distress had 67% higher

odds of using formal services than victims who reported no emotional distress (OR = 1.670, 95%

CI: 1.510, 1.847). However, social distress had no relationship with service use (p > .1).

Key situational factors of violence—i.e., victim-offender relationship and sexual

violence—also predicted victims’ use of formal services. These relationships were mostly

consistent with my expectations, with one exception. The initial hypotheses stated that the

relational closeness between the victim and offender would be either positively or negatively

related to formal service use. However, the analyses indicated that this association was

curvilinear, in that the odds of formal service use were highest among domestic and stranger

violence victims and lowest among acquaintance violence victims. There was no significant

difference in formal service use between stranger violence victims and domestic violence victims

(p > .10). By contrast, acquaintance violence victims had 26% lower odds than domestic violence

victims to use formal services (OR = 0.739, 95% CI: 0.642, 0.850). As expected, sexual violence

victims had 46% lower odds of using formal services than victims of nonsexual violence (OR =

0.544, 95% CI: 0.437, 0.678). This finding is interesting because my supplementary analyses in

Chapter 4 indicated that sexual violence victims were at a higher risk of emotional distress, social

distress, and long-term emotional and physical problems (see Appendix C and D).

Other situational factors were also associated with victims’ use of formal services. For

instance, weapon use was associated with an increased likelihood of service use. Firearm

presence was particularly important, as victims of firearm violence had 2.2 times the odds of

using formal services than victims attacked by unarmed assailants (OR = 2.229, 95% CI: 1.890,

2.628). The presence of multiple offenders was associated with a 33% increase in the odds that

97

victims used formal services (OR = 1.329, 95% CI: 1.150, 1.536). While the offender’s gender

was unrelated to service use, victims attacked by adult offenders were generally more likely than

victims attacked by only youth offenders to use services (p < .05). Repeat victimizations had 33%

lower odds than non-repeat victimizations to involve formal services (OR = 0.671, 95% CI:

0.599, 0.752). The presence of a third party was associated with 63% higher odds of victims using

a formal service (OR = 1.629, 95% CI: 1.483, 1.791). Finally, violence that occurred in a private

residence was more likely than violence in all other types of formal services to involve formal

services (p < .001).

Several predisposing factors were also associated with victims’ use of formal services.

Female victims had 17% greater odds than male victims to use formal services (OR = 1.165, 95%

CI: 1.055, 1.285). Concerning racial-ethnic differences, non-Hispanic Black victims (OR = 1.293,

95% CI: 1.121, 1.492) were more likely than non-Hispanic White victims to use formal services.

However, non-Hispanic victims of other/mixed racial groups were the least likely racial-ethnic

group to use formal services (OR = 0.749, 95% CI: 0.631, 0.888). Age had a curvilinear

relationship with service use. Further analyses (not presented) found that service use tended to be

lowest among adolescent victims (12 to 18 years old) and highest among the elderly (75 to 90).

There was little difference in service utilization among middle- (35 to 49) and older-aged (50 to

65) adults.

Additionally, service use varied by the victim’s social characteristics and geographic

location. Victims who reported higher levels of education had a lower likelihood of using formal

services. Service use was especially low among victims with a college degree, as victims with a

Bachelor’s degree or more had 18% lower odds than victims with less than a high school

education to use formal services (OR = 0.821, 95% CI: 0.696, 0.969). Married victims had

slightly higher odds of service use than unmarried victims (OR = 1.189, 95% CI: 1.060, 1.333).

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Victims who lived in suburban (OR = 0.849, 95% CI: 0.731, 0.987) or urban (OR = 0.846, 95%

CI: 0.725, 0.988) areas were slightly less likely than victims in rural areas to use formal services.

Police Services vs. Only Medical Care/Victim Service Agencies

Model 2 (Table 5-3) examined the type of services victims used, i.e., whether victims

used the police or only medical care/victim service agencies. Unlike the previous section, this

discussion is limited to the factors pertinent to the hypotheses listed in Table 5-1. According to

the needs-barrier framework, victims might use different types of services based on their

physiological, psychological, and safety-related needs after a crime. This argument was partly

supported. Consistent with my expectations, the severity of the physical injury was positively

related to victims using medical/victim services (as opposed to involving the police). Violence

involving serious injury had 2.8 times greater odds of involving only medical/victim services than

involving the police (OR = 2.883, 95% CI: 1.944, 4.274). Victims who reported minor injuries

(OR = 1.288, 95% CI: 0.960, 1.728) or other injuries (OR = 1.508, 95% CI: 1.151, 1.976) were

also more likely to use only medical/victim services. The type of distress victims reported also

related to the type of formal services they used. Specifically, violence victims who reported social

distress had 2.1 times higher odds of using only medical/victim services than police services (OR

= 2.065, 95% CI: 1.584, 2.694). Emotional distress was unrelated to the type of services formal

help-seeking victims used (p > .10).

It is interesting to note that, even though sexual violence victims were generally less

likely than nonsexual violence victims to use formal services (Model 1), they were significantly

more to use only medical/victim services when they did receive formal help (Model 2). This

association was relatively strong, as the odds of using medical/victims services (vs. involving the

police) were around two times higher for sexual violence than nonsexual violence (OR = 2.058,

95% CI: 1.300, 3.257).

99

Victim-offender relationship was unrelated to whether victims used police services or

only medical/victim service agencies.

In some cases, victims’ who used services preferred to involve the police, as opposed to

using only medical/victim service agencies. Consistent with expectations, victims were generally

more reliant on police services as the threat of violence increased. For example, victims were

generally less likely to use only medical care/victim service agencies than police services when

the offender had a knife than when the offender had no weapon (OR = 0.451, 95% CI: 0.225,

0.904). While other types of weapons were in the same predicted direction, they were not

significant.20 Furthermore, when the violence involved multiple offenders, victims who used

services were less likely to use only medical care/victim service agencies and were more likely to

rely on the police (OR = 0.601, 95% CI: 0.377, 0.956).

Follow-up Medical Care

Table 5-4 estimates whether victims used follow-up medical care services for emotional

and physical symptoms they experienced a month or more after the victimization occurred. Like

the previous section, I focus only on the results relevant to the hypotheses presented in Chapter 2.

However, the full models are available in Appendix E.

Model 3 estimates the likelihood that victims used follow-up care for emotional problems

experienced for a month or more (i.e., follow-up emotional care). According to the needs-barrier

framework, victims who use formal services shortly after violence occurs should be more likely

to use more formal services in the future. Consistent with this expectation, previous service use

was positively related to follow-up emotional care. Using formal services after a violent crime

was associated with 2.1 times higher odds of using follow-up emotional care (OR = 2.094, 95%

CI: 1.737, 2.526).

20 When treated as a dichotomous predictor (weapon vs. no weapon), weapon use was negatively associated

with the odds that victims used only medical care/victim services agencies (vs. police services).

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Table 5-4. Logistic regression models of victims’ use of follow-up medical care


Model 3

Follow-up emotional care

Model 4

Follow-up physical care

OR 95% [LL, UL] OR 95% [LL, UL]

Previous service use 2.094*** [1.737,2.526] 1.795*** [1.441,2.236]

Need factors

Physical problems (#) 1.255*** [1.205,1.306] 1.385*** [1.312,1.462]

Emotional problems (#) 1.208*** [1.142,1.279] 1.038 [0.967,1.114]

Injury severity

Minor injury 1.070 [0.883,1.297] 0.575*** [0.456,0.726]

Serious injury 0.951 [0.739,1.225] 0.836 [0.614,1.137]

Other injury 1.265 [0.719,2.226] 1.057 [0.567,1.968]

Financial loss 1.003+ [0.999,1.006] 1.002 [0.999,1.005]

Emotional distress 1.657** [1.163,2.360] 2.068** [1.253,3.413]

Social distress 1.845*** [1.546,2.202] 1.523*** [1.238,1.874]

Situational factors


Stranger 0.506*** [0.393,0.650] 0.983 [0.727,1.329]


Sexual violence 1.969*** [1.496,2.591] 1.318 [0.948,1.833]


Clustered standard errors X X

Survey weights X X

Sample 7,947 5,175

OR = odds ratio, LL = lower limit, UL = upper limit; 95% confidence intervals in brackets. + p < 0.10, * p < 0.05, ** p < 0.01, *** p < 0.001. All models include year fixed effects, robust

standard errors, and survey weights

Unlike other formal help-seeking outcomes, the severity of injury was not a significant

need factor in victims’ use of follow-up emotional care. In analyses not presented, I found that the

relationship between injury severity and follow-up emotional care was explained by victims’

reported emotional problems, physical problems, emotional distress, and social distress—all of

which positively predicted follow-up emotional care. For every physical and emotional problem a

victim reported, their odds of using follow-up emotional care increased by 26% (OR = 1.255,

95% CI: 1.205, 1.306) and 21% (OR = 1.208, 95% CI: 1.142, 1.279), respectively. Victims who

reported emotional distress had 66% higher odds of using follow-up emotional care (OR = 1.657,

101

95% CI: 1.163, 2.360), and victims who reported social distress had 85% higher odds of using

follow-up emotional care (OR = 1.845, 95% CI: 1.546, 2.202).

Similar to other formal help-seeking outcomes, victim-offender relationship and sexual

violence were significant predictors of follow-up emotional care, but in unique ways. Consistent

with previous models of formal service use (see Table 5-2), relational closeness was positively

related to follow-up emotional care. Stranger and acquaintance violence victims had 49% lower

odds (OR = 0.506, 95% CI: 0.393, 0.650) and 34% lower odds (OR = 0.662, 95% CI: 0.527,

0.833) than domestic violence victims of using follow-up emotional care. Inconsistent with my

expectations and findings regarding formal service use after a crime, sexual violence victims (vs.

nonsexual violence victims) had 97% higher odds of using follow-up emotional care. I address

these conflicting findings in conclusion.

Model 4 estimates whether victims used follow-up care for physical problems

experienced for a month or more (i.e., follow-up physical care). Again, previous service use was

positively associated with follow-up care. Victims who used formal services (vs. no formal

services) after the crime had 1.8 higher odds of using follow-up physical care (OR = 1.795, 95%

CI: 1.441, 2.236).

Most—but not all—need factors predicted whether the victim sought follow-up physical

care. Inconsistent with my expectations, victims who reported minor injuries had 43% lower odds

than victims with no injury to use follow-up physical care, after controlling for other factors (OR

= 0.575, 95% CI: 0.455, 0.726). Additionally, serious injury was unrelated to using follow-up

physical care (p > .10).

Regarding victims’ long-term problems, only the number of physical symptoms

positively predicted follow-up physical care (OR = 1.381, 95% CI: 1.308, 1.458), whereas the

number of emotional problems was not a significant predictor. Both emotional (OR = 2.082, 95%

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CI: 1.263, 3.433) and social distress (OR = 2.579, 95% CI: 1.224, 1.856) were also positively

associated with follow-up physical care.

Victim-offender relationship and sexual violence were unrelated to whether victims use

follow-up physical care.

Conditioning Harm by Victim-offender Relationship

I expected the positive associations between need factors (e.g., injury severity) and

formal service use would be attenuated as the relational distance between the victim and the

offender narrowed. To test this hypothesis, I re-estimated models of victims’ use of formal

services and their use of follow-up care but included interaction terms between all need factors

and victim-offender relationship. Similar to Chapter 4, the estimated coefficients were then used

to estimate the marginal effects of need factors on the predicted probabilities of formal service

use and follow-up care outcomes by victim-offender relationship (see page 62 for a more detailed

description of the methodology).

Figure 5-3 describes the marginal association of injury severity (vs. no injury) with

victims’ use of formal services by victim-offender relationship. Consistent with my expectations,

injury severity had a weaker influence on formal service use as the victim and the offender's

relational closeness increased. The probability of formal service use was 8.1 points higher for

domestic violence victims if they experienced a minor injury (vs. no injury; 95% CI: 3.08, 13.11).

However, for acquaintance violence and stranger violence victims, the probability of formal

service use was 16.8 points (95% CI: 12.10, 21.58) and 18.6 points higher (95% CI: 14.35,

22.85), respectively, if they experienced a minor injury (vs. no injury; p < .05). Compared to

domestic violence, these associations were significantly stronger according to pairwise

comparisons at the 95% confidence level (vs. acquaintance: τ = 8.73, 95% CI: 3.00, 14.47; vs.

stranger τ = 10.50, 95% CI: 5.00, 16.00).

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Analyses of serious injuries revealed similar findings. The probability of formal service

use was 15.6 points higher for domestic violence victims if they experienced a serious injury (vs.

no injury; 95% CI: 9.80, 21.42). For acquaintance violence and stranger violence victims, the

probability of formal service use was 28.4 points (95% CI: 22.17, 34.69) and 35.0 points higher

(95% CI: 29.84, 40.16) if they experienced a serious injury (vs. no injury), respectively. Again,

these associations were significantly stronger than domestic violence according to a pairwise

comparison test (vs. acquaintance: τ = 12.82, 95% CI: 6.00, 19.64; vs. stranger τ = 19.39, 95%

CI: 13.05, 25.72).

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Figure 5-4 illustrates the marginal associations of emotional and social distress with

victims’ use of formal services by victim-offender relationship. The association between

emotional distress and formal service use did not significantly differ between victim-offender

relationships, but the estimated associations were in the predicted direction. The probability of

formal service use was 13.6 points (95% CI: 9.78, 17.51) and 13.2 points higher (95% CI: 9.80,

16.70) for acquaintance violence and stranger violence victims—respectively—if they reported

+.081

+.168+.186

-.05

.05

.15

.25

.35

.45


Chan

ge

in p

r(fo

rmal

ser

vic

e)


+.156

+.284

+.350

-.05

.05

.15

.25

.35

.45


Chan

ge

in p

r(fo

rmal

ser

vic

e)


Figure 5-3. Conditional association of injury severity and victims’ use of formal services by victim-

offender relationship

Note. The estimates above present the percentage point change in the probability a victim used

formal services when they experienced minor injuries (vs. no injuries) and when they experienced

serious injuries (vs. no injuries). + indicates a positive change in the probability. This figure

compares this effect across different victim-offender relationship categories (i.e., domestic violence

[DV], acquaintance/friend [Friend], and stranger). Categories within each panel that do not share a

subscript ( a b ) are significantly different at the 95% confidence level according to pairwise

comparison t-tests. Estimates are based on logit models of formal service use that interacted

relationship with injury severity. All covariates were held at their mean values.

a b b a b b

105

emotional distress (vs. no emotional distress), whereas it was 9.3 points higher for domestic

violence victims if they reported emotional distress (95% CI: 4.05, 14.48). Regarding social

distress, the probability of formal service use was 6.3 points higher (95% CI: 2.00, 10.66) for

stranger violence victims if they reported social distress (vs. no social distress). This estimate was

higher than both domestic violence (τ = 7.33, 95% CI: 1.20, 13.47) and acquaintance violence (τ

= 6.7, 95% CI: 3.00, 14.47). Social distress was unrelated to service use in domestic violence

victims or acquaintance violence.

In models of follow-up medical care for long-term emotional and physical problems,

need factors (i.e., injury severity, emotional distress, social distress, and long-term physical and

emotional problems) did not demonstrate a significant interaction with victim-offender

relationship. In short, the influence of need factors on victims’ use of follow-up emotional care

and follow-up physical care were relatively constant across victim-offender relationship

categories.21

21 I omitted these results for the sake of brevity, but they are available upon request.

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Conclusion

This study investigated violence victims’ use of police, medical, and victim service

agencies after a crime. It specifically focused on testing hypotheses derived from the needs-

barriers framework discussed in Chapter 2. Table 5-5 provides a brief description of these

hypotheses and a broad-stroke evaluation of the evidence for them. In addition to testing these

hypotheses, this study also had interesting findings that have important empirical implications for

+.093

+.136 +.132

-.05

.00

.05

.10

.15

.20

.25


Chan

ge

in p

r(fo

rmal

ser

vic

e)

Emotional distress

(vs. no emotional distress)

-.010 -.004

+.063

-.05

.00

.05

.10

.15

.20

.25


Chan

ge

in p

r(fo

rmal

ser

vic

e)

Social distress

(vs. no social distress)

Figure 5-4. Conditional associations of emotional distress and social distress with victims’ use

of formal services by victim-offender relationship

Note. The estimates above present the percentage point change in the probability a victim used formal

services when they experienced emotional distress (vs. no emotional distress) and when they experienced

social distress (vs. no social distress). + indicates a positive change in the probability, whereas – indicates

a negative change in the probability. This figure compares this effect across different victim-offender

relationship categories (i.e., domestic violence [DV], acquaintance/friend [Friend], and stranger).

Categories within each panel that do not share a subscript ( a e ) are significantly different at the 95%

confidence level according to pairwise comparison t-tests. Estimates are based on two logit models: one

that interacted relationship with emotional distress and another that interacted relationship with social

distress. All covariates were held at their mean values.

a a a a a b

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victims’ formal help-seeking outcomes. This section highlights these major findings, which are

discussed—in detail—in the following chapter.

Prevalence and trends in victims’ use of services

Victims used formal services in roughly half of the violent incidents, and the vast

majority of victims who used services relied on the police. When victims used formal services,

the police were involved 94% of the time. Except for victims who reported severe injuries,

violence victims rarely utilized medical care, and the utilization of victim service agencies was

relatively low for all victims (regardless of injury severity). Unfortunately, the NCVS data cannot

determine whether reporting to the police came before or after victims used other formal services,

such as medical care and victim service agencies. Nevertheless, it is clear that if victims decide to

seek formal help, the police will usually be involved.

Analyses of trends in violence victims’ use of formal services revealed important

findings. For victims who report serious injuries, utilization of health care and police services has

declined for the last 10 to 15 years. Health care utilization has declined at a particularly high rate,

and this decline is not readily explained by changes in the type or severity of violence. Further

analyses also indicated that this temporal change was not explained by the nature of the victim’s

injuries (measured using dummy variables of injury categories). By contrast, there has been no

significant change in violence victims’ use of victim service agencies. Moreover, utilization of

victim agencies remains very low relative to police and medical services.

Revisiting the hypotheses

Analyses of victims’ use of formal services provided support for some—but not all—of

the hypotheses derived from the needs-barrier framework (Table 5-5). Consistent with hypothesis

3, variables reflecting individual differences in need were the primary drivers of whether victims

used police, medical, or victim service agencies. Victims who reported severe injuries, emotional

108

distress, and social problems were far more likely than their counterparts to use formal services.

Additionally, victims were more likely to use follow-up care months after the incident when they

reported more long-term emotional or physical problems, emotional distress, and social problems.

However, need factors did not always predict victims’ use of formal services in expected ways.

For example, after accounting for other harms and factors related to the crime, victims who

reported a minor injury were less likely than non-injured victims to use follow-up physical care a

month or more after the crime. The needs-barriers framework does not readily explain this

curious finding.

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Table 5-4. Revisiting proposed hypotheses

Hypotheses Description Support

Hypothesis 3 The physical, emotional, and social harms of violence

are positively related to victims’ use of formal services

(i.e., police, hospital, or victim service agencies).

Yes

Hypothesis 4a Victims with severe physical injuries are more likely to

use only medical or social services than use police

services.

Yes

Hypothesis 4b Victims who are attacked by a weapon or multiple

offenders are more likely to use police services than

only medical or social services.

Yes

Hypothesis 4c Victims who report emotional or social distress are more

likely to use only medical/social services than police

services.

Partial

Hypothesis 5 The positive relationship between physical, emotional,

and social harms of violence and victims’ use of formal

services will decrease as the relational closeness

between the victim and the offender increases.

Partial

Hypothesis 6 Relational closeness between the victim and the offender

is negatively/positively associated with victims’ use of

formal services.

No

Hypothesis 6a Relational closeness between the victim and the offender

is positively associated with victims’ use of formal

services.

Yes

Hypothesis 7 Sexual violence victims are less likely than nonsexual

violence victims to use formal services.

Partial

The evidence also suggests that whether the police are accessed when victims use formal

services is dependent on the victim’s type of need. Not surprisingly, victims who used only

medical care or victim service agencies had higher rates of serious injury than victims who

involved the police (hypothesis 4a). This association is likely due to the fact that there is a high

proportion of victims who experience only minor trauma or injury that may use the police but

have no need to see a doctor or social worker. I found that victims who reported social distress

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were also more likely to use only health care or victim service agencies when they sought help

(hypothesis 4b). Violence victims may see the police as particularly unhelpful for handling the

social distress caused by victimization. Finally, I found that direct threats to victim safety, such as

weapon use and multiple offenders, increased the likelihood that victims involved the police

when they sought help (hypothesis 4c). In this type of violence, help-seeking victims are likely

incentivized to involve the police, as law enforcement can provide protection and ensure their

safety.

Need factors were the drivers of victims’ use of formal services, but the current study

found that the victim’s relationship to the offender can condition their influence. Consistent with

hypothesis 5, the positive associations between injury severity and social distress with victims’

use of formal services weakened as relational distance between the victim and offender narrowed.

This interaction was not observed in analyses of emotional distress. In the analyses of victims’

use of follow-up medical care a month or more after the crime, I found no significant interactions

between need and the victim-offender relationship. These non-significant findings suggest that

the interaction between need and victim-offender relationship may be most relevant to police

reporting or short-term help-seeking outcomes.

I argued that the victim-offender relationship and sexual violence acted as two potential

barriers to victims’ use of formal services. However, the analyses provided mixed support for

these arguments. Consistent with prior research (Hullenaar and Frisco 2020), sexual violence was

associated with a far lower likelihood that victims used formal services immediately after a crime

(hypothesis 7). Further analyses suggested that sexual violence victims may have preferences for

certain types of services. For example, among help-seeking victims, sexual violence victims were

more likely to use only medical care/victim services, as opposed to involving the police.

Preference for health care services was also observed in sexual violence victims’ follow-up care

decisions, as sexual violence was associated with a greater likelihood of follow-up emotional

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care (but not physical care). These findings suggest that sexual violence victims may experience

barriers to formal services related to police intervention or treatment for physical injuries, as

opposed to other types of services, such as counseling or therapy.

The association between victim-offender relationship and formal help-seeking depended

on the outcome of interest, but no evidence supported the expectation that victims are more likely

to use formal services the less they know their offender (Black 2010; Gottfredson and

Gottfredson 1987). The current study estimated a curvilinear association between the victim’s

relationship to the offender and their use of police, medical, or victim services. More specifically,

formal service use was most likely among victims of domestic violence and stranger violence and

least likely among victims of acquaintance violence. However, this curvilinear association was

not brought to bear in analyses of follow-up care. For example, domestic violence victims were

far more likely than stranger or acquaintance violence victims to use health care to treat long-term

emotional problems caused by violence. Unlike previous research (Hullenaar and Frisco 2020;

Overstreet and Quinn 2013; Straus, Gelles, and Steinmetz 2017), these findings suggest that the

victim’s relationship to the offender may not be as significant of a barrier to help-seeking as

previously thought. Additionally, there is some evidence that victims who know their offender

may actually be more likely to seek help.

In the following chapter, I discuss the key takeaway points of the studies presented in

chapters 4 and 5 and situate these findings in the victim help-seeking literature. I focus

specifically on the theoretical and practitioner-related implications for findings regarding the

harms of violence, victim-offender relationship, and victims’ formal help-seeking outcomes.

References



112






Straus, Murray A., Richard J. Gelles, and Suzanne K. Steinmetz. 2017. Behind Closed Doors:

Violence in the American Family. Routledge.

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Chapter 6

Discussion

Violence victims can experience serious physical, emotional, and social harms that

should motivate them to use police, health, and victim services, but many victims do not seek any

formal help (Greenberg and Ruback 1992; Tjaden and Thoennes 2000). To explain victims’

formal help-seeking outcomes, I offered a needs-barriers framework that builds on Gottfredson

and Gottfredson’s (1987) rational choice theory of victims’ crime reporting decisions. The basic

assumption of this framework is that victims use formal services when (a) the service satisfies

one or more of their valued needs (e.g., physiological, psychological, and social health) and (b)

there are limited physical, psychological, or social barriers to accessing the service. I argue that

victims determine needs and barriers by evaluating available information about the harms they

experience (e.g., injury severity) and the situational factors of the crime (e.g., victim-offender

relationship. The two studies I presented (Chapter 4 and 5) demonstrated how this framework

provides insight into the associations between crime severity, victim-offender relationship, and

victims’ use of formal services after a crime.

Based on the findings from these studies, this dissertation has four key implications. The

first implication is that need serves as a central factor in victims’ formal help-seeking outcomes.

This implication is unsurprising and consistent with a vast body of research (Gottfredson and

Hindelang 1979; Skogan 1984; Xie and Baumer 2019). Victims who experience greater harm

from violence are generally more likely to use police, medical care, or victim service agencies.

Even though half of violence victims did not seek formal help, they commonly did so when they

experienced serious injuries. Along with injury severity, I found that the less-studied measures of

harm (i.e., emotional and social problems) were also strong predictors of victims’ use of services.

Going beyond only traditional measures of severity (e.g., injury, weapon use, and sexual

114

violence; Felson and Paré 2005; Galvin and Safer-Lichtenstein 2018), this dissertations highlights

how emotional and social problems caused by the violence are critical to victims’ short- and long-

term help-seeking outcomes.

While need factors are central to victims’ help-seeking outcomes, some argue that a

narrow focus on need has practical limitations. For instance, Skogan (1984) questioned whether

institutions could even influence victims’ crime reporting decisions if these decisions were rooted

in “direct personal experience” and primarily determined by the “seriousness of the incident” (p.

131). In other words, are victims’ formal help-seeking outcomes mutable if only the harms of

violence influence them? I argue that understanding harms and victims’ needs is the first and

most critical step to influencing victims’ formal help-seeking outcomes. In work on violence

intervention programs, for example, a formal assessment of violence victims’ needs lays the

foundation for program development (Chong et al. 2015). Mitigating the consequences of

violence requires a deep understanding of the harm that also extends beyond physical injury or

other traditional indicators of violence severity. The emotional and social distress caused by

violence, for example, explains a significant amount of variance in victims’ use of formal

services, even after controlling for physical injury and weapon use. If policymakers and

practitioners gear violence intervention strategies toward addressing these needs, victims may

have a greater incentive to seek formal help.

The second implication is that victims’ formal help-seeking is likely a dynamic process,

in that victims who use formal services now are more likely to use formal services in the future.

In Chapter 5, victims who received help from police, health care, or victim services were more

likely to use follow-up care to treat long-term emotional or physical problems. This association is

consistent with theory and research on formal help-seeking in criminology (i.e., police reporting;

Greenberg and Ruback 1992; Xie and Baumer 2019) and medical sociology (i.e., healthcare

utilization; Andersen 1995). This dynamic process may work by increasing victims’ perceived

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need for further help. For example, a victim who presents with a presumed superficial injury to an

emergency room may later be diagnosed with serious internal injuries through medical imaging,

which may require follow-up care or physical therapy to maintain the victim’s quality of life.

Formal services may also further increase opportunities for victims to seek help. When victims

call the police, an ambulance may arrive merely as a safety precaution but then end up taking the

victim to the hospital. When doctors treat a violence victim in the emergency room, they may

write referrals to other social or health services. Social services referrals, for instance, are

extremely common in treatment plans for domestic violence victims identified in hospital settings

(Richardson et al. 2002).

However, this dissertation also shows that the links between different formal services

considerably vary. For violence involving serious victim injury, rates of police and medical

service utilization were quite similar. More than half of victimizations with serious injuries

involved a police report and/or a visit to a medical center. Furthermore, at the descriptive level,

the temporal trends in police and medical service utilization were remarkably parallel. These

findings imply a strong link between police and medical interventions in violence. By contrast,

victims rarely used victim service agencies (roughly 1 in 5 violent victimizations involving

serious injury), and this low utilization rate has remained stable over time. In fact, trends in the

victim services utilization seemed mostly unresponsive to changes in either police or medical care

utilization. Thus, while police and medical services often work in tandem to help serious violence

victims, victim service agencies remain relatively underutilized.

In the U.S., violence intervention programs often strengthen the connection between

victim service agencies, the police, and healthcare services, and in this regard, hospital-based

violence intervention programs (HVIP) have shown some promise (Juillard et al. 2016). The

basic goal of HVIPs is to approach the treatment of violence injuries from a holistic perspective.

Eschewing the “treat em’ and street em’” philosophy, emergency rooms in the U.S. are

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connecting violence victims with much-needed mental health and social services that maintain a

continuum of care long after victims leave the hospital (Rosenblatt et al. 2019). This type of

intervention explicitly involves victim service agencies in the process of helping victims.

The third implication is that the victim’s relationship to the offender is a critical predictor

of victims’ help-seeking outcomes, but in unique ways not previously addressed in prior research.

Even though their theories of crime reporting conflicted in many respects, Gottfredson and

Gottfredson (1987) and Black (2010) generally agreed that reporting to the police is less likely to

occur when the victim and the offender know each other well. Gottfredson and Gottfredson

(1987) argued that this association was due to stranger violence being perceived as more serious,

whereas Black asserted that the law was less available to victims who have a close relationship

with the offender. However, the data point to the opposite conclusions.

Conflicting with Gottfredson and Gottfredson’s expectations, Chapter 4 found that

relational closeness was a key risk factor for the physical, emotional, and social consequences of

violence to the victim. Victims who knew their offender intimately had a greater risk of injury,

emotional distress, social problems, long-term emotional problems, and long-term physical

problems. The presence of an attacker in a social network seems to have persistent, deleterious

consequences to victims’ physical and mental health. These consequences likely motivate victims

to seek outside help more than social norms that view stranger violence as more “reprehensible”

than violence by known offenders (Gottfredson and Gottfredson 1987; Rossi et al. 1974).22

22 While these findings indicate relationship-based disparities in the sequelae of violence, they should not

be treated as conclusive evidence for domestic violence being more “serious” than stranger/acquaintance

violence. The NCVS data has limitations. First, the data provide no information on violence lethality, as it

does not measure homicide victimization. Second, sample selection could bias results. If domestic violence

occurs “behind closed doors” (Straus, Gelles, and Steinmetz 1982), then victims may not tell NCVS

interviewers about violent incidents unless they are serious enough. Thus, NCVS respondents may be more

willing to mention minor forms of violence by a stranger perpetrator, which means that less serious

violence by family members or intimate partners may be omitted from the sample.

117

Indeed, conflicting with Black’s expectations, the results from Chapter 5 suggest that the

relational closeness between the victim and the offender may have a curvilinear or positive

association with victims’ use of formal services. After controlling for the characteristics of the

crime, victim, and offender, victims were most likely to use services if they were attacked by

strangers, family members, or intimate partners, whereas they were least likely to use services if

acquaintances or friends attacked them.23 While Black’s theory only addressed crime reporting, it

is interesting to note that the vast majority of violence involving formal services also involved the

police (94%). Relational closeness also had a strong positive association with victims’ use of

follow-up emotional care. Domestic violence victims were far more likely than

acquaintance/stranger violence victims to use services to treat long-term emotional problems. In

sum, it seems that the victim-offender relationship, on average, may not be a significant barrier

that reduces victims’ likelihood of using formal services.

However, sexual violence—which is most often perpetrated by those known to the victim

(Ullman and Siegel 1993)—was generally associated with a lower likelihood of victims using

formal services. However, this association depended on service type. Compared to nonsexual

violence victims who sought formal help, sexual violence victims who sought formal help were

less willing to report to the police but relatively more willing to use health care services. This

pattern was particularly apparent in follow-up care outcomes, as sexual violence victims were far

more likely to use follow-up care to treat long-term emotional problems. These victims may

prefer to use medical care (instead of the police) because they fear the secondary traumatization

caused by the legal system, which is often referred to as a “second rape” (Campbell 2008, 2013).

Indeed, previous research suggests that rape victims tend to use medical care more than legal

23 In analyses not presented, relational closeness was negatively related to victims’ use of formal services

without accounting for other covariates. This association, however, changed significantly after introducing

measures of the harms of violence and the location of the incident.

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services, and they are also more likely to rate their contact with legal services as more hurtful

(Campbell et al. 2001).

The fourth implication is that this dissertation provided strong evidence that the short-

and long-term impact of injury on the emotional and social sequelae of violence may depend on

the victims’ relationship to the offender. Chapter 4 found that physical injury was strongly linked

to an array of negative outcomes caused by violence, but this link was weaker for victims who

knew their offender intimately. It is unlikely that victims consider violence by known offenders

to be less serious than stranger violence (Black 1979; Gottfredson and Hindelang 1979; Rossi et

al. 1974), as relational closeness was positively related to poorer health outcomes for victims (see

above). Thus, alternative explanations should be considered.

It is possible that victims who are attacked by someone they know or love may grapple

with unique stressors that reduce the overall impact of physical injury on their well-being.

Victimization shatters people’s sense of safety and trust in the world (Janoff-Bulman 2010), and

this type of vulnerability may be more pronounced when the perpetrator is from the victim’s

social network. Victims of family or intimate partner violence, for example, are likely to see their

offender again, and thus they tend to be more vulnerable to revictimization than stranger violence

victims (Johnson 2010). Additionally, domestic violence victims may also be subjected to

different forms of constant aggression that extend beyond physical violence. Their offender may

engage in economic abuse (e.g., perpetrator prevents the victim from working), constant threats

or coercion, emotional abuse, or attempt to isolate the victim from friends or other family

members (Johnson 2010; Pence, Paymar, and Ritmeester 1993). When facing these multiple

forms of abuse, domestic violence victims may be more “resilient” to physical injury from any

single violent incident. Alternatively, they may also experience a “ceiling effect,” in that their risk

of emotional or social distress is so high from other forms of abuse that a physical injury may

have a limited impact.

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Understanding how victims contextualize their injuries is also relevant to their formal

help-seeking outcomes. In Chapter 5, violence victims were generally more likely to use formal

services if they experienced serious injury. Yet, the influence of injury on victims’ use of formal

services was conditional on the victim’s relationship to the offender. Specifically, the association

between injury (both minor and serious) and victims’ formal service use tended to be strongest

for victims of stranger or acquaintance violence and weakest for victims of domestic violence.

However, this statistical interaction was observed only for victims’ use of formal services after

the crime—which almost always involved the police—but not their use of follow-up medical care

in the months after.

One possibility is that the interaction effect between injury severity and victim-offender

relationship may be most relevant to police reporting outcomes. In 94% of cases involving a

formal service, the police were involved, and in sensitivity analyses where I examined only police

reporting (as an outcome), I found a similar statistical interaction. Injury severity may matter less

to domestic violence victims’ (vs. stranger/acquaintance violence victims) crime reporting

outcomes because preventing revictimization is a primary focal concern. Regardless of injury,

domestic violence offenders may present a greater threat to victims than stranger offenders

(Felson et al. 2002; Felson and Paré 2005), which would motivate victim help-seeking. Consistent

with this notion, I found that, in further analyses, victims who experienced no injuries were

significantly more likely to use formal services if the offender was a family member or intimate

partner (vs. a stranger).

Limitations

There are three significant limitations to mention. First, and perhaps most critical, this

dissertation could not address violent crimes where victims had little to no agency in their formal

help-seeking outcome. For example, if a victim decided against using formal services but a third

party reported to the police, the application of rational choice principles becomes moot because

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the victim did not have a choice. Unfortunately, merely removing incidents involving a third-

party reporter does not solve this issue, as there is strong evidence that victims often agree with

third parties when deciding to report to the police (Greenberg and Ruback 1992; Ruback 1994).

In sensitivity analyses, I controlled for whether a third party reported to the police and found

similar results presented in Chapter 5. While this robustness check is imperfect, it provides some

evidence that the same findings would be observed in violent crimes where victims had agency

over their help-seeking outcomes.

Second, the analyses ignored how informal sources of support (e.g., family and friends)

encourage or even act as a substitute for formal service use. In her critique of rational choice

theories of help-seeking, Pescosolido (1992) argued that people handle difficulties by leaning on

their social networks. Thus, help-seeking decisions are socially constructed and not easily

explained by individual-focused rational choice assumptions, such as utility maximization.

Indeed, victims’ help-seeking outcomes are highly influenced by the advice of others (Ruback

1994). It is possible that one reason victims of family or intimate partner violence seek formal

help more often is because they are more likely to rely on informal sources of support (Kaukinen

2002).

Third, while I used a series of criterion-related validity checks on the measure of injury

severity, issues in its operationalization remain. The primary issue is linked to the data. The

NCVS provides little context regarding the severity of victims’ injuries, except for broad

descriptive categories. Some studies have measured injury severity by including whether it

involved hospitalization, but this tactic could not be used because this dissertation focused on

help-seeking outcomes (i.e., healthcare utilization). This measurement limitation has potential

implications for the interaction effects between injury severity and victim-offender relationship

on the sequelae of violence and victims’ help-seeking outcomes. For example, victims who

reported a minor or serious injury (as measured by this dissertation) may have experienced less

121

physical harm if they were attacked by a family member/intimate partner than if a stranger

attacked them. As a result, it would be expected that injury severity would have less influence on

the former’s help-seeking outcomes.

Final Remarks

Violence victims’ formal help-seeking outcomes result from a complex interplay between

their needs for formal services and the barriers they face in accessing them. A needs-barriers

framework lends insight into the unique ways commonly studied measures of violence—e.g.,

injury severity and victim-offender relationship—influence victims’ help-seeking outcomes. This

dissertation presents evidence that these factors may directly influence the harm victims

experience and whether they use formal services. Even further, this dissertation suggests that

victims often contextualize the harm they experience based on their relationship to the attacker.

Thus, the link between the violence harms and help-seeking cannot be separated from its

situational circumstances.

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Appendix A

Descriptive Statistics of Analytic Sample

Variables Pr (M)

Formal services

No services .49

Police services involved .03

Only medical or victim services .48



Female .50

Race/ethnicity

Non-Hispanic White .62

Non-Hispanic Black .15

Non-Hispanic other/mixed .07

Hispanic .16

Age (34.16)

Education LT high school .29

High school equivalent .23

Some college .30

Bachelor's or more .18

Economic status(factor) -.02

Married .24

Urbanicity Rural .14

Suburban .45

Urban .42

Region Northeast .16

Midwest .24

South .32

West .28

Need factors

Injury severity

No injury .74

Minor injury .18

Serious injury .06

126

Other injury .01

Emotional distress .54

Social distress .28

Situational factors

Weapon No weapon .75

Knife .09

Firearm .07

Other/unknown weapon .09

Multiple offenders .18

Offender age

Juvenile(s) only .17

Juveniles and adults .03

Adult(s) only .80

Offender sex

Female(s) only .05

Mixed sex .19

Male(s) only .76

Sexual violence .07

Relationship

Stranger .45

Acquaintance/friend .33

Family/Intimate partner .22

Repeat victimization .47

Third party present .61

Victim used violence .09

Location

Private residence .48

School/work site .24

Open area .15

Other area .14

Note: Pr = proportion; M = mean.

Estimates are based on imputed data.

127

Appendix B

Serious Injury Profile

.30

.05 .06

.11

.03

.25

.16.19

.42

.00

.10

.20

.30

.40

.50

Pro

po

rtio

n

Injury type

Note. Proportions do not sum to 1 because violence victims may report more than one injury.

128

Appendix C

Full Models of Emotional and Social Distress

Table 3. Logistic regression models of emotional distress and social dsitress

Emotional distress Social distress

Independent variables OR [LL,UL] OR [LL,UL]

Need

Injury

Minor injury 1.734*** [1.536,1.957] 1.479*** [1.307,1.673]

Serious injury 2.728*** [2.145,3.468] 2.573*** [2.083,3.179]

Other injury 1.549* [1.095,2.192] 1.583* [1.108,2.262]

Financial loss 1.000*** [1.000,1.000] 1.000*** [1.000,1.000]

Financial loss2 0.999*** [0.999,0.999] 0.999*** [0.999,0.999]


Female 2.420*** [2.181,2.685] 1.648*** [1.474,1.843]

Race/ethnicity

Non-Hispanic Black 0.791** [0.684,0.916] 0.959 [0.815,1.127]

Non-Hispanic other/mixed 0.973 [0.804,1.178] 1.179 [0.963,1.443]

Hispanic 0.942 [0.821,1.082] 1.105 [0.947,1.289]

Age 0.615*** [0.479,0.790] 0.790+ [0.610,1.023]

Age2 1.255*** [1.180,1.335] 1.060+ [0.993,1.132]

Education

High school 0.970 [0.828,1.137] 0.924 [0.785,1.089]

Some college 0.857* [0.735,0.998] 1.003 [0.855,1.176]

Bachelor's or more 0.897 [0.752,1.070] 0.802* [0.667,0.964]

Economic status 0.921** [0.869,0.975] 0.927* [0.871,0.986]

Married 0.924 [0.822,1.038] 0.886+ [0.781,1.004]

Urbanicity

Suburban 1.124 [0.964,1.312] 1.157+ [0.994,1.346]

Urban 1.009 [0.865,1.176] 0.977 [0.836,1.141]

Region

Midwest 0.888 [0.756,1.042] 1.072 [0.905,1.271]

South 0.807** [0.692,0.943] 1.123 [0.959,1.317]

West 1.046 [0.891,1.229] 1.174+ [0.990,1.392]

Situational factors

Weapon

Knife 1.396*** [1.149,1.697] 1.147 [0.934,1.408]

Firearm 2.352*** [1.946,2.843] 1.820*** [1.504,2.202]

Other/unknown weapon 1.147+ [0.988,1.331] 1.409*** [1.194,1.662]

Multiple offenders 1.577*** [1.365,1.821] 1.392*** [1.172,1.653]

Offender age

Juveniles and adults 0.869 [0.630,1.198] 1.779** [1.239,2.554]

Adult(s) only 1.132 [0.952,1.345] 1.375** [1.137,1.662]

Offender sex

Female(s) only 0.842** [0.743,0.953] 1.151* [1.015,1.304]

Mixed sex 1.032 [0.801,1.329] 1.034 [0.798,1.340]

Sexual violence 1.520*** [1.214,1.904] 1.712*** [1.377,2.129]

Relationship

Stranger 0.678*** [0.582,0.789] 0.542*** [0.469,0.626]


Repeat victimization 1.070 [0.952,1.202] 1.244*** [1.105,1.401]

Third party present 0.937 [0.848,1.034] 1.245*** [1.121,1.382]

129

Location

School/work site 0.573*** [0.501,0.654] 1.076 [0.927,1.249]

Open area 0.890+ [0.775,1.022] 0.845* [0.715,0.999]

Other area 0.809** [0.700,0.935] 0.754** [0.635,0.895]

Note: Note: OR = odds ratio; CI = confidence interval; LL = lower limit, UL = upper limit.

All models include year fixed effects, clustered standard errors, and survey weights.

130

Appendix D

Full Models of Long-term Emotional and Physical Problems

Table 4-4. Predicting financial loss, emotional distress, and social distress

Long-term physical problems Long-term emotional problems

IRR 95% CI [LL,UL] IRR 95% CI [LL,UL]

Injury severity

Minor injury 1.275*** [1.185,1.371] 1.100*** [1.066,1.137]

Serious injury 1.755*** [1.596,1.931] 1.160*** [1.114,1.208]

Other injury 1.458*** [1.192,1.784] 1.131** [1.043,1.227]

Financial loss 1.000*** [1.000,1.000] 1.000*** [1.000,1.000]

Financial loss2 0.999*** [0.999,1.000] 0.999*** [0.999,1.000]


Female 1.494*** [1.382,1.616] 1.241*** [1.199,1.285]

Race/ethnicity

Non-Hispanic Black 0.953 [0.863,1.054] 1.008 [0.967,1.051]

Non-Hispanic other/mixed 1.143* [1.021,1.279] 1.027 [0.978,1.079]

Hispanic 1.013 [0.918,1.118] 1.023 [0.983,1.065]

Age 0.902 [0.731,1.114] 0.913* [0.835,0.997]

Age2 1.106*** [1.051,1.163] 1.045*** [1.023,1.068]

Education

High school equivalent 1.013 [0.913,1.124] 0.968 [0.929,1.009]

Some college 0.946 [0.855,1.047] 0.946** [0.908,0.985]

Bachelor's or more 0.881* [0.782,0.992] 0.924** [0.880,0.970]

Economic status(factor) 0.864*** [0.830,0.900] 0.960*** [0.942,0.977]

Married 0.982 [0.906,1.064] 0.970+ [0.937,1.004]

Urbanicity

Suburban 1.085 [0.984,1.196] 1.044+ [1.000,1.090]

Urban 1.038 [0.940,1.146] 1.060* [1.014,1.108]

Region

Midwest 1.131* [1.013,1.262] 1.020 [0.973,1.069]

South 1.109+ [0.996,1.234] 1.034 [0.989,1.082]

West 1.147* [1.024,1.283] 1.053* [1.004,1.103]

Situational factors

Weapon

Knife 1.077 [0.952,1.219] 1.072** [1.018,1.129]

Firearm 1.217*** [1.095,1.353] 1.182*** [1.134,1.232]

Other/unknown weapon 1.134* [1.023,1.257] 1.088*** [1.042,1.136]

Multiple offenders 1.207*** [1.087,1.340] 1.142*** [1.093,1.194]

Offender age

Juveniles and adults 1.177 [0.913,1.517] 1.073 [0.971,1.186]

Adult(s) only 1.141+ [0.985,1.322] 1.088* [1.020,1.160]

Offender sex

Female(s) only 0.985 [0.907,1.069] 0.943** [0.907,0.980]

Mixed sex 1.106 [0.954,1.282] 0.974 [0.915,1.038]

Sexual violence 1.166** [1.054,1.290] 1.185*** [1.136,1.236]

Relationship

Stranger 0.905* [0.832,0.985] 0.973 [0.937,1.010]


Repeat victimization 1.305*** [1.214,1.404] 1.101*** [1.066,1.138]

Third party present 1.056+ [0.992,1.124] 0.976+ [0.950,1.003]

Location

131

School/work site 0.837** [0.746,0.938] 0.891*** [0.845,0.940]

Open area 0.843** [0.759,0.936] 0.920*** [0.881,0.962]

Other area 0.854** [0.771,0.947] 0.926*** [0.886,0.966]

Note: OR = odds ratio; CI = confidence interval; LL = lower limit, UL = upper limit. All models include year fixed effects,

clustered standard errors, and survey weights.

132

Appendix E

Full Models of Follow-up Care for Long-term Emotional and Physical

Problems


Model 3

Follow-up care : Emotional problems

Model 4

Follow-up service physical problems

OR 95% [LL, UL] OR 95% [LL, UL]

Previous service use 2.094*** [1.737,2.526] 1.795*** [1.441,2.236]

Need factors

Physical problems (#) 1.255*** [1.205,1.306] 1.385*** [1.312,1.462]

Emotional problems (#) 1.208*** [1.142,1.279] 1.038 [0.967,1.114]

Injury severity

Minor injury 1.070 [0.883,1.297] 0.575*** [0.456,0.726]

Serious injury 0.951 [0.739,1.225] 0.836 [0.614,1.137]

Other injury 1.265 [0.719,2.226] 1.057 [0.567,1.968]

Financial loss 1.003+ [0.999,1.006] 1.002 [0.999,1.005]

Emotional distress 1.657** [1.163,2.360] 2.068** [1.253,3.413]

Social distress 1.845*** [1.546,2.202] 1.523*** [1.238,1.874]


Stranger 0.506*** [0.393,0.650] 0.983 [0.727,1.329]


Situational factors

Sexual violence 1.969*** [1.496,2.591] 1.318 [0.948,1.833]

Weapon

Knife 1.072 [0.786,1.462] 0.833 [0.592,1.173]

Firearm 0.833 [0.616,1.127] 0.864 [0.606,1.234]

Other/unknown weapon 0.789+ [0.598,1.039] 1.164 [0.862,1.571]

Multiple offenders 0.930 [0.703,1.231] 1.004 [0.719,1.402]

Offender age

Juveniles and adults 0.838 [0.484,1.452] 1.773+ [0.962,3.267]

Adult(s) only 0.544*** [0.403,0.736] 0.991 [0.699,1.405]

Offender sex

Female(s) only 1.019 [0.826,1.256] 1.032 [0.811,1.314]

Mixed sex 1.169 [0.794,1.720] 0.802 [0.513,1.256]

Repeat victimization 1.306** [1.084,1.574] 1.192 [0.964,1.475]

Third party present 1.003 [0.851,1.182] 1.262* [1.033,1.543]

Location

School/work site 1.131 [0.858,1.491] 1.388* [1.019,1.891]

Open area 1.273+ [0.964,1.682] 1.080 [0.780,1.494]

Other area 1.185 [0.902,1.556] 1.175 [0.853,1.619]


Female 1.393** [1.135,1.709] 1.106 [0.874,1.400]

Race/ethnicity

Non-Hispanic Black 0.701** [0.538,0.914] 0.989 [0.728,1.342]

Non-Hispanic other/mixed 0.855 [0.610,1.198] 0.933 [0.650,1.340]

Hispanic 0.793+ [0.612,1.027] 0.895 [0.671,1.194]

Age 0.888* [0.811,0.973] 1.009** [1.002,1.016]

Age2 1.003** [1.001,1.005] -

Age3 1.000** [1.000,1.000] -

Education

133

High school equivalent 0.876 [0.665,1.153] 0.867 [0.644,1.168]

Some college 0.929 [0.717,1.202] 0.850 [0.639,1.130]

Bachelor's or more 1.411* [1.043,1.907] 1.107 [0.795,1.539]

Economic status(factor) 0.892* [0.806,0.986] 0.990 [0.872,1.125]

Married 0.841 [0.681,1.039] 0.893 [0.705,1.130]

Urbanicity

Suburban 0.890 [0.693,1.142] 0.917 [0.682,1.232]

Urban 0.905 [0.696,1.177] 0.947 [0.695,1.289]

Region

Midwest 0.764* [0.586,0.996] 0.842 [0.607,1.169]

South 0.771* [0.599,0.992] 0.842 [0.611,1.162]

West 0.679** [0.519,0.888] 0.692* [0.494,0.970]

Sample 7,947 5,175

Note: OR = odds ratio; CI = confidence interval; LL = lower limit, UL = upper limit. All models include year fixed

effects, clustered standard errors, and survey weights.

VITA

KEITH HULLENAAR

601 Oswald Tower, Office 1017, University Park, PA, 16802

[email protected]

ACADEMIC INTERESTS

Victimization, youth violence, public health, and victim help-

seeking

EDUCATION

Pennsylvania State University, State College, PA

Ph.D. in Criminology (expected May 2021) 2016 -

Dissertation: Correlates and consequences of victim help-

seeking

Committee: Eric Baumer, Thomas Loughran, David Ramey,

Jocelyn Anderson, PhD, RN

Northern Arizona University, Flagstaff, AZ

M.S. in Applied Criminology, With Distinction 2014 - 2016

B.S. in Criminology and Criminal Justice, Summa Cum Laude 2012 - 2014

PEER-REVIEWED ARTICLES

Hullenaar, K.L. & Frisco, M.L. (2020). Understanding the barriers of victims’ health care

use. Journal of Health and Social Behavior.

Featured in Penn State News:

https://news.psu.edu/story/637201/2020/10/29/research/barriers-health-care-violence-

victims

Hullenaar, K.L., & Ruback, R. B. (2020). Gender interaction effects on reporting assaults to

the police. Journal of Interpersonal Violence.

Felson, R.B. & Hullenaar, K.L. (2020 ). Adversary effects and the tactics of violent

offenders. Aggressive Behavior.

GOVERNMENT REPORTS

Hullenaar, K. L., & Ruback, R. B. (2020). Juvenile violent victimization 1995-2018. Office

of Justice Programs: Office of Juvenile Justice and Delinquency Prevention.

understanding victims’ use of formal services after

Documents