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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.
iv
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.
v
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
vi
Long-term Physical and Emotional Problems .......................................................... 69 Conditioning Injury Severity by Victim-offender Relationship ............................... 72
Conclusion ....................................................................................................................... 79 References ........................................................................................................................ 81
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
Conclusion ....................................................................................................................... 106 References ........................................................................................................................ 111
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
vii
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.
3
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,
4
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
5
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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34
Felson, Richard B., Steven F. Messner, Anthony W. Hoskin, and Glenn Deane. 2002. “Reasons for
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Felson, Richard B. and Paul Philippe Paré. 2005. “The Reporting of Domestic Violence and Sexual
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Women 11(3):290–310.
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Galvin, Miranda A. and Aaron Safer-Lichtenstein. 2018. “Same Question, Different Answers:
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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
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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]
Predisposing factors
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]
Victim-offender relationship
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]
Victim-offender relationship
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
Year fixed effects 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
Family/IP Friend Stranger
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
Family/IP Friend Stranger
Chan
ge
in p
r(so
cial
dis
tres
s)
Minor injury (vs. no injury)
+.095
+.204
+.244
-.05
.05
.15
.25
.35
Family/IP Friend Stranger
Chan
ge
in p
r(so
cial
dis
tres
s)
Serious injury (vs. no injury)
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
Family/IP Friend Stranger
Chan
ge
in e
xp
ecte
d c
ount
of
physi
cal
pro
ble
ms
Minor injury (vs. no injury)
+0.82
+1.26
+1.84
-0.05
0.45
0.95
1.45
1.95
2.45
2.95
Family/IP Friend Stranger
Chan
ge
in e
xp
ecte
ed c
ount
of
physi
cal
pro
ble
ms
Serious injury (vs. no injury)
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
Family/IP Friend Stranger
Ch
ange
in e
xp
ecte
d c
ou
nt
of
emo
tio
nal
pro
ble
ms
Minor injury (vs. no injury)
+.434
+.670
+.960
-0.25
0.05
0.35
0.65
0.95
1.25
Family/IP Friend Stranger
Ch
ange
in e
xp
ecte
d c
ou
nt
of
emo
tio
nal
pro
ble
ms
Serious injury (vs. no injury)
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
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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.
Black, Donald. 1979. “Common Sense in the Sociology of Law.” American Sociological Review
18–27.
Black, Donald. 2010. The Behavior of Law. Emerald Group Publishing.
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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
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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.
Gottfredson, Michael R. and Don M. Gottfredson. 1987. Decision Making in Criminal Justice:
Toward the Rational Exercise of Discretion. Vol. 3. Springer Science & Business Media.
Gottfredson, Michael R. and Michael J. Hindelang. 1979. “A Study of the Behavior of Law.”
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Hullenaar, Keith L. and Michelle Frisco. 2020. “Understanding the Barriers of Violence Victims’
Health Care Use.” Journal of Health and Social Behavior.
Long, J. Scott and Sarah A. Mustillo. 2018. “Using Predictions and Marginal Effects to Compare
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Overstreet, Nicole M. and Diane M. Quinn. 2013. “The Intimate Partner Violence Stigmatization
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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.
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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.
87
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).
88
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
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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
91
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
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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
Victim-offender relationship
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]
Predisposing factors
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
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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
Independent variables
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
Victim-offender relationship
Stranger 0.506*** [0.393,0.650] 0.983 [0.727,1.329]
Acquaintance/friend 0.662*** [0.527,0.833] 0.971 [0.743,1.268]
Sexual violence 1.969*** [1.496,2.591] 1.318 [0.948,1.833]
Year fixed effects X X
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%
102
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).
103
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).
104
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
Family/IP Friend Stranger
Chan
ge
in p
r(fo
rmal
ser
vic
e)
Minor injury (vs. no injury)
+.156
+.284
+.350
-.05
.05
.15
.25
.35
.45
Family/IP Friend Stranger
Chan
ge
in p
r(fo
rmal
ser
vic
e)
Serious injury (vs. no injury)
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.
106
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
Family/IP Friend Stranger
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
Family/IP Friend Stranger
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
107
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.
109
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
110
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
111
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
Black, Donald. 2010. The Behavior of Law. Emerald Group Publishing.
Gottfredson, Michael R. and Don M. Gottfredson. 1987. Decision Making in Criminal Justice:
112
Toward the Rational Exercise of Discretion. Vol. 3. Springer Science & Business Media.
Hullenaar, Keith L. and Michelle Frisco. 2020. “Understanding the Barriers of Violence Victims’
Health Care Use.” Journal of Health and Social Behavior.
Overstreet, Nicole M. and Diane M. Quinn. 2013. “The Intimate Partner Violence Stigmatization
Model and Barriers to Help Seeking.” Basic and Applied Social Psychology 35(1):109–22.
Straus, Murray A., Richard J. Gelles, and Suzanne K. Steinmetz. 2017. Behind Closed Doors:
Violence in the American Family. Routledge.
113
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
115
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
116
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.
118
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.
119
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
120
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
Independent variables
Predisposing factors
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]
Predisposing factors
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]
Acquaintance/friend 0.460*** [0.396,0.535] 0.225*** [0.192,0.263]
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]
Predisposing factors
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]
Acquaintance/friend 0.674*** [0.613,0.740] 0.902*** [0.867,0.939]
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
Independent variables
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]
Victim-offender relationship
Stranger 0.506*** [0.393,0.650] 0.983 [0.727,1.329]
Acquaintance/friend 0.662*** [0.527,0.833] 0.971 [0.743,1.268]
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]
Predisposing factors
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
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.