Posted: February 26th, 2023

Diversity in healthcare, Psychopathology, Complementary, Crisis, Writing and rhetoric, Recreational Therapy, Inclusive Recreation Services, and Psychopharmacology

 

APA format

1) Minimum 32 pages  (No word count per page)-   Follow the 3 x 3 rule: minimum of three paragraphs per page 

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

The number of words in each paragraph should be similar

24 hours: 11

44 hours: 9

64 hours: 10

84 hours: 2

Part 1: minimum 2 pages (Due 24 hours)

Part 2: minimum 2 pages  (Due 24 hours)

Part 3: minimum 3 pages (Due 64 hours)

Part 4: minimum1 page  (Due 24 hours)

Part 5: minimum 3 pages  (Due 64 hours)

Part 6: minimum 1 page  (Due 44 hours)

Part 7: minimum 2 pages  (Due 64 hours)

Part 8: minimum 2 pages  (Due 64 hours)

Part 9: minimum 2 pages  (Due 24 hours)

Part 10: minimum 2 pages   (Due 24 hours)

Part 11: minimum 2 pages  (Due 44 hours)

Part 12: minimum 2 pages   (Due 44 hours)

Part 13: minimum 2 pages  (Due 84 hours)

Part 14: minimum 2 pages   (Due 84 hours)

Part 15: minimum 2 pages   (Due 44 hours)

Submit 1 document per part

2)¨******APA norms

        The number of words in each paragraph should be similar

        Must be written in the third person

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

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

         Bulleted responses are not accepted

         Don’t write in the first person 

  Do not use subtitles or titles      

         Don’t copy and paste the questions.

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

Submit 1 document per part

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

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

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

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

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

 

Example:

Q 1. Nursing is XXXXX

Q 2. Health is XXXX

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

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

Example:
Part 1  
Part 2

__________________________________________________________________________________

Part 1:  Diversity in healthcare

7Hyde Pfiefer, a retired 70-year-old German American, has lived in the United States for the last 50 years. A widower of 5 years, Mr. Pfiefer prepares his own meals following his wife’s recipes from the old country. Nine months ago, Mr. Pfiefer was told that his cholesterol is elevated, and he was instructed about a low-fat diet. His most recent t3st results show his values to be unchanged.

1. Discuss the meaning of food in German culture. (One paragraph)

2. Explain diseases related to cholesterol in German culture, including (Two paragraphs: One paragraph for 2; One paragraph for a and b)

a.  National static data (Germany)

b. National static data for the mortal diseases related to cholesterol (Germany)

3. Using the predominant health beliefs of people of German ancestry (Two paragraphs) 

a. How might you help Mr. Pfiefer reduce his cholesterol level?

4. How to promote a healthy diet in this case (One paragraph)

Part 2: Psychopathology

C.Z. is a 20-year-old Caucasian male who is in his second year of college. He is seeking treatment due to persistent fears that campus security and the local police are tracking and surveilling him. He cites occasional lags in his internet speed as evidence that surveillance devices are interfering with his electronics. His intense anxiety about this has begun getting in the way of his ability to complete schoolwork, and his friends are concerned – he says they have told him, “you’re not making sense.”

C.Z. occasionally laughs abruptly and inappropriately and sometimes stops speaking mid-sentence, looking off in the distance as though he sees or hears something. He expresses concern about electronics in the room (phone, computer) potentially being monitored and asks repeatedly about patient confidentiality, stating that he wants to be sure the police won’t be informed about his treatment. His beliefs are fixed, and if they are challenged, his tone becomes hostile.

1. Schizophrenia (Three paragraphs)

a. Etiology (One paragraph)

b. Course (One paragraph)

c. Structural/functional abnormalities of schizophrenia. (One paragraph)

2. Discuss the treatment’s evidence-based  (Two paragraphs)

a. Pharmacological (One paragraph)

b. Nonpharmacological  (One paragraph)

3. Explain two evidence-based US Clinical Guidelines.(One paragraph)

Part 3: Complementary and Alternative Health Care (Write in the first person)

1. Introduction to the pap3r, including (One paragraph)

a.  Purpose  

b. Explain how  addresses BSN Essentials 2 ” Systems leadership and Basic Organizational for patient safety and quality care ” is relates to the course (Complementary and Alternative Health Care)

2. Reflect on the curse readings, discussion threads, and applications you have completed across this course and write a reflective 3ssay regarding the extent to which you feel you are now prepared to: 

a.  Define complementary, alternative and integrative practices as identified by current health paradigms.  (Two paragraphs)

b.  Discuss history for complementary and alternative medicine  (One paragraph)

c.  Given case studies, describe the extent to which complementary and alternative health practices are encouraged and used among multiple cultures (One paragraph)

d.  Analyze the research regarding the efficacy of selected complementary and alternative practices and products.  (One paragraph)

e.  Incorporate integrative medicine which embodies conventional and complementary and alternative medicine, making use of the best available evidence of all three approaches to healing within patient’s personal plan of care  (Two paragraphs)

3. Conclusion (One paragraph)

Part 4: Crisis intervention 

Consider the hurricane Andrew or Katrina, then put yourself in the role of the Local Emergency Management Agency Coordinator and answer the following questions.

1. What helpful or positive role can the local media play in helping to resolve the crisis?  (One paragraph)

a. How does one facilitate that to happen?

2. What kind of training, education, and experience do you believe should be required to be an effective and competent manager of a crisis such as the scenario one described above? (One paragraph)

3. Given a natural disaster such as is contained in this scenario, how do you go about coordinating and communicating an effective response? (One paragraph)

Part 5: Crisis Intervention (Write in the first person)

1. Introduction to the pap3r, including (One paragraph)
a.  Purpose  

b. Explain how  addresses BSN Essentials 2 ” Systems leadership and Basic Organizational for patient safety and quality care ” is relates to the course (Crisis Intervention)

2. Reflect on the curse readings, discussion threads, and applications you have completed across this course and write a reflective 3ssay regarding the extent to which you feel you are now prepared to: 

a.  Apply knowledge of social and cultural factors to the care of diverse populations  (Two paragraphs)

b.   Use skills of inquiry, analysis, and information literacy to address practice issues  (One paragraph)

c.   Integrate the knowledge and methods of a variety of disciplines to inform decision making in crisis intervention (One paragraph)

d.    Demonstrate tolerance for the ambiguity and unpredictability of the world and its effect on the healthcare system in crisis intervention.  (One paragraph)

e.  Value the ideal of lifelong learning to support excellence in nursing practice  in crisis intervention (Two paragraphs)

3. Conclusion (One paragraph)

Part 6: Crisis intervention

Here are a lot of individuals that have addictions, whether they are drinking alcohol, eating chocolate, gambling on blackjack, buying plaid sport coats, overspending on credit cards, or reading the sports page at breakfast. Anything that we start out wanting and not necessarily needing but end up either psychologically or physically craving may be considered addicting. Such addictive behaviors may be as simple as not being able to pass the candy bar machine to attending every place with them.

1. What would be some of the the difficulties they will face in forgoing their addiction for a day.? (Three paragraphs)

 

Part 7:  Writing and rhetoric

Check file 7

Audience: Your instructor and classmates

Genre: Blog

Skills learned/practiced: source selection, rhetorical analysis, summary, synthesis

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

Four paragraphs per page

 

1. Rhetorical summary  Sources 1 (Check Part 7-1) (One paragraph)

a. Introduce the source concisely 

b. Describe their rhetorical situation

i. Genre

ii. Audience

iii. Purpose

2. Rhetorical summary  Sources 2 (Check Part 7-2) (One paragraph)

a. Introduce the source concisely 
b. Describe their rhetorical situation
i. Genre
ii. Audience
iii. Purpose

3. Include a brief summary for each source that highlights the most important things you learned about your topic from that source.  (One paragraph)

a. Source 1

b. Source 2

4. According to Parts 7 1 and 2 (Five paragraphs)

a.What questions do you have now that you did not have before? 

b. What might you want to research next? 

c. What do you understand (overall) about your research question and its potential answers? 

d. What aspect of the topic are you most interested in? 

e. Explain why your research question, is a question within your general topic. 

f. What ideas do you have for this narrowed focus? 

g. If you were going to explain this topic to someone,

   i. What are the parts you would be less confident explaining? 

Part 8:  Writing and rhetoric

Check file 8

Audience: Your instructor and classmates
Genre: Blog
Skills learned/practiced: source selection, rhetorical analysis, summary, synthesis

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

Four paragraphs per page
 

1. Rhetorical summary  Sources 1 (Check Part 8-1) (One paragraph)

a. Introduce the source concisely 
b. Describe their rhetorical situation
i. Genre
ii. Audience
iii. Purpose

2. Rhetorical summary  Sources 2 (Check Part 8-2) (One paragraph)

a. Introduce the source concisely 
b. Describe their rhetorical situation
i. Genre
ii. Audience
iii. Purpose
3. Include a brief summary for each source that highlights the most important things you learned about your topic from that source.  (One paragraph)
a. Source 1
b. Source 2

4. According to Parts 8 1 and 2 (Five paragraphs)

a.What questions do you have now that you did not have before? 
b. What might you want to research next? 
c. What do you understand (overall) about your research question and its potential answers? 
d. What aspect of the topic are you most interested in? 
e. Explain why your research question, is a question within your general topic. 
f. What ideas do you have for this narrowed focus? 
g. If you were going to explain this topic to someone,
   i. What are the parts you would be less confident explaining? 

 Parts 9 and 10  have the same questions. However, you must answer with references and different writing, always addressing them objectively, as if you were different students. Similar responses in wording or references will not be accepted. 

Part 9: Recreational Therapy

According to the link

https://fiu.instructure.com/media_objects_iframe/m-51sd8TgM4wG2PV4Mq2DJQERt4VeEKcZt?type=video?type=video

1. Guest speaker’s background (One paragraph)

a. Description of the agency they work at

2. What populations are served (One paragraph)

a. Types of activities that are offered

b. General job responsibilities

3. Summary of what was mentioned about the APIED process (Assessment, Planning, Implementation, Evaluation and Documentation)

(Two paragraphs)

a. How this is implemented at their workplace

4. Explain recreational therapy services offered at these different locations.(One paragraph)

a. RT at Highlands Behavioral Health System (Emotional, Psychiatric and Addictive Behavioral Health Challenges)

b. RT at Henry Ford Maplegrove (Addiction Treatment Center)

c. RT at Recovery Ways (Substance Use Rehabilitation)

5. Reflection (One paragraph)

a.Takeaways and interesting things you learned

b. Discussion of personal fit for this setting based on personal attributes, interests, skills and career goals

Part 10: Recreational Therapy

According to the link

https://fiu.instructure.com/media_objects_iframe/m-51NRhgsnFtS6xSjto5FVRdK1g9xqRGmD?type=video?type=video

1. Guest speaker’s background  (One paragraph) 

a. Description of the agency they work at

2. What populations are served  (One paragraph) 

a. Types of activities that are offered
b. General job responsibilities
3. Summary of what was mentioned about the APIED process (Assessment, Planning, Implementation, Evaluation and Documentation)
a. How this is implemented at their workplace

4. Explain recreational therapy services offered at these different locations. (One paragraph) 

a. RT at the VAMC in O’Hara Township, PA

b. RT at Riverworks (Veterans Administration)

c. RT at the National Veterans Wheelchair Games

5. Reflection  (One paragraph) 

a.Takeaways and interesting things you learned
b. Discussion of personal fit for this setting based on personal attributes, interests, skills and career goals

 Parts 11 and 12  have the same questions. However, you must answer with references and different writing, always addressing them objectively, as if you were different students. Similar responses in wording or references will not be accepted. 

Part 11: Inclusive Recreation Services

Movie: THE SAVAGES

Directed by: Tamara Jenkins

United States, 2007

1. Summary about/plot of the movie. 

a. What was the disability of the main character(s)?

2. In Part 11 and 12 file,  there are seven ways in how an environment can facilitate self-determination for people with disabilities. According to the movie

a. Briefly describe how self-determination was fostered (or not fostered) for the individual(s) with the disability in each of these seven ways.

3. According to Part 11 and 2 B file, 

a. Describe how the people with and without disabilities in your movie experienced (or did not experience) these benefits. 

4. Discuss three of the benefits for the individual(s) with disabilities 

5. Discuss three benefits for the individual(s) without disabilities.

Part 12: Inclusive Recreation Services

Movie: A IS FOR AUTISM

Directed by:

Tim Webb

United Kingdom, 1992 

1. Summary about/plot of the movie. 
a. What was the disability of the main character(s)?
2. In Part 11 and 12 file,  there are seven ways in how an environment can facilitate self-determination for people with disabilities. According to the movie
a. Briefly describe how self-determination was fostered (or not fostered) for the individual(s) with the disability in each of these seven ways.
3. According to Part 11 and 2 B file, 
a. Describe how the people with and without disabilities in your movie experienced (or did not experience) these benefits. 
4. Discuss three of the benefits for the individual(s) with disabilities 
5. Discuss three benefits for the individual(s) without disabilities.

Parts 13 and 14  have the same questions. However, you must answer with references and different writing, always addressing them objectively, as if you were different students. Similar responses in wording or references will not be accepted. 

Part 13: Inclusive Recreation Services

Topic: Global Awareness Outcome

Country: Canada

Purpose: A student group has to show how the Country (selected) addresses the influence s on accessibility for individuals with disabilities in communities

Role 1 (Selected): An individual with a disability who is visiting this country for vacation.

Focused questions:

Question 1: Are race, religion, national or ethnic origin, colour, sex, age or physical or mental disability, factors to be access to rights in this country?

Question 2: There is in Canada Act, Charter, or legislation that advocate for the right´s people with disability?

Question 3: In Canada, what are the most important barriers for people with disabilities?

Question 4: Is Canada wheelchair accessible and friendly?

Question 5: What are some strategies in Canada for facilitating the mobilization of people with visual disabilities?

Question 6: How does Canada deal with disability?

Question 7: How do I register as disabled in Canada?

Question 8: How long can you be on disability in Canada?

Role 2: A leader in the selected country who is trying to increase tourism.

Role 3: A professor taking her students to this foreign country for a study abroad focused on the recreation and leisure resources provided for individuals with disabilities in that country.

1. Explain your selected role and the questions you focused on (Role 1). (One paragraph)

2. Did anything surprise you in your role?(One paragraph)

2. Did anything surprise you in your role? ou got  into the research? (One paragraph)

4. How did you feel about your chosen role? (One paragraph)

5. How did your group work together to lack their of? (One paragraph)

6. Conclusion (One paragraph)

Part 14: Inclusive Recreation Services

Topic: Global Awareness Outcome
Country: Canada
Purpose: A student group has to show how the Country (selected) addresses the influence s on accessibility for individuals with disabilities in communities

Role 1: An individual with a disability who is visiting this country for vacation.

Role 2 (Selected): A leader in the selected country who is trying to increase tourism.

Question 1: What type of tourists with disabilities are the main ones to travel to Canada?

Question 2: For tourists with disabilities, what characteristics do you expect to find in Canada?

Question 3: Is there a preferred travel agency in Canada for tourists with disabilities?

Question 4: What time of year do tourists with disabilities prefer to travel to Canada?

Question 5: What accessibility features do tourists with disabilities consider most important?

Question 6: What do tourists with disabilities think of Canada’s Physical or Architectural Barriers?

Question 7: Which communities are more friendly for tourists with disabilities?

Question 8: Is public transport services for tourists with disabilities effective?

Role 3: A professor taking her students to this foreign country for a study abroad focused on the recreation and leisure resources provided for individuals with disabilities in that country.

1. Explain your selected role and the questions you focused on (Role 2). (One paragraph)

2. Did anything surprise you in your role?(One paragraph)

3. Did you have to change questions once you got into the research?(One paragraph)

4. How did you feel about your chosen role?(One paragraph)

5. How did your group work together to lack their of?(One paragraph)

6. Conclusion(One paragraph)

Part 15: Psychopharmacology

Mood Stabilizing Agents

Case Discussion on Bipolar Disorder:

Wendy is a 30-year-old, unemployed white female. She is no stranger to therapy, having seen counselors for most of her teen and adult years. Her friends would describe her as a “wild woman” who takes no crap from anyone. She has held various part-time jobs for the last few years because she usually gets angry at her boss or coworkers and quits. While she has had a string of boyfriends over the years, she has been seeing one man for the last year or so. He too is unemployed and has both an alcohol and methamphetamine problem. She describes the relationship as “addictive and dysfunctional, yet exciting and hot.” Wendy is back in treatment at the urging of her parents, who describe her behavior as erratic and unpredictable. They also claim that she has periods where she “sleeps little and parties lots.” There were also several occasions in the last five years when she was so depressed she didn’t eat or want to leave the house. Her father also admits to periods of depression, and Trisha’s grandfather was diagnosed with manic depression, resulting in numerous hospitalizations in the 1950s and 1960s. Wendy’s only brother died in a car accident several years ago. He was drunk at the time, but she claims he had a long history of depression. Recently Trisha was arrested for disorderly conduct at a friend’s party. She had not slept for nearly 24 hours and was drunk and combative. When she was first approached by police, she solicited them for sex. They report that she was rather hyperverbal and hyperactive. They later had to investigate a complaint from local storeowners for bad checks she wrote in excess of $7,000.

1. Which diagnosis should be considered (One paragraph)

a. What is your rationale for the diagnosis

2. Explain three differential diagnosis should be considered (One paragraph)

a. Explain

3. What t3st or screening tools should be considered to help identify the correct diagnosis (One paragraph)

a. Explain

4. Treatment (Two paragraphs)

a. Psychopharmacology

b. Diagnostics t3sts

c. Referrals

d. Psychotherapy

e. Psychoeducation)

5. Explain two standard guidelines would you use to assess or treat this patient (One paragraph)

1

Research Blog #1: Finding and Understanding Your Sources

Research question

Could legally recognizing female sex work in Florida reduce the incidence of sexual diseases in this population due to free access to the health system?

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

Bias questions

Can the quality of life of female sex workers be improved by allowing free access to the health system?

Could legalizing female sex work improve the quality of life of this population?

Could sexually transmitted diseases be preventable in sex workers if they have access to sex education?

Would the legalization of female sex work offer health resources for STD evaluation?

Rhetorical summary


Source 1

Link:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6424363/

Author (s): Sawicki et al

Year: 2019

Tittle: Culturally Competent Health Care for Sex Workers: An Examination of Myths That Stigmatize Sex-Work and Hinder Access to Care.

In the first source, Sawicki et al. (2019) sought to examine the myths that prevent sex workers from access healthcare due to stigmatization. The authors highlight the issues surrounding the provision of quality care for sex workers. The genre of the article is academic research. The audience is targeted at researchers, practitioners, and policymakers. The purpose of the article is to examine the myths that lead to the stigmatization of sex work preventing sex workers from accessing care and to advocate for culturally competent health care for this population (Sawicki et al., 2019).


Source 2

Link:

https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002680

Author (s): Platt et al

Year: 2018

Tittle: Associations between sex work laws and sex workers’ health: A systematic review and meta-analysis of quantitative and qualitative studies.

In the second source, Platt et al. (2018) comprehensively reviewed the existing literature on the association between sex work laws and sex workers’ health. The genre of the source is academic research. The audience for this source is primarily medical professionals, researchers, and policymakers. The purpose of the article is to present a comprehensive overview of the existing literature on the subject and to inform policy decisions that impact the health of sex workers.

Sources Summary

The first source argues that the stigma against sex work prevents sex workers to access to health care services. In some ways, it advocates for sex workers to access culturally competent care, which is in line with what has been learned on the topic. Equal rights for sex workers are important as they are humans and should receive care services just like any other person (Welch, 2021). In the second source, the authors conducted a meta-analysis and systematic review of existing research on the relationship between sex work laws and sex workers’ health. The authors found that laws governing sex work have a significant impact on determining sex workers’ 25health outcomes. Criminalization of sex work is associated with a greater risk of violent attacks and negative health outcomes (Argento et al., 2020).


Research questions: source 1

The questions to be answered are: What are the current benefits available to sex workers as professionals? How does stigmatization affect the lives of sex workers? What are some potential barriers or challenges to treating sex workers? What resources can be used to support sex workers? This source answers the questions fairly because it addresses the impact of the stigma surrounding sex work on the access to healthcare services for sex workers (West et al., 2021). Additionally, it gives recommendations for the promotion of culturally competent care for all.

This source is useful for answering the research question because it provides insight into the importance of according sex workers’ competent healthcare services. The source focuses on the issue of stigma and how it affects health services provision for sex workers and what can be done to provide quality and fair treatment for sex workers (Sawicki et al., 2019). Legalization of sex work can lead to improved health outcomes and access to healthcare services.

This source does not discuss sex workers in Florida, and neither does it discuss sexual health in terms of diseases. The new and surprising information that came up in this source is the extent to which sex work should be understood and not just prostitutes (Sawicki et al., 2019). Additionally, it highlights that even economic and political factors in the use have contributed to the challenges that sex workers face.


Research questions: source 2

The authors found that decriminalization or legalization of sex work is associated with improved access to healthcare services and reduced risks of sexually transmitted infections (Platt et al., 2018). This source provides evidence that recognizing female sex work in Florida would allow women in this industry to access the health system and improve their sexual health. (b) The authors found that the criminalizing sex work exposes sex workers to increases the risk of violent attacks and poor health outcomes.

This source is particularly useful for answering the research questions because it provides a comprehensive review of the existing literature on the subject and draws conclusions based on a review of multiple studies (Platt et al., 2018). The authors have also used a meta-analysis to combine the results of multiple studies, providing a more robust analysis of the data. The focus of this source is the relationship between laws governing sex work and sex workers’ health outcomes. The authors aim to analyze the findings of previous studies on the topic and draw conclusions based on the data they analyzed (Platt et al., 2018).

This source does not discuss the broader social and economic implications of recognizing female sex work in Florida. The authors have focused specifically on the health outcomes of sex workers rather than the broader social and economic implications of sex work recognition (Welch, 2021). One surprising finding from this source was the association between the criminalizing sex work and greater risk of sex workers being violently attacked and negative health outcomes. This highlights the importance of recognizing female sex work in Florida to improve the safety and health of women in this industry.

Topic summary

Based on the research thus far, the lessons taken by the student are that sex workers can highly benefit from having free access to healthcare services and that discrimination affects their profession and themselves in social life (Sawicki et al., 2019). However, the confusing part still is about how recognizing sex work would affect the stigma surrounding this industry and how the safety of sex workers can be guaranteed. The remaining question is on the sexual health of sex workers.

The questions asked now include: what are the potential challenges and drawbacks of recognizing sex work, and how can these be addressed? And what is the status of sex workers in other states? Next, a person would want to compare the status of sex workers in different states, which can help understand the differences in the challenges faced by sex workers across different states (Welch, 2021). This information can be vital in policy implementation.

Overall, the student understands that recognizing female sex work in Florida could have positive impacts on the sexual health of this population (West et al., 2021). However, there are still some potential challenges that need to be addressed. The most interesting aspect of the topic is exploring the potential benefits of recognizing sex work and how it could improve the lives of female workers in this industry.

References

Argento, E., Goldenberg, S., Braschel, M., Machat, S., Strathdee, S. A., & Shannon, K. (2020). The impact of end-demand legislation on sex workers’ access to health and sex worker-led services: A community-based prospective cohort study in Canada. 
PloS One, 
15(4), e0225783.

https://doi.org/10.1371/journal.pone.0225783

Platt, L., Grenfell, P., Meiksin, R., Elmes, J., Sherman, S. G., Sanders, T., … & Crago, A. L. (2018). Associations between sex work laws and sex workers’ health: A systematic review and meta-analysis of quantitative and qualitative studies. 
PLoS Medicine, 
15(12), e1002680.

Sawicki, D. A., Meffert, B. N., Read, K., & Heinz, A. J. (2019). Culturally competent health care for sex workers: an examination of myths that stigmatize sex work and hinder access to care. 
Sexual and Relationship Therapy, 
34(3), 355-371.

Welch, B. M. (2021). Public Health and Sex Work: Using History to Motivate Change. 
Journal of Legal Medicine, 
41(1-2), 95-108.

https://doi.org/10.1080/01947648.2021.1935633

West, B. S., Liz Hilton and Empower Thailand, Montgomery, A. M., & Ebben, A. R. (2021). Reimagining sex work venues: Occupational health, safety, and rights in indoor workplaces. 
Sex Work, Health, and Human Rights: Global Inequities, Challenges, and Opportunities for Action, 207-230.

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How Does the Environment Stimulate Self-Determination?
Self-determination occurs when people take control of their freedom. The
environment encourages self-determination by being responsive and informa-tional, or it discourages self-determination through controlling and unpredict-able responses to behaviors.

Older adults exposed to responsive environments maintain their sense of mastery by adjusting their standards for competence. When we inter-viewed older adults, we found that they continue to identify competence, autonomy, and relatedness as needs they hope to meet. They recognize achievement of these needs to be important outcomes of their leisure.

A responsive and informational environment reacts to a person’s initiatives, pro-vides information about the person’s competence, and encourages further action. It fosters intrinsic motivation and internal causality, resulting in self-determined behavior.

Events involving choice and positive feedback provide information to the person, thereby enhancing self-determination. By creating environments that are option-rich, responsive, and informative, we increase the likelihood of par-ticipants becoming self-determined.

How Is Self-Determination in Leisure Facilitated?

Self-determination involves a lifelong interplay between the individual and
the environment. A supportive, responsive context is important when encour-aging people to become self-determined. Optimal environments offer peo-ple opportunities to express and further develop self-determination. To pro-mote self-determination, we shift from services directed by professionals to services directed by participants. Research supports the connection between self-determination and participation in recreation activities.

Researchers found an increased amount of time spent by adolescents and young adults actively engaged in recreation predicted higher levels of self-determination (McGuire & McDonnell, 2008).
Our challenge is to structure services to encourage self-determined leisure participation. Many strategies facilitate self-determination. An environment that fosters self-determination requires us to do the following:

• Provide opportunities for choice

• Promote communication

• Respond to preferences

• Foster active participation

• Encourage empowerment

• Increase competence

• Advocate goal setting

Provide Opportunities for Choice

Choice refers to the act of selecting one option, ideally a preferred one, from among others that are simultaneously available. The characteristic of choice is common to most discussions of self-determination; however, some families and professionals act in a paternalistic manner and make choices for people rather than allow participants to decide for themselves. As described, paternalism in-volves an approach to relationships in which the desire to help, advise, and even protect may result in neglecting individual choice and personal responsibility. Though the intention to care for others is responsible, disregarding people’s ability to take control of their lives is often disrespectful. Opportunities to ex-press interests and preferences have been prevented by people who incorrect-ly assume that participants such as older adults, people who do not speak the dominant community language, or those who have a disability are incapable of making informed choices.

When people are given choices, they engage in activities more, increase their interest, become more enthusiastic, increase their participation, and reduce challenging behaviors. We encourage participants to make choices within activi-ties when we present multiple and diverse options such as what materials to use, with whom to participate, and when to stop an activity.

We can facilitate opportunities for participants to make choices during the course of an activity by simply following the person’s lead and interests. To en-courage self-determination, we should support initiation of activities by pro-viding participants with opportunities to express preferences, allowing them to make choices regarding their leisure participation, and providing opportunities for them to experience outcomes based on their choices

Freedom of choice is vital to the pursuit of enjoyable, satisfying, and mean-ingful experience. Personal autonomy for people is an essential aspect of inde-pendent functioning and self-reliance. When we encourage people to choose activities, they are more enthusiastic about learning skills needed to participate, more readily apply those skills to other settings, and are more likely to continue to participate in those activities

The ultimate goal of any leisure program is to facilitate self-initiated, inde-pendent use of free time in meaningful, enjoyable, and acceptable recreation ac-tivities. When we provide opportunities for people to make self-determined and responsible choices that reflect their needs to grow, explore, and realize their potential, they are more likely to experience leisure.

Amy’s favorite activity is doing artwork. When she attends art class, she selects paper; she chooses between colors, sizes, and textures. She decides to use watercolors today rather than chalk or markers. After she has her materials, Amy positions her easel where she prefers and begins her cho-sen project while carefully selecting her color scheme.
It is important to maintain a delicate balance between providing opportuni-ties for choice and encouraging socially acceptable leisure behaviors. Sometimes people choose to exhibit behaviors that society has identified as being offensive or detrimental. It is helpful to redirect these people to participate in socially ac-ceptable activities of their choosing that do not bring psychological or physical discomfort to themselves or others.

Helping people determine appropriateness of behaviors is useful. All people must learn that they are rarely completely free to do anything they wish. To ex-perience leisure on an ongoing basis, people must learn to assert their rights and to respect other people they encounter. The appropriateness of behaviors may vary according to the location such as the bedroom versus a public swimming pool, frequency such as asking once versus asking several times, timing such as laughing when someone is making a joke versus when someone is crying, and relationship of people present such as a brother versus a teacher.

Encouraging participants to make choices and take charge of their lives is an important aspect of leisure services. The earlier we present opportunities for choices to people, the more likely they will acquire self-determined behaviors. We can support participants to become more self-determined by inviting them to try new experiences, while continually offering opportunities for them to make choices.

Promote Communication

Effective communication facilitates involvement with others. However, for a variety of reasons, some people take considerable time to formulate a commu-nication turn. At times, when responding to these individuals, we do not provide them with adequate time to respond. This unwillingness to wait for people to take their turn results in us taking control of the conversation and often the en-tire situation.

Because choosing to initiate involvement is critical to the leisure experience, it is helpful if we encourage people to initiate interactions and share conver-sations. Construction of a supportive environment responsive to the commu-nicative attempts is important. A supportive environment is created when we approach the person, attend to the person, and wait at least 10 seconds for that person to initiate interaction. This will encourage leisure involvement and, more important, demonstrate respect for that person.

Because a perception of freedom to choose to participate in meaningful, en-joyable, and satisfying experiences is fundamental to leisure, independent lei-sure participation is stifled when we rely on a directive approach to service de-livery. A directive approach to leisure services occurs when we maintain control and limit choice for participants.

A directive approach to hiking is to have hikers follow the leader and to remain on the blue-marked trail.

When we provide leisure services, it is helpful to take a nondirective ap-proach. A nondirective approach occurs when we encourage participants to pro-vide input freely, resulting in us strongly considering the individual’s prefer-ences and choices. Nondirective instructional strategies help us avoid instilling a sense of dependency within our participants.

A nondirective approach to hiking is to have hikers examine a map and plan a hike that includes taking various color-marked trails. Hikers work with the leader to estimate trip distance and length of time and assess plan feasibility. Once the plan is initiated, at occasional rest periods a dis-cussion is held to determine if the group wants to revise the e group wants to revise the plan

Because much daily communication is not verbally prompted, encourag-ing people to initiate communication is an important goal. As people engage in reciprocal exchanges stimulated by them initiating interactions, their abil-ity to communicate preferences, make meaningful choices, and experience lei-sure is enhanced. When communication is reciprocal, the interaction is mutual; the conversation is shared relatively equally between two people. Reciprocal communication happens when comments and thoughts of both parties are ex-pressed, listened to, and respected.

Simply providing people who have limited communication skills with an al-ternative form of communication is not sufficient. It is valuable to respond to their conversational attempts. We must be as responsive as possible to commu-nicative attempts made by all people.

If people do not initiate communication, they are still supported. Their initiations are supported when we complete actions such as providing them with objects they request, returning greetings to them, and extending and ex-panding their comments. When people do not initiate interactions, we can ask open-ended questions beginning with what and how as opposed to questions forcing them into a yes/no response.

Respond to Preferences

The most common way to determine someone’s preferences is to ask. How-ever, some individuals do not have verbal skills to communicate, and others feel pressured to identify certain preferences that correspond with expectations of privileged individuals. Consequently, it is helpful to observe people when they are presented with choices to determine if there is pattern in their selections. Preference refers to a desire for an option following a comparison of that op-tion against a continuum of other options. The distinction between choice and preference is subtle but important.

Arbitrarily providing an option that is preferred by someone removes the chance for that person to experience the joy of making the choice, such as taking Alonzo to his favorite playground without asking him to choose a playground. Conversely, helping someone to choose among options that are not preferred is problematic, such as offering Tonia the chance to choose between tap, ballet, and jazz dance classes even though Tonia does not enjoy dance and would prefer to choose among playing sports such as soccer, basketball, or field hockey.

When providing leisure services, it is valuable to determine a person’s pref-erences and create supporting opportunities for the person to choose among preferred options. Each day presents many opportunities to express preferences and make choices about leisure. These choices include not only what to do, but also where, when, and with whom to perform the activity. To respond to the needs of diverse participants, we can assess their preferences and develop strate-gies for determining preferred activities.

Foster Active Participation

People who have been oppressed are often excluded from recreation activi-ties, at times because of their assumed inability to participate independently. However, a person deemed unable to engage in an activity independently should not be denied a chance for partial participation.

Partial participation involves the use of adaptations and assistance to facili-tate leisure participation regardless of skill level. This approach affirms the right of people to participate in environments and activities without regard to degree of assistance required.

Through partial participation, individuals may experience the exhilaration and satisfaction associated with the challenge inherent in a particular recreation activity. The following is an example of partial participation:

Miguel and his friends entered a softball league. At the start of the season, a few rules were adjusted to facilitate Miguel’s league play because he uses a walker. Instead of the ball being pitched to him, he hit it off a tee. After he hit the ball, a teammate, Nicole, ran the bases. When Nicole touched home plate, the team congratulated Miguel and Nicole.

The principle of partial participation ensures that even those people who might never be able to acquire a large-enough complement of skills to completely par-ticipate in recreation activities independently could still learn enough to par-ticipate to some degree. However, challenges arise when we attempt to promote partial participation.

First, we might narrowly define participation as simply presence. When pas-sive participation such as keeping score on the sidelines is the dominant form of participation, this is problematic. It is helpful to encourage active participation by all participants regardless of skill level.

Second, sometimes we fail to consider the person’s preferences, his or her long-term learning needs, family priorities, reactions of peers, and other socially validated, community-referenced guidelines. It is important to solicit this infor-mation from participants and their families.

Third, we may interpret “doing things independently” as doing them alone, which results in too narrow a prescription for performance. The supportive presence of another person offers a way to enhance a person’s participation. This supportive person performs those parts of the activity that a participant deter-mines to be burdensome, overly time consuming, stressful, or exhausting.

Encourage Empowerment Empowerment

is the transfer of power and control over the values, deci-sions, choices, and directions of services from external entities such as service providers to consumers of services. This results in increased motivation to par-ticipate and enhances feelings of dignity. Unfortunately, we do not always allow people and their families the right to make decisions and therefore fail to em-power them.

People who experience communication barriers such as recent immi-grants who do not effectively know the dominant language or those with cognitive, physical, communicative, or sensory impairments encounter challenges in expressing preferences and being understood by others.

For many people who have been oppressed, opportunities for learning and practicing decision making and self-direction are limited. Reasons that these individuals experience such powerlessness and lack of self-direction have less to do with their lack of ability than with attitudes and practices of service providers, funding agencies, and social institutions.

Every person has the right to be empowered by communicating with others, expressing everyday preferences, and exercising some control over life. We need to give each individual the choice, education, technology, respect, and encour-agement to do so. It is valuable if we create empowering environments in which people and their families are given information to make choices and chances to exercise their choices.

Learning to make good choices requires experience with the process of decision making, which involves choosing among viable alternatives and deal-ing with consequences of decisions. When independent choice making is not feasible or safe, we can adapt or support choice making, and individuals can partially participate in decision-making processes. Development of autonomy, the importance of choice making, opportunities for self-initiation, and environ-mental manipulation all facilitate learning, enjoyment, and empowerment.

Making timely and correct decisions leads to a sense of personal effective-ness and interest that promotes investment of attention and enjoyment. People who do not possess the decision-making skills needed for activity involvement are more likely to acquire these skills if they participate in recreation activities and are given considerable autonomy to do so.

We should encourage participants to evaluate their decisions, determine the effects of their decisions, and decide whether they would act in a similar way in a similar circumstance. Teaching people to locate facilities, learn about participa-tion requirements, and obtain answers to questions stimulates decisions about leisure and empowers them. To empower participants to be self-determined, we should give them as many opportunities as possible to practice making manage-able decisions.

Increase Competence

Perceived competence refers to people’s evaluation of their own ability to achieve tasks when compared to others of the same age and gender. Perceived competence is an important feature of leisure because it results in feelings of personal control.

Psychological comfort is perceived when people compare their perfor-mance to standards adopted internally and feel satisfied with their performance. This comfort is important because it allows the option that people use a crite-rion other than social comparison to judge their competence.

People who perceive they are competent in many available activities are in
a better situation to experience leisure than those who do not. Participation in activities in which people perceive themselves as competent throughout their lives is important for us to consider when planning services

A
leisure repertoire includes the breadth of activities that people do for en-joyment and fun. Expanding a person’s leisure repertoire tends to increase a sense of competence. Activities that people do frequently for their leisure they do well, and what they do well in their leisure they do often. Though expanding a person’s leisure repertoire is often valuable, it is helpful to consider some people prefer frequently engaging in a few meaningful and enjoyable recreation activi-ties. So rather than focusing solely on expanding people’s leisure repertoire, we can help people have meaningful choices to engage in preferred pursuits.

Advocate Goal Setting

Self-determination includes attitudes and abilities that lead people to define goals and to take the initiative to achieve those goals. Activities with clear goals are more likely to lead to participant enjoyment. In many activities, the goals are implicit, and therefore goal setting is not important.

For a person to complete a painting, the main concern is to develop skills that result in recognizing an aesthetically pleasing finished product.

One of our roles as service providers is to encourage participants to set goals
when they are not apparent and work toward achieving them. Participants usu-ally problem solve when an environment fosters interdependence. It is impor-tant that these goals are challenging and individualized so that they are relevant to the person who works to achieve them. Different people may have different goals associated with the same activity.

Elena and Bassem chose to build a birdhouse. Elena’s primary goal is to challenge herself to make the birdhouse more quickly than the last time she made one. In contrast, Bassem’s primary goal is to make it as attrac-tive as possible.

There are many strategies to use when facilitating self determination as seen
in Figure 12.4. Leisure contexts are ideal for implementing these strategies.

Final Thoughts

Self-determination is necessary for the optimal experience of enjoyment. It
makes effort and investment of attention worthwhile for a person. This experi-ence of enjoyment serves in turn to develop competence, thereby reinforcing self-determination.
All people need to have opportunities to take charge of their own lives. Their
experiences are organized by principles that promote self-determination. If people are supported to make choices, participate in decisions, set goals, and experi-ence control in their lives, they become more self-determined. As people become more self-determined, they are more likely to assume greater control, make more c

What Are Benefits of Social Inclusion for Participants?

Inclusive leisure participation prepares all people for life in a diverse society
and prepares society to accept individual diversity. Inclusion has many benefits, and greater social acceptance by peers and social inclusion in the community are among the most important. Benefits of inclusion include accepted social behav-iors, increased interactions with others, positive feelings, increased friendships, and improved communication.

When discussing benefits of inclusion, people often focus on benefits experi-enced by people who have been oppressed, such as those who are not members of the dominant race or religion. Benefits to these individuals are numerous, yet benefits to people who are privileged are also plentiful.

Learning to live and play with people who are different is a critical part of a
person’s development. Inclusive communities provide people with a chance to learn from each other; grow to care for one another; and gain the attitudes, skills, and values necessary for advancing society.

When we include all people in community programs, those who have been
oppressed enjoy life in their community, practitioners improve their profes-sional skills, and overall society operates according to the social value of equity for all people. The following are benefits of inclusion:

• Cultivate friendships

• Acquire social skills

• Develop lifelong skills

• Enhance image

• Improve academic performance

• Improve attitudes

• Increase understanding

• Develop acceptance

Cultivate Friendships

People develop friendships when they participate in inclusive community
leisure programs. Friendship is a social relationship between two people that is reciprocal, rewarding, and enjoyable for both parties and characterized by mul-tiple, voluntary contacts and shared experiences across time.

Friendships are reciprocal because the relationship is mutual and thus pro-vides opportunities to give and receive. People become friends with someone voluntarily; they freely choose who they consider to be their friend. When people are with a friend, they typically enjoy that person’s company; they take pleasure in being with that person. Another characteristic of a friend is that the person shares similar interests. Similar interests create opportunities to bond with that person and engage in conversations and joint participation.

Research supports the conclusion that quality friendships are associated with positive attitudes and reduce the chance of a person being victimized by peers. Often participants develop friendships that emerge out of shared interests iden-tified during inclusive leisure experiences.

Because Eryn made friends while participating in a community recre-ation program, she was invited to birthday parties, received telephone calls from friends, and had friends visit her house to play.

When parents are asked about what they want for their children, often they indicate that they want their child to have friends.

Linda talked about her dreams for her daughter: “Our goals for Katie in-clude wanting her to feel loved. She is a very social child and while I think she has a great capacity to make friends, I wonder how other children will accept her” (U.S. Department of Health and Human Services Administra-tion for Children and Families, 1994, p. 2).

Recreation activities that permit interaction with a person’s peers provide opportunities for shared interests, a sense of accomplishment, feelings of be-longing, formation of a personal identity, and mastery over the environment. Inclusive leisure services help to reduce barriers and create a forum for emerg-ing relationships and making of friends.

Friends usually help us to be better people, because we tend to behave better when we know our friends are watching. An effective way to develop or strength-en existing friendships is to provide individuals with the opportunity to engage in fun yet challenging activities together. Friendship are inspired in times of dif-ficulty and enjoyment.

Acquire Social Skills

People are more likely to develop the social skills needed to develop rela-tionships when participating in inclusive leisure opportunities. Having friends is important to the quality of every person’s life, and people learn best when learn-ing what their friends are learning. Inclusive environments give people a chance to learn to get along with others, interact, seek and lend assistance, understand when assistance is needed, make sense of changing contexts, ask questions, com-municate with others, and behave appropriately.

People who are disenfranchised have a tendency not to learn social skills associated with the mainstream of society. As discussed, people who are disen-franchised have been deprived of certain privileges or rights and are congre-gated in a particular area. When people enjoy leisure in inclusive environments, they tend to interact with one another and develop relationships with their peers.

Researchers have identified that children interact more often with oth-er children and exhibit more socially advanced skills in inclusive set-tings (Dreimanus et al., 1992). Inclusive playgroups facilitate peer in-teraction, whereas segregated ones constrain peer interaction and promote adult–child interaction (Guralnick & Groom, 1988). Social interactions increase during inclusive programs associated with art (Schleien, Ray, Soderman-Olson, & McMahon, 1987).

Researchers consistently find that people’s feelings of self-worth, communica-tion and interaction abilities, leadership skills, and tolerance of diversity are en-hanced when they participate in inclusive environments.

Develop Lifelong Skills

The presence of inclusive options promotes development of lifelong func-tional recreation skills. People learn interdependent behaviors such as asking for assistance by experiencing challenges that are part of inclusive community life. As discussed, behaviors are interdependent when they require people to rely on one another and when there is mutual support for each person’s efforts.

Participants of all abilities feel enjoyment when we, as professionals, value each person’s contribution. A variety of lifelong recreation activity skills are de-veloped in inclusive situations.

Martial arts including tae kwon do, karate, and judo are engaged in across the life span. Forms of inclusive creative arts such as playing a musical in-strument in a band or being a member of a community theater group are enjoyed throughout life. Lifelong recreation activities promoting social engagement and fitness include golf and tennis.

Enhance Image

Placement of people in a segregated context results in people being viewed
negatively. Conversely, when people are included, their image is enhanced be-cause they become part of a community that is representative of a society.

Researchers examined attitudes of college students toward a woman in either Special Olympics for people with developmental disabilities or in recreation activities in an inclusive setting. The woman was regarded as younger and needing more assistance in the Special Olympics than in typical recreation activities. This study supports the belief that the image of a person is more positive when the person is in an inclusive context as opposed to a segregated one (Storey, Stern, & Parker, 1991).

Improve Academic Performance

Many individuals who are involved in inclusive programs do better academi-cally and socially than do individuals in segregated environments.

Researchers concluded that children in inclusive settings did better than they did in previous years when they were in segregated programs. Par-ents stated that inclusion resulted in removing barriers to learning includ-ing increased vocabulary, use of coping strategies, being less dependent, being more interactive, and reducing inappropriate behaviors (Ryndak, Downing, Jacqueline, & Morrison, 1995).

In summary, people accrue many benefits from participating in inclusive leisure services. The most prominent benefits associated with inclusion relate to participants’ abilities to engage in social interactions with their peers and de-velop meaningful friendships.

Improve Attitudes

People often positively alter their attitudes about diverse individuals as a re-sult of joint participation in selected activities.

Research supports the practice of carefully planning inclusive programs, because this often results in positive outcomes. After children participat-ed in inclusive arts, their attitudes toward their peers improved (Schleien et al., 1987).

If joint participation results in people having positve attitudes toward oth-ers who differ from them in some manner, then they will likely participate in activities with these people again. These people bring a positive attitude to the activity, resulting in them confidently influencing others’ attitudes, thus creating a cycle of positive attitudes.

Increase Understanding

For people of all abilities, enjoyment of recreation opportunities occurs when others value their contribution. Exposure to inclusive leisure services results in a greater understanding and acceptance of individuals with varying backgrounds and ability levels. This exposure creates the potential for inclusion to have a pos-itive effect on social development of all individuals.

When involved in inclusive programs, people become more accepting of dif-ferences and begin to appreciate the capacities of all participants. The following quote from the Georgia Advocacy Office over 25 years ago illustrates the benefits people receive when participating in inclusive programs:

Our world includes an array of people who, we believe, are more alike than different. What children learn from each other about difference and acceptance is equally as important as the technical education that they receive. We all need to learn how to live and work together. Students develop more fully when they welcome people with different gifts and abilities into their lives and when all feel secure that they will receive in-dividualized help when they need it.

Develop Acceptance

We take an active role in reducing social stigmas by emphasizing similarities rather than differences. Such a reduction in stigmatization increases acceptance.

After conducting multiple interviews with youth, researchers found that youth reported positive results when the leisure context emphasized similarities in participant abilities (Devine & Wilhite, 2000).

Long-term interactions between different groups of people facilitate devel-opment of skills, attitudes, and values that prepare these groups to share, par-ticipate, and contribute to their communities. As a result of participation in inclusive leisure services, people learn new ways to solve problems and adapt to difference, develop positive attitudes toward people who are different from them, and increase acceptance of people in general.

Surveying almost 1,500 high school students, researchers found that youth educated in inclusive settings expect and recommend inclusion. However, if they attend schools providing limited inclusion, they expect and recommend segregation; youth with inclusive experiences are better prepared for adulthood when they meet diverse people in their commu-nity (Fisher, Pupian, & Sax, 1998).

As a result of participating in inclusive leisure opportunities, many people report that they experience personal growth and increased social sensitivity, including improved capacity for compassion, kindness, and respect for others. Others report that they develop the skills and attitudes needed to live harmoni-ously in communities that include diverse members.

Research demonstrates that children in inclusive situations achieve at levels equal to or above peers in noninclusive situations. Inclusive expe-riences promote improved response to other’s needs, tolerance of oth-ers, personal values, appreciation of human diversity, and status (Kliewer, 1998).

In summary, benefits of an inclusive leisure opportunity extend beyond lei-sure service providers and participants who have been disenfranchised. All peo-ple benefit from inclusion. Figure 10.1 provides a summary of the many benefits associated with inclusion and making positive contact with diverse people

image1

EDITORIAL

School Shootings and the Need for More
School-Based Mental Health Services

Martell L. Teasley

The uptick in school shootings has gener-
ated much debate in our society over
methods to reduce this growing and tragic

problem. The increase in school shootings is real.
“Specifically, school shootings increased from 23
to 179 between the 1980s and 1990s and also
increased from 179 to 245 between the 1990’s and
2013” (Paolini, 2015, p. 4; data from Lee, 2013).
High-profile school shootings have generated
a national dialogue resulting in calls for remedy
in the form of more mental health providers
in schools, greater gun control measures, and more
guns in schools to counter potential or active
shooters. Whereas the “guns in schools” debate is
highly controversial, the need for more mental
health services is not.

Research demonstrates a complex web of factors
associated with school shootings, of which mental
health challenges is one variable. “Nationwide,
16.2% of all students; 16.0% of heterosexual students;
18.9% of gay, lesbian, and bisexual students; and
14.7% of not sure students had carried a weapon
(e.g., gun, knife, or club)” to school (Kann et al.,
2016, p. 9). In an overview of research literature on
school shootings, Paolini (2015) determined that
many school shooters were male (99 percent), with a
high percentage having experienced school bullying,
isolation because of not getting along with others,
and noncompliance in the use of psychiatric medica-
tion and problems with the side effects of such medi-
cation. Most school shooters have no previous record
of criminal justice activities, have access to guns at
home, and may have dealt with a recent significant
loss in their lives (Paolini, 2015). Exposure to gun
violence in the media such as violent video games
and films helps to increase youth aggression (Paolini,
2015). According to Paolini’s (2015) review, most at-
tacks are premeditated, with 61 percent of school
shooters carrying out attacks to “get revenge, and

81% of attackers held a grievance against another per-
son at the time of the attack” (p. 3).

A study conducted by the Centers for Disease
Control and Prevention found that nationwide
about 20 percent of all students need mental health
services for a variety of reason. Yet, many do not
receive these services (Kann et al., 2016). “Approxi-
mately half of all lifetime mental health disorders
start by the mid-teens, and the onset of all major
mental illnesses happen as early as 7 to 11 years of
age” (Paolini, 2015, p. 5). The demand for greater
mental health services comes while public school
systems are facing many monetary challenges, as
witnessed by mass school teacher strikes throughout
the country. During the economic downturn of
the Great Recession, cash-strapped school districts
made cuts to what are considered “nonessential”
personnel. For example, the Philadelphia school
district attempted to cut in half its workforce of 110
school social workers. Although the national eco-
nomic outlook has improved in recent years, school
funding continues to face challenges. During early
2018, school teachers in Pueblo witnessed the first
teacher strike in the state of Colorado in 25 years,
and New Jersey teachers engaged in their first strike
in 20 years. With the lowest pay for school teachers
in the nation and state cuts to the school system by
9 percent since 2008, the Oklahoma school board
backed the teacher strike in February 2018. More-
over, demanding greater pay and benefits, the states
of Arizona, Kentucky, and West Virginia all wit-
nessed school teacher strikes in the first six months
of 2018. State legislators avoided strikes in St. Paul,
Minnesota, and in Pittsburgh through legislative
action. When school revenues are cut, the hiring of
related services personnel is considered nonessential.

A major challenge in gaining school-based men-
tal health services is the high ratio of students
to related services personnel. “The recommended

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ratio of school social worker to students by the
National Association of Social Work[ers] is 1:250
general education students or 1:50 at-risk or inten-
sive needs students” ( Johnston, n.d.). Yet, some
states have ratios of one school social worker for
every 1,000 students. The American School Coun-
selor Association (ASCA, n.d.) also recommends a
250:1 ratio of students to school counselors. The
ASCA October 2017 report identified wide dispa-
rities in student-to-school-counselor ratios (Bray,
2017). Among states, rates were found as high as
924 to one and as low as 202 to one. Similarly, the
National Association of School Psychologists (NASP,
2013) recommends a student-to-psychologists ratio
of between 500 and 700 to one; however, the aver-
age rate is approximately 1,000 to one. These less
than optimal ratios for related services to students
create barriers to mental health services and prevent
students with problematic behaviors from getting
access to services in schools. Overburdened service
providers reduce the probability of service avail-
ability and thus efforts aimed at violence preven-
tion in schools. Collaboration to reduce school
violence and identify students who need mental
health services and measures to de-escalate anger
are of extreme importance in a resource-deprived
school system.

Another challenge to school-based mental health
services is our national stigma toward seeking help
frommental health providers. Gulliver, Griffiths, and
Christensen’s (2010) review of quantitative and
qualitative studies (N = 22) on adolescent percep-
tion of barriers and facilitators to help seeking for
mental health problems determined that “young
people perceived stigma and embarrassment, prob-
lems recognizing symptoms (poor mental health
literacy), and a preference for self-reliance as the
most important barriers to help-seeking” (p. 5). In
addition, parents often find it difficult to recognize
that their child is experiencing mental health
problems and are reluctant to enforce medication
compliance.

PREVENTION AND SCHOOL SAFETY
On the prevention side, Paolini’s (2015) research
identified several measures that should be con-
sidered for schools working with youths who
develop negative behaviors and have negative
experiences that can lead to anger, academic prob-
lems, and antisocial peer relationships. Among
these measures are the use of psychosocial groups

to address grief and loss, the need for group bully-
ing intervention, self-esteem and conflict resolu-
tion, and prosocial group work to assist students
with coping skills. NASP recommends a compre-
hensive school safety policy that includes the
following:

• Increased access to mental health services and
supports in schools

• Development of safe and supportive schools
• Implementation of school safety initiatives

that consider both psychological and physical
safety

• Improved screening and threat assessment
procedures to identify and meet the needs of
individuals at risk for causing harm to them-
selves and others

• Establishment of trained school safety and cri-
sis teams

• A national campaign to reduce stigma around
mental illness and to promote mental health
on par with physical health

• Policies that limit exposure to media vio-
lence among children, youths, and vulnera-
ble populations

• Review and revision of current policies and
legislation addressing access to firearms by
those who have the potential to cause harm
to themselves or others.

THE NEED FOR LEGISLATIVE ACTION
Given the dynamics and research findings surround-
ing the increase in school shootings, state legislators
not only need to consider the best alternative to
increasing school safety, but must likewise provide
teachers with the time to focus on their jobs minus
the headache of inadequate school resources and
insufficient supportive services, particularly in the
form of preventive measures. In March 2018 the
state of Florida passed a bill that provides new men-
tal health programs and more police for schools; the
law has provisions to keep guns away from people
with violent behavior and who show signs of mental
illness. At the time of this writing the Charlotte–
Mecklenburg, North Carolina, school board is con-
sidering adding $4.4 million to 2018–2019 school
year budget to hire more school social workers,
counselors, and psychologists, as opposed to more
school police (Glenn, 2018). Similarly, in Spring-
field, Illinois, the state house legislators voted to
hire more school mental health providers over the

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request to hire more police officers to maintain
school safety; the bill has now moved on to the
state senate (Associated Press, 2018).

The country appears to be at a crossroads on the
need to repair and prepare public school systems
for the rest of the 21st century and the ongoing
decline in importance of the American public
education enterprise. The increasing number of school
shootings is a sign of adolescence affected by the
social order and a need to build youth social com-
petences and supportive services. Such a situation
will require attention and resolve based on evi-
dence and not politics. “Schools should be enabled
to hire more school-based mental health profes-
sionals (e.g. school counselors, school psychologists
and school social workers) and funds should be
allocated specifically for hiring these professionals”
(NASP, 2013, p. 2). Although more correlation
studies are needed on the effectiveness of related
services personnel in prevention of school vio-
lence, “model programs using school-based mental
health and student service providers have reduced
school suspensions, reduced referrals to the princi-
pal’s office, reduced the use of weapons, force, and
threats, and increased students’ feelings of safety”
(American Counseling Association, 2013, p. 1). CS

REFERENCES
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American School Counselor Association. (n.d.). Student-to-
school-counselor ratio 2014–2015. Retrieved from
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home/Ratios14-15

Associated Press. (2018, April 27). Illinois House passes plan to
put more social workers in schools.Retrieved from http://
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plan-to-replace-security-guards-with-social-workers-
481098321.html

Bray, B. (2017, October 20). U.S. student-to-school coun-
selor ratio shows slight improvement. Counseling
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2017/10/u-s-student-school-counselor-ratio-shows-
slight-improvement/

Glenn, G. (2018).More mental health workers sought for
increased demand in schools. Retrieved from http://wfae
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increased-demand-schools#stream/0

Gulliver, A., Griffiths, K. M., & Christensen, H. (2010).
Perceived barriers and facilitators to mental health
help-seeking in young people: A systematic review.
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Johnston, R. (n.d.). School social work: A vital link in
schools: A report on school social work services for the

Mankato area public school district [PowerPoint pre-
sentation]. Retrieved from http://sbs.mnsu.edu/
socialwork/graduate/johnston

Kann, L., O’Malley Olsen, E., McManus, T., Harris, W. A.,
Shanklin, S. L., Flint, K. H., et al. (2016, August 12).
Sexual identity, sex of sexual contacts, and health-
related behaviors among students in grades 9–12—
United States and selected sites, 2015.Morbidity and
Mortality Weekly Report, 65(9), 1–202. Retrieved from
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ss6509

Lee, J. H. (2013). School shootings in the U.S. public
schools: Analysis through the eyes of an educator.
Review of Higher Education and Self-Learning, 6, 88–120.

National Association of School Psychologists. (2013, Janu-
ary).NASP recommendations for comprehensive school
safety policies.Retrieved from https://www.nasp
online.org/about-school-psychology/media-room/
press-releases/nasp-calls-for-comprehensive-school-
safety-measures-and-common-sense-gun-violence-
prevention-efforts

Paolini, A. (2015). School shootings and student mental
health: Role of the school counselor in mitigating vio-
lence (Article 90). VISTAS Online.Retrieved from
https://www.counseling.org/docs/default-source/
vistas/school-shootings-and-student-mental-health.p

Martell L. Teasley, PhD, is dean, College of Social Work,
University of Utah, 395 South 1500 East, Salt Lake City,
UT 84112; e-mail: martell.teasley@utah.edu.

Advance Access Publication June 8, 2018

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      School Shootings and the Need for More School-Based Mental Health Services

      Prevention and School Safety

      The Need for Legislative Action

      References

    U.S. Department of Justice

    Federal Bureau of Investigation

    A STUDY OF THE

    PRE-ATTACK BEHAVIORS

    OF ACTIVE SHOOTERS

    IN THE UNITED STATES
    BETWEEN 2000 AND 201

    3

    JUNE 2018

    2

    Authors

    James Silver, Ph.D., J.D., Worcester State University

    Andre Simons, Supervisory Special Agent, Behavioral Analysis Unit, FBI

    Sarah Craun, Ph.D., Behavioral Analysis Unit, FBI

    This publication is in the public domain. Authorization to reproduce this publication in whole or in part is granted.

    The citation should be: Silver, J., Simons, A., & Craun, S. (2018). A Study of the Pre-Attack Behaviors of Active

    Shooters in the United States Between 2000 – 2013. Federal Bureau of Investigation, U.S. Department of Justice,

    Washington, D.C. 20535.

    3

    A Study of the Pre-Attack Behaviors of
    Active Shooters in the United States
    Between 2000 and 20

    13

    Acknowledgments ……………………………………………………………………………………………………….

    4

    Introduction ………………………………………………………………………………………………………………….

    6

    Key

  • Findings
  • ………………………………………………………………………………………………………………….

    7

    Methodology ………………………………………………………………………………………………………………..

    8

    Findings

    Shooter Demographics ………………………………………………………………………………………………………….

    9

    Planning and Preparation ……………………………………………………………………………………………………13

    Firearms Acquisition …………………………………………………………………………………………………………….

    14

    Stressors ………………………………………………………………………………………………………………………………..1

    5

    Mental Health ………………………………………………………………………………………………………………………

    17

    Concerning Behaviors ………………………………………………………………………………………………………….17

    Primary Grievance ………………………………………………………………………………………………………………..

    21

    Targeting ………………………………………………………………………………………………………………………………

    23

    Suicide: Ideation and Attempts ……………………………………………………………………………………………

    24

    Concerning Communications ……………………………………………………………………………………………..24

    Limitations ………………………………………………………………………………………………………………….

    26

  • Conclusion
  • ………………………………………………………………………………………………………………….

    27

    Appendices …………………………………………………………………………………………………………………

    28

    Click on a link above to jump to a page.

    4

    Acknowledgments

    The authors wish to thank the many dedicated members and former members of the FBI’s Behavioral Analysis

    Unit (BAU) who supported this study, including Crime Analyst Kristen Solik, BAU; Unit Chief John Wyman,

    BAU; Unit Chief Kristen Slater, BAU; Unit Chief Kevin Burton, BAU; Unit Chief Shawn VanSlyke, BAU (ret.);

    Research Coordinator Kristen Lybert, BAU; Supervisory Special Agents (SSAs) Karie Gibson and Adrienne Isom,

    BAU; Mr. Bryan Czako; Mr. Davis Moore; and Mr. James Russell. The authors also offer special thanks and

    gratitude to our colleagues in the BAU’s Behavioral Threat Assessment Center (BTAC).

    Further, the authors express their appreciation to Assistant Director Kerry Sleeper, Section Chief Katherine Schweit

    (ret.), Unit Chief James Green, and Supervisory Intelligence Analyst Deborah Cryan of the FBI’s Office of Partner
    Engagement for their past and ongoing support of this project. Special thanks as well to Visual Information

    Specialist Erin Kim of the FBI’s Office of Public Affairs.

    The authors are exceptionally grateful to our many threat assessment colleagues who have partnered with and

    supported the BAU over several years. These professionals quietly and tirelessly work each day to prevent active

    shootings in our schools, universities, houses of worship, and businesses.

    5

    The authors and researchers from the FBI’s Behavioral Analysis Unit involved in preparing this

    report are aware of the horrific impact these shootings have had on victims, survivors, families,
    and communities. We extend our deepest sympathies to those who have suffered the unimaginable

    tragedy of an active shooting, either personally or as a family member. We know that behind

    the statistics and numbers presented here are thousands of individuals with personal stories of

    grief, bravery, and resilience. In partnership with other law enforcement and threat assessment

    professionals, we remain committed to doing everything possible to prevent future attacks. Although

    much work remains, we present this report as a step towards disrupting those who would seek to

    inflict catastrophic harm.

    6

    Introduction

    In 2017 there were 30 separate active shootings in the United States, the largest number ever recorded by the

    FBI during a one-year period.1 With so many attacks occurring, it can become easy to believe that nothing can

    stop an active shooter determined to commit violence. “The offender just snapped” and “There’s no way that

    anyone could have seen this coming” are common reactions that can fuel a collective sense of a “new normal,”

    one punctuated by a sense of hopelessness and helplessness. Faced with so many tragedies, society routinely

    wrestles with a fundamental question: can anything be done to prevent attacks on our loved ones, our children,

    our schools, our churches, concerts, and communities?

    There is cause for hope because there is something that can be done. In the weeks and months before an attack,

    many active shooters engage in behaviors that may signal impending violence. While some of these behaviors

    are intentionally concealed, others are observable and — if recognized and reported — may lead to a disruption

    prior to an attack. Unfortunately, well-meaning bystanders (often friends and family members of the active

    shooter) may struggle to appropriately categorize the observed behavior as malevolent. They may even resist

    taking action to report for fear of erroneously labeling a friend or family member as a potential killer. Once

    reported to law enforcement, those in authority may also struggle to decide how best to assess and intervene,

    particularly if no crime has yet been committed.

    By articulating the concrete, observable pre-attack behaviors of many active shooters, the FBI hopes to make

    these warning signs more visible and easily identifiable. This information is intended to be used not only by law
    enforcement officials, mental health care practitioners, and threat assessment professionals, but also by parents,
    friends, teachers, employers and anyone who suspects that a person is moving towards

    violence.

    In 2014, the FBI published a report titled A Study of Active Shooter Incidents in the United States Between 2000

    and 2013.2 One hundred and sixty active shooter incidents in the United States occurring between 2000 and 2013

    were included in the sample. In this first report, the FBI focused on the circumstances of the active shooting
    events (e.g., location, duration, and resolution) but did not attempt to identify the motive driving the offender,

    nor did it highlight observable pre-attack behaviors demonstrated by the offender. The 2014 report will be

    referred to as the “Phase I” study.

    The present study (“Phase II”) is the natural second phase of that initiative, moving from an examination of

    the parameters of the shooting events to assessing the pre-attack behaviors of the shooters themselves. This

    second phase, then, turns from the vitally important inquiry of “what happened during and after the shooting”

    to the pressing questions of “how do the active shooters behave before the attack?” and, if it can be determined,

    “why did they attack?” The FBI’s objective here was to examine specific behaviors that may precede an attack
    and which might be useful in identifying, assessing, and managing those who may be on a pathway to deadly

    violence.

    1 https://www.fbi.gov/file-repository/active-shooter-incidents-us-2016-2017 /view

    2 https://www.fbi.gov/file-repository/active-shooter-study-2000-2013-1 /view

    7

    Key Findings of the Phase II Study

    1. The 63 active shooters examined in this study did not appear to be uniform in any way such that they

    could be readily identified prior to attacking based on demographics alone.

    2. Active shooters take time to plan and prepare for the attack, with 77% of the subjects spending a week

    or longer planning their attack and 46% spending a week or longer actually preparing (procuring the

    means) for the attack.

    3. A majority of active shooters obtained their firearms legally, with only very small percentages obtaining a
    firearm illegally.

    4. The FBI could only verify that 25% of active shooters in the study had ever been diagnosed with a

    mental illness. Of those diagnosed, only three had been diagnosed with a psychotic disorder.

    5. Active shooters were typically experiencing multiple stressors (an average of 3.6 separate stressors) in the

    year before they attacked.

    6. On average, each active shooter displayed 4 to 5 concerning behaviors over time that were observable to

    others around the shooter. The most frequently occurring concerning behaviors were related to the active

    shooter’s mental health, problematic interpersonal interactions, and leakage of violent intent.

    7. For active shooters under age 18, school peers and teachers were more likely to observe concerning

    behaviors than family members. For active shooters 18 years old and over, spouses/domestic partners were

    the most likely to observe concerning behaviors.

    8. When concerning behavior was observed by others, the most common response was to communicate

    directly to the active shooter (83%) or do nothing (54%). In 41% of the cases the concerning

    behavior was reported to law enforcement. Therefore, just because concerning behavior was recognized

    does not necessarily mean that it was reported to law enforcement.

    9. In those cases where the active shooter’s primary grievance could be identified, the most common
    grievances were related to an adverse interpersonal or employment action against the shooter (49%).

    10. In the majority of cases (64%) at least one of the victims was specifically targeted by the active shooter.

    *All percentages in this report are rounded to the nearest whole number.

    8

    Methodology

    With the goal of carefully reviewing the pre-attack lives and behaviors of the active shooters, the FBI developed a

    unique protocol of 104 variables covering, among other things:

    ■ Demographics

    ■ Planning and preparation

    ■ Acquisition of firearms in relation to the attack

    ■ Stressors

    ■ Grievance formation

    ■ Concerning pre-attack behaviors and communications

    ■ Targeting decisions

    ■ Mental health

    Whereas Phase I analyzed event circumstances that are typically well documented both in law enforcement

    incident reports and reliable open sources3, this second phase is substantially based on observations of what are

    often nuanced behavioral indicators demonstrated by the active shooter prior to the attack. Given the subtle nature

    of many of the factors relevant to the inquiry, the FBI decided to use data that have been verified to the greatest
    possible extent, relying almost exclusively on information contained in official law enforcement investigative files.4
    For this reason, Phase II includes only those cases where the FBI obtained law enforcement investigative files that
    contained “background” materials (e.g., interviews with family members, acquaintances, neighbors; school or

    employment records; writings generated by the subject) adequate to answer the protocol questions.5 In addition,

    as Phase II focused on identifying pre-attack behaviors of those on a trajectory to violence, active shooting events

    which appeared to be spontaneous reactions to situational factors (e.g., fights that escalated) were excluded. This
    resulted in a final sample of 63 active shooting incidents included in the Phase II study.

    The use of law enforcement investigative case files as the primary source of data makes this study unique in
    comparison to other reports that typically rely upon unverified data derived from open sources. The comprehensive
    evaluation of law enforcement case files for suitability and completeness also contributed to the substantial time it
    has taken to prepare and publish this study.

    The FBI examined whether the 63 cases included in Phase II are representative of the entire Phase I sample

    (N = 160). To identify the differences in the samples between Phase I and Phase II (N = 160 versus N = 63), the

    FBI compared those cases that were only in Phase I (n = 97) to those cases included in Phase II (N = 63), assessing

    potential differences between the active shooters (e.g., race, gender, age, and whether the offender committed

    suicide subsequent to the attack), as well as potential differences in the characteristics of the incidents (number of

    victims killed, number of law enforcement officers killed, location of the incident, active shooter movement during
    the event, and if the event concluded prior to the arrival of law enforcement).

    3 Incident overview (e.g., date, location), incident specifics (weapon(s) used, duration of event), and incident outcome (deaths, injuries, resolution).

    4 For one incident, the study relied on publicly available official reports which were based on the complete law enforcement investigative files.

    5 The investigative files did not contain uniform amounts of subject-related behavioral information, as the depth and breadth of investigations varied based on several factors, including available

    resources, the prospect or not of trial, and the complexity of the event.

    9

    As compared to the 97 cases that were only in Phase I, the 63 cases in Phase II had the following characteristics:

    ■ Had a higher number of victims killed on average during each shooting;

    ■ Were more likely to end before law enforcement arrived;

    ■ Were more likely to include offenders who identified with Asian and Caucasian ethnicity, with active shooters
    identified with African American and Hispanic ethnicity generally underrepresented as compared to Phase I;

    ■ Were more likely to occur in an educational facility or a house of worship; and

    ■ Were more likely to end with the active shooter committing suicide.

    After cases were identified, a three-stage coding process was utilized. First, two researchers read all case materials
    and independently coded each of the cases across all protocol variables. The researchers took a conservative

    approach to coding, declining to definitively answer any question that was not supported by record evidence.
    Second, another experienced coder (the “reviewer”) also read each investigative file. In the final stage, the coders
    and the reviewer met for each of the 63 cases, compared answers, discussed disagreements, and produced a single

    reconciled set of data.

    SHOOTER DEMOGRAPHICS
    The sample comprised individuals who varied widely along a range of demographic factors making it impossible to

    create a demographic profile of an active shooter. Indeed, the findings and conclusions of this study should be consid-

    ered in light of the reality that these 63 active shooters did not appear to be uniform in any way such that they could be

    readily identified prior to attacking based on demographics alone.

    Age:

    The youngest active shooter was 12 years old and the oldest was 88 years old with an average age of 37.8 years.

    Grouping the active shooters by age revealed the following:

    10

    Gender and Race:

    The sample was overwhelmingly male (94%, n = 59), with only four females in the data set (6%, n = 4), and varied

    by race as shown in Figure 2:6

    Highest Level of Education7:

    None of the active shooters under the age of 18 had successfully completed high school, and one (age 12) had not

    yet entered high school. When known, the highest level of education of adults varied considerably, as shown in

    Figure 3:

    6 Descriptors of active shooters’ races were obtained from law enforcement records.

    7 Active shooters under the age of 18 (n=8) were excluded in analyses for those variables not typically pertaining to juveniles (e.g., marital status, higher education).

    11

    Employment:

    The active shooters who were under 18 years old were all students. As featured in Figure 4, nearly equal percent-

    ages of the adult active shooters 18 years or older were employed as were unemployed, and 7% (n = 4) were

    primarily students. The rest of the adults were categorized as retired, disabled/receiving benefits, or other/unknown.

    Military:

    Of the active shooters 18 and older, 24% (n = 13) had at least some military experience, with six having served in

    the Army, three in the Marines, two in the Navy, and one each in the Air Force and the Coast Guard.

    Relationship Status:

    The active shooters included in the Phase II study were mostly single at the time of the offense (57%, n = 36).

    Thirteen percent (n = 8) were married, while another 13% were divorced. The remaining 11% were either partnered

    but not married (n = 7) or separated (6%, n = 4).

    Criminal Convictions and Anti-Social Behavior8:

    Nineteen of the active shooters aged 18 and over (35%) had adult convictions prior to the active shooting event.

    As visualized in Figure 5, the convictions can be categorized as crimes against society, property, or persons. The

    category of “crimes against society” included offenses such as driving under the influence, disorderly conduct and
    the possession of drug paraphernalia. Both the misdemeanor and felony “crimes against property” involved non-vi-

    olent offenses, such as conspiracy to commit theft, theft, possession of stolen property, and criminal mischief. The

    misdemeanor “crimes against persons” were not inherently dangerous, but the felony “crimes against persons”

    involved convictions for criminal sexual assault of a family member, aggravated stalking, and endangering a person

    (although no active shooter was convicted of more than one crime against a person).

    8 The study does not include juvenile adjudications; therefore, we did not run the analyses on those aged 17 and younger.

    12

    In sum, the active shooters had a limited history of adult convictions for violent crime and a limited history of adult

    convictions for crime of any kind.

    Because formal criminal proceedings may not capture the full range of anti-social behaviors in a person’s

    background, the FBI also looked for evidence of behaviors that were abusive and/or violent, but which did not

    result in a criminal charge. For some active shooters, no evidence of these behaviors was found, but given that these

    actions by definition did not involve the formal criminal justice system, it is possible that more violent incidents
    occurred than are reported here.

    We found evidence that 62% (n = 39) of the active shooters had a history of acting in an abusive, harassing, or

    oppressive way (e.g., excessive bullying, workplace intimidation); 16% (n = 10) had engaged in intimate partner

    violence; and 11% (n = 7) had engaged in stalking-related conduct.9

    Considerations

    There were very few demographic patterns or trends (aside from gender) that could be identified, reinforcing the
    concept that there is no one “profile” of an active shooter. Perhaps most noteworthy is the absence of a pronounced
    violent criminal history in an overwhelming majority of the adult active shooters. Law enforcement and threat

    management professionals assessing a potentially violent person may therefore wish to avoid any reliance on

    demographic characteristics or on evidence (or lack thereof) of prior criminal behavior in conducting their

    assessments.

    9 This number may be underrepresented given the high percentage of unknown responses as related to stalking behaviors (68%).

    13

    PLANNING AND PREPARATION
    This study examined two related but separate temporal aspects of the active shooters’ pre-attack lives — total

    time spent planning the attack and total time spent preparing for the attack.10,11,12 The purpose in analyzing these

    chronologies was to establish the broad parameters during which active shooters were moving toward the attack

    and to identify behaviors that may have been common during these time periods.

    In this context, planning means the full range of considerations involved in carrying out a shooting attack. This

    includes the decision to engage in violence, selecting specific or random targets, conducting surveillance, and
    addressing all ancillary practical issues such as victim schedules, transportation, and site access. Planning is

    more specific than a general intent to act violently and involves the thought processes necessary to bring about
    an intended outcome. Since planning may primarily be an internal thought process, it was often difficult to find
    objective, observable indications of an active shooter’s planning. In nearly half of the cases, the total time spent

    planning is unknown. However, this is different than declaring that there was no evidence of planning at all,

    because in every case there was at least some evidence that the active shooter planned the attack; the challenge

    was ascertaining when the planning began.

    In establishing the total duration of planning, the FBI looked for evidence of behaviors that were observable (e.g.,

    conversations, conducting surveillance) as well as in materials that were private to the active shooter (e.g., journals,

    computer hard drives) and likely unknowable to others until after the attack. As demonstrated in Figure 6, there was a

    wide range of planning duration in the 34 cases where the time spent planning could reasonably be determined.

    With regard to specific planning activities, care should be taken in the interpretation of the data. For instance, our
    study indicates that few active shooters overall approached or conducted surveillance on their target (14%, n = 9),

    and fewer still researched or studied the target site where the attack occurred (10%, n = 6). While this could indicate

    that the active shooters were uninterested in knowing about their targets or attack sites in advance or engaged in

    little tactical planning, this is inconsistent with the operational experience of the FBI. The likely reason for this

    finding is that the active shooters often attacked people and places with which they were already familiar. There was

    10 Calhoun, T., & Weston, S., (2003). Contemporary threat management. San Diego: Specialized Training Services;

    11 Fein, R. & Vossekuil, B. (1999). Assassination in the United States: an operational study of recent assassins, attackers, and near-lethal approachers. Journal of Forensic Sciences.

    12 Vossekuil, B., Fein, R., Reddy, M., Borum, R., & Modzeleski, W. (2004). The final report and findings of the safe school initiative: Implications for the prevention of school attacks in the United States.

    Washington, DC: U.S. Secret Service and the U.S. Department of Education.

    14

    a known connection between the active shooters and the attack site in the majority of cases (73%, n = 46), often a

    workplace or former workplace for those 18 and older (35%, n = 19), and almost always a school or former school

    for those younger than 18 (88%, n = 7), indicating that in most cases the active shooter was already familiar with

    both the attack site as well as the persons located at the site. Conversely, those active shooters with no affiliation to
    the targeted site behaved differently. Active shooters with no known connection to the site of their attack were more

    likely to conduct surveillance (p < .05) and research the site (p < .01). With routine contact, pre-attack surveillance

    could presumably be conducted concurrent to normalized activity and eliminate the need for a more formalized or

    detectable reconnaissance of a chosen target.

    The investigative files also demonstrated that only some active shooters researched or studied past attacks by others
    (21%, n = 13). This is not to say that other active shooters were unaware of past attacks — it is difficult to imagine
    that they did not have at least some basic knowledge of prior infamous shootings that received national media

    coverage. The FBI again suspects that this behavior may be underrepresented in the study sample, especially as we

    could not determine if active shooters researched past attacks in 46% of the cases.

    Preparing was narrowly defined for this study as actions taken to procure the means for the attack, typically items
    such as a handgun or rifle, ammunition, special clothing and/or body armor. The focus was on activities that could
    have been noticed by others (e.g., a visit to a gun store, the delivery of ammunition) and which were essential to the

    execution of the plan. The FBI was able to find evidence of time spent preparing in more cases than for time spent
    planning (likely reflecting the overt nature of procuring materials as opposed to the presumably largely internal
    thought process of planning). As Figure 7 demonstrates, in more than half of the cases where the time spent prepar-

    ing was known, active shooters spent one week or less preparing for the attack.

    FIREARMS ACQUISITION
    As part of the review of the active shooter’s preparations, the FBI explored investigative records and attempted to

    identify how each active shooter obtained the firearm(s) used during the attack. Most commonly (40%, n = 25), the

    active shooter purchased a firearm or firearms legally and specifically for the purpose of perpetrating the attack. A
    very small percentage purchased firearms illegally (2%, n = 1) or stole the firearm (6%, n = 4). Some (11%, n = 7)

    borrowed or took the firearm from a person known to them. A significant number of active shooters (35%, n = 22)

    already possessed a firearm and did not appear (based on longevity of possession) to have obtained it for the express
    purpose of committing the shooting.

    15

    Considerations

    Active shooters generally take some time to plan and carry out the attack. However, retrospectively determining

    the exact moment when an active shooter decided to engage in violence is a challenging and imprecise process.

    In reviewing indicators of planning and preparing, the FBI notes that most active shooters (who demonstrated

    evidence of these processes in an observable manner) spent days, weeks, and sometimes months getting ready to

    attack. In fact, in those cases where it could be determined, 77% of the active shooters (n = 26) spent a week or

    longer planning their attack, and 46% (n = 21) spent a week or longer preparing. Readers are cautioned that simply

    because some active shooters spent less than 24 hours planning and preparing, this should not suggest that potential

    warning signs or evidence of an escalating grievance did not exist before the initiation of these behaviors. In the

    four cases where active shooters took less than 24 hours to plan and prepare for their attacks, all had at least one

    concerning behavior and three had an identifiable grievance.

    Perhaps unsurprisingly, active shooters tended to attack places already familiar to them, likely as a result of a personal

    grievance which motivated the attack and/or as a result of operational comfort and access. A unique challenge for

    safety, threat assessment, and security professionals will be to identify “outside” active shooters who are not already

    operating within the target environment. Pre-attack site surveillance by an outsider may be one observable behavior in

    physical or online worlds indicative of planning and preparation activities.

    STRESSORS

    Stressors are physical, psychological, or social forces that place real or perceived demands/pressures on an individual

    and which may cause psychological and/or physical distress. Stress is considered to be a well-established correlate of

    criminal behavior.13 For this study, a wide variety of potential stressors were assessed, including financial pressures,
    physical health concerns, interpersonal conflicts with family, friends, and colleagues (work and/or school), mental
    health issues, criminal and civil law issues, and substance abuse.14

    13 Felson, R.B., Osgood, D.W., Horney, J. & Wiernik, C. (2012). Having a bad month: General versus specific effects of stress on crime. Journal of Quantitative Criminology, 28, 347-363 for a

    discussion of various theories describing the relationship between stress and crime.

    14 See Appendix A.

    16

    The FBI recognizes that most (if not all) people in some way confront similar issues on a regular basis in their daily

    lives, and that most possess adequate personal resources, psychological resiliency, and coping skills to successfully

    navigate such challenges without resorting to violence. Therefore, the FBI focused on identifying stressors that

    appeared to have more than a minimal amount of adverse impact on that individual, and which were sufficiently
    significant to have been memorialized, shared, or otherwise noted in some way (e.g., in the active shooter’s own
    writings, in conversation with family or friends, work files, court records). Given the fluid nature of some (although
    not all) of the stressors, the analysis was limited to the year preceding the attack.

    The variables were treated as binary, that is, either the stressor was present or not, without regard for the number of

    separate circumstances giving rise to the stressor. So, an active shooter who had conflict with one family member

    and a shooter who had conflicts with several family members were both coded as “yes” for “conflict with other
    family members.”

    Overall, the data reflects that active shooters were typically experiencing multiple stressors (an average of 3.6
    separate stressors) in the year before they attacked. For example, in the year before his attack, one active shooter

    was facing disciplinary action at school for abuse of a teacher, was himself abused and neglected at home, and had

    significant conflict with his peers. Another active shooter was under six separate stressors, including a recent arrest
    for drunk driving, accumulating significant debt, facing eviction, showing signs of both depression and anxiety, and
    experiencing both the criminal and civil law repercussions of an incident three months before the attack where he

    barricaded himself in a hotel room and the police were called.

    The only stressor that applied to more than half the sample was mental health (62%, n = 39). Other stressors that

    were present in at least 20% of the sample were related to financial strain, employment, conflicts with friends and
    peers, marital problems, drug and alcohol abuse, other, conflict at school, and physical injury.

    TABLE 1: STRESSORS

    Stressors Number %

    Mental health 39 62

    Financial strain 31 49

    Job related 22 35

    Conflicts with friends/peers 18

    29

    Marital problems 17 27

    Abuse of illicit drugs/alcohol 14

    22

    Other (e.g. caregiving responsibilities) 14 22

    Conflict at school 14 22

    Physical injury 13 21

    Conflict with parents 11

    18

    Conflict with other family members 10 16

    Sexual stress/frustration 8 13

    Criminal problems 7 11

    Civil problems 6 10

    Death of friend/relative 4 6

    None 1 2

    17

    MENTAL HEALTH
    There are important and complex considerations regarding mental health, both because it is the most prevalent

    stressor and because of the common but erroneous inclination to assume that anyone who commits an active

    shooting must de facto be mentally ill. First, the stressor “mental health” is not synonymous with a diagnosis of

    mental illness. The stressor “mental health” indicates that the active shooter appeared to be struggling with (most

    commonly) depression, anxiety, paranoia, etc. in their daily life in the year before the attack. There may be complex

    interactions with other stressors that give rise to what may ultimately be transient manifestations of behaviors and

    moods that would not be sufficient to warrant a formal diagnosis of mental illness. In this context, it is exceedingly
    important to highlight that the FBI could only verify that 25% (n = 16) of the active shooters in Phase II were

    known to have been diagnosed by a mental health professional with a mental illness of any kind prior to the

    offense.15 The FBI could not determine if a diagnosis had been given in 37% (n = 23) of cases.

    Of the 16 cases where a diagnosis prior to the incident could be ascertained, 12 active shooters had a mood disor-

    der; four were diagnosed with an anxiety disorder; three were diagnosed with a psychotic disorder; and two were

    diagnosed with a personality disorder. Finally, one active shooter was diagnosed with Autism spectrum disorder;

    one with a developmental disorder; and one was described as “other.” Having a diagnosed mental illness was

    unsurprisingly related to a higher incidence of concurrent mental health stressors among active shooters.

    Considerations

    It is clear that a majority of active shooters experienced multiple stressors in their lives before the attack. While the

    active shooters’ reactions to stressors were not measured by the FBI, what appears to be noteworthy and of impor-

    tance to threat assessment professionals is the active shooters’ ability to navigate conflict and resiliency (or lack
    thereof) in the face of challenges. Given the high prevalence of financial and job-related stressors as well as conflict
    with peers and partners, those in contact with a person of concern at his/her place of employment may have unique

    insights to inform a threat assessment.

    In light of the very high lifetime prevalence of the symptoms of mental illness among the U.S. population, formally

    diagnosed mental illness is not a very specific predictor of violence of any type, let alone targeted violence.16,17,18

    Some studies indicate that nearly half of the U.S. population experiences symptoms of mental illness over their

    lifetime, with population estimates of the lifetime prevalence of diagnosable mental illness among U.S. adults at

    46%, with 9% meeting the criteria for a personality disorder.19,20 Therefore, absent specific evidence, careful consid-

    eration should be given to social and contextual factors that might interact with any mental health issue before

    concluding that an active shooting was “caused” by mental illness. In short, declarations that all active shooters

    must simply be mentally ill are misleading and unhelpful.

    CONCERNING BEHAVIORS

    Concerning behaviors are observable behaviors exhibited by the active shooter. For this study, a wide variety of

    concerning behaviors were considered, including those related to potential symptoms of a mental health disorder,

    interpersonal interactions, quality of the active shooter’s thinking or communication, recklessness, violent media

    usage, changes in hygiene and weight, impulsivity, firearm behavior, and physical aggression.21 Although these may

    be related to stressors in the active shooter’s life, the focus here was not on the internal, subjective experience of

    15 The number of documented, diagnosed mental illness may be the result of a number of factors, including those related to situational factors (access to health care) as well as those related to

    the study factors (access to mental health records).

    16 Elbogen, E.B., & Johnson, S.C. (2009). The intricate link between violence and mental disorder. Arch Gen Psychiatry,66(2),152-161.

    17 Glied, S.A., and Frank, R.G. (2014). Mental illness and violence: Lessons from the evidence. American Journal of Public Health, 104, e5-e6 doi:10.2015/AJPH.2013.301710

    18 Monahan, J., Steadman, H. J., Silver, E., Applebaum, P.S., Clark Robbins, P., Mulvey, E. P., & Banks, S. (2001). Rethinking Risk Assessment: The MacArthur Study of Mental Disorder and Violence.

    Oxford, UK: Oxford University Press

    19 Kessler, R.C., Berglund, P., Demler, O., Jin, R., Merikangas, K.R., Walters, E.E. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey

    Replication. Arch Gen Psychiatry. 2005:62(6): 593-602.

    20 Lenzweger, M.F., Lane, M.C., Loranger, A.W., Kessler, R.C., DSM-IV personality disorders in the National Comorbidity Survey Replication. Biol Psychiatry. 2007;62(6): 553-564.

    21 See Appendix B.

    18

    the active shooter, but rather on what was objectively knowable to others. So, while the assessment of stressors is

    meant to provide insight into the active shooter’s inner turmoil, the examination of concerning behaviors addresses

    a related but separate issue — the possibility of identifying active shooters before they attack by being alert for

    observable, concerning behaviors. The FBI looked for documented confirmation that someone noticed a facet of
    the shooter’s behavior causing the person to feel a “more than minimal” degree of unease about the well-being and

    safety of those around the active shooter.

    Before examining what behaviors were observable by others, it is useful to address the widespread perception

    that active shooters tend to be cut off from those around them. In general, the active shooters in Phase II were not

    completely isolated and had at least some social connection to another person. While most of the active shooters

    age 18 and older were single/never married (51%, n = 28) or separated/divorced (22%, n = 12) at the time of the

    attack, the majority did live with someone else (68%, n = 43). This percentage was slightly less (64%, n = 35) for

    only those active shooters who were 18 years or older. Most had significant in-person social interactions with at
    least one other person in the year before the attack (86%, n = 54), and more than a quarter of them had significant
    online interactions with another person within a year of the attack (27%, n = 17). All active shooters either: a) lived

    with someone, or b) had significant in-person or online social interactions.

    Since the observation of concerning behaviors offers the opportunity for intervention prior to the attack, this

    study examines not only what was observed, but when the observations were made, who made them, and what

    if anything the person(s) did with regard to these observations. To better serve threat assessment teams, mental

    health professionals, community resources, and law enforcement officials, the FBI expanded the inquiry to capture
    behaviors that may have been observed at any point (in many cases beyond one year) before the attack.

    Overall, active shooters showed concerning behaviors in multiple ways, with an average of 4.7 concerning behav-

    iors per active shooter. Behaviors observed in more than half of the sample were related to the shooter’s mental

    health22, interpersonal interactions, leakage (the communication to a third-party of an intent to harm someone,

    discussed with threats in a separate section), and the quality of the active shooter’s thinking or communication.

    Of note was that contextually inappropriate firearms behavior was noted in approximately one fifth of the active
    shooters, while drug and alcohol abuse figured even less prominently in the sample (for the purposes of the study,
    contextually inappropriate firearms behavior was defined as interest in or use of firearms that appeared unusual
    given the active shooter’s background and experience with firearms).

    TABLE 2: CONCERNING BEHAVIORS

    Concerning Behavior Number %

    Mental health 39 62

    Interpersonal interactions 36 57

    Leakage 35 56

    Quality of thinking or communication 34 54

    Work performance* 11 46

    School performance** 5 42

    Threats/confrontations 22 35

    Anger 21 33

    Physical aggression 21 33

    22 Thirty-nine active shooters were experiencing a mental health stressor, and 39 active shooters showed concerning behaviors related to mental health, but the same 39 active shooters did not

    appear in each category; there were five active shooters who had a mental health stressor but who did not show a concerning behavior, and five other active shooters who showed a mental

    health-related concerning behavior but for whom there was no evidence of mental health stress.

    Continues on next page

    19

    Risk-taking 13 21

    Firearm behavior 13 21

    Violent media usage 12 19

    Weight/eating 8 13

    Drug abuse 8 13

    Impulsivity 7 11

    Alcohol abuse 6 10

    Physical health 6 10

    Other (e.g. idolizing criminals) 5 8

    Sexual behavior 4 6

    Quality of sleep 3 5

    Hygiene/appearance 2 3

    * Based on the 24 active shooters who were employed at the time of the offense

    ** Based on the 12 active shooters who were students at the time of the offense

    When Were the Concerning Behaviors Noticed?

    Since the overwhelming majority of active shooters (all but three) displayed at least two concerning behaviors,

    there are a number of different ways to assess the data. One way is to examine the data by active shooter and to

    observe the first instance that any concerning behavior was noticed (this could not be determined for three active
    shooters). Figure 9 shows this data and helps frame the longest time before a shooting during which others were

    concerned about the active shooter’s behavior.

    Again, this chart shows the first instance of any concerning behavior, and it should be kept in mind that this

    behavior might not have been the type that by itself would cause a reasonable person to be alarmed or to report it to

    others. For example, a co-worker who noticed that an active shooter had more than the normal amount of conflict
    with a supervisor might be unlikely to take any action. Perhaps only after an attack and with the benefit of hindsight
    would this singular behavior be considered to be — in and of itself — troubling or concerning. Yet, on average,

    each active shooter displayed four to five concerning behaviors over time. While it may only be the interaction and

    cumulative effect of these behaviors that would cause alarm, early recognition and detection of growing or interre-

    lated problems may help to mitigate the potential for violence.

    20

    In What Way Were the Concerning Behaviors Noticed?

    Concerning behaviors came to the attention to others in a variety of ways, with some far more common than

    others. The most prevalent way in which concerning behaviors were noticed was verbal communication by the

    active shooter (95%, n = 60), followed by observing the physical actions of the active shooter (86%, n = 54),

    written communication (27%, n = 17), and finally instances where concerning behavior was displayed online
    (16%, n = 10). A large majority of active shooters (89%, n = 56) demonstrated concerning behaviors that were

    noticed in multiple ways.

    Who Noticed the Concerning Behaviors?

    At least one person noticed a concerning behavior in every active shooter’s life, and on average, people from

    three different groups noticed concerning behaviors for each active shooter. As shown below, classmates (for

    those who were students), partners (for those in relationships), family members and friends most frequently

    noticed concerning behavior, followed by co-workers, other, and law enforcement:

    TABLE 3: WHO NOTICED CONCERNING BEHAVIORS

    Who Noticed Number %

    Schoolmate* 11 92

    Spouse/domestic partner** 13 87

    Teacher/school staff* 9 75

    Family member 43 68

    Friend 32 51

    Co-worker 25 40

    Other (e.g. neighbors) 23 37

    Law enforcement 16

    25

    Online individual 6 10

    Religious mentor 3 5

    * Percentage calculated only with those active shooters who were students at the time of the offense

    ** Percentage calculated only with those active shooters who were in a relationship at the time of the offense

    What, If Anything, Did the Concerned Party Do?

    If the person recognizes behaviors as problematic but takes no action, the opportunity for intervention is missed.

    Whether and how a person responds to an active shooter’s concerning behavior is likely influenced by a host of
    personal and situational factors (e.g., whether the behavior is threatening to the observer or others, the relationship

    of the observer and active shooter, avenues for anonymous reporting, and/or confidence in authorities or others to
    address the behavior).

    In this study, even in cases where an active shooter displayed a variety of concerning behaviors that might indicate

    an intent to act violently, the observer(s) of that information did not necessarily pass it along to anyone else. As

    shown above, the people most likely to notice concerning behaviors were those who knew the active shooter best

    — family, friends and classmates. For the very reason they are the people most likely to take note of concerning

    behaviors, they are also people who may feel constrained from acting on these concerns because of loyalty,

    disbelief, and/or fear of the consequences.23

    23 Borum, R. (2013). Informing Lone‐Offender Investigations. Criminology & Public Policy, 12(1), 103-112.

    21

    Again, keeping in mind that active shooters displayed multiple concerning behaviors and those who observed these

    behaviors might have responded in different ways to each, the most common response was to communicate directly

    to the active shooter (83%, n = 52) or do nothing (54%, n = 34). Thus, in many instances, the concern stayed

    between the person who noticed the behavior and the active shooter.

    The next most common responses were: report the active shooter to a non-law enforcement authority (51%, n = 32);

    discuss the concerning behavior with a friend or family member (49%, n = 31); and, report the active shooter to law

    enforcement authority (41%, n = 26).

    Considerations

    The analysis above is not intended to, nor could it, encompass the innumerable ways in which the observer of a

    concerning behavior might react. Nor does it suggest that every concerning behavior warrants assertive intervention;

    many of the concerning behaviors that registered with others likely would not have presaged deadly violence to a

    reasonable person. The FBI is aware that in retrospect certain facts may take on a heightened degree of significance
    that may not have been clear at the time.

    Nevertheless, understanding that there are often opportunities before a shooting to recognize concerning behaviors

    that may suggest progression toward violence, the FBI is highlighting the most common behaviors displayed in the

    sample. There is no single warning sign, checklist, or algorithm for assessing behaviors that identifies a prospective
    active shooter. Rather, there appears to be a complex combination of behaviors and interactions with bystanders

    that may often occur in the days, weeks, and months leading up to an attack. Early recognition and reporting of

    concerning behaviors to law enforcement or threat assessment professionals may initiate important opportunities

    for mitigation.

    PRIMARY GRIEVANCE
    A grievance is defined for this study as the cause of the active shooter’s distress or resentment; a perception — not
    necessarily based in reality — of having been wronged or treated unfairly or inappropriately.24,25,26 More than a

    typical feeling of resentment or passing anger, a grievance often results in a grossly distorted preoccupation with

    a sense of injustice, like an injury that fails to heal. These thoughts can saturate a person’s thinking and foster a

    pervasive sense of imbalance between self-image and the (real or perceived) humiliation. This nagging sense of

    unfairness can spark an overwhelming desire to “right the wrong” and achieve a measure of satisfaction and/or

    revenge. In some cases, an active shooter might have what appeared to be multiple grievances but, where possible,

    the FBI sought to determine the primary grievance. Based on a review of the academic literature and the facts of

    the cases themselves, the FBI identified eight categories of grievances, with an additional category of “other” for
    grievances that were entirely idiosyncratic.

    As shown in the following table, the FBI could not identify a primary grievance for 13 (21%) of the active

    shooters, either because they did not have one or because there was insufficient evidence to determine whether
    one existed. While it may be particularly difficult to understand the motivation(s) for attacks that do not appear
    to be based on identifiable grievances, these active shooters still displayed concerning behaviors, were under
    identifiable stressors, and engaged in planning and preparation activities. For example, for the active shooters
    where no grievance could be identified, all had at least two behaviors (with an average of 5.4 behaviors) that
    were noted to be concerning by others.

    24 Calhoun, T., & Weston, S., (2003).

    25 Fein, R., & Vossekuil, B. (1999).

    26 Vossekuil, B., Fein, R., Reddy, M., Borum, R., & Modzeleski, W. (2004).

    22

    The majority (79%, n = 50) of the active shooters did appear to be acting in accord with a grievance of some kind.

    Of course, the grievance itself may not have been reasonable or even grounded in reality, but it appeared to serve as

    the rationale for the eventual attack, giving a sense of purpose to the shooter. Most of these grievances seem to have

    originated in response to some specific action taken regarding the active shooter. Whether interpersonal, employment,
    governmental, academic, or financial, these actions were (or were perceived to be) directed against the active shooter
    personally. In contrast, grievances driven by more global or broad considerations — such as ideology or hatred of a

    group — account for less than 7% of the overall cases. In general then, active shooters harbored grievances that were

    distinctly personal to them and the circumstances of their daily lives.

    TABLE 4: PRIMARY GRIEVANCE

    Primary Grievance Number %

    Adverse interpersonal action against the shooter 21 33

    Adverse employment action against the shooter 10 16

    Other (e.g. general hatred of others) 6 10

    Adverse governmental action against the shooter 3 5

    Adverse academic action against the shooter 2 3

    Adverse financial action against the shooter 2 3

    Domestic 2 3

    Hate crime 2 3

    Ideology/extremism 2 3

    Unknown 13 21

    Precipitating Events

    Of the 50 active shooters who had an identifiable grievance, nearly half of them experienced a precipitating
    or triggering event related to the grievance (44%, n = 22). Seven active shooters (14%) did not experience a

    precipitating event, and the FBI could not determine whether the remaining 21 (42%) did. Precipitating events

    generally occurred close in time to the shooting and included circumstances such as an adverse ruling in a legal

    matter, romantic rejection, and the loss of a job.

    These precipitating events were of more consequence in the timing of the attack, and while they appear to have

    accelerated the active shooter’s movement on the trajectory to violence, they did not by themselves appear to set

    the course.

    Considerations

    Of course, many people have grievances and never act violently. What caused the active shooters in this study to

    act the way they did cannot be explained simply by the presence of a grievance. There was likely the interaction

    of a variety of operational considerations and psychological stressors that eventually crystallized in the decision

    to ignore non-violent options and choose to attack. However, the types of grievances most commonly experienced

    by the active shooters in this study may be important considerations for the many threat assessment teams and law

    enforcement professionals who work each day to assess a subject’s progression along the pathway to violence.

    23

    TARGETING
    For this study, a target is defined as a person or group of people who were identifiable before the shooting
    occurred and whom the active shooter intended to attack. It was not necessary that the active shooter knew the

    target by name; intending to attack a person holding a position at or affiliated with a business, educational facil-
    ity, or in a governmental agency sufficed. The target could be a group, so long as members of that group could
    have been identified

    prior to the attack.

    In cases where the victims could not reasonably have been identified prior to the shooting, the active shooter was
    deemed to have selected the victims at random. While there is some element of selection in any attack where there

    is more than one potential victim (unless the active shooter literally does not aim at all), the FBI considered victims

    to be random where there was: 1) no known connection between the active shooter and the victims, and 2) the

    victims were not specifically linked to the active shooter’s grievance.

    In many cases, there was a mix of targeted and random victims in the same shooting. The typical circumstance

    occurred when an active shooter went to a location with targets in mind and also shot others who were at the same

    location, either because they presented some obstacle in the attack or for reasons that could not be identified.

    The overall numbers for targeted and random victims are listed below:

    Considerations

    While approximately one-third of active shooters in this sample victimized only random members of the public,

    most active shooters arrive at a targeted site with a specific person or persons in mind. Awareness of targeting
    behaviors can provide valuable insight for threat assessment professionals. Relatedly, the FBI has observed that

    when an active shooter’s grievance generalizes — that is, expands beyond a desire to punish a specific individual
    to a desire to punish an institution or community — this should be considered to be progression along a trajectory

    towards violence and ultimately a threat-enhancing characteristic.

    24

    SUICIDE: IDEATION AND ATTEMPTS
    For this study, “suicidal ideation” was defined as thinking about or planning suicide, while “suicide attempt” was
    defined as a non-fatal, self-directed behavior with the intent to die, regardless of whether the behavior ultimately
    results in an injury of any kind. Although these definitions are broad, the FBI concluded that an active shooter had
    suicidal ideation or engaged in a suicide attempt only when based on specific, non-trivial evidence.

    Nearly half of the active shooters had suicidal ideation or engaged in suicide-related behaviors at some time prior to

    the attack (48%, n = 30), while five active shooters (8%) displayed no such behaviors (the status of the remaining
    28 active shooters was unknown due to a lack of sufficient evidence to make a reasonable determination).

    An overwhelming majority of the 30 suicidal active shooters showed signs of suicidal ideation (90%, n = 27), and

    seven made actual suicide attempts (23%). Nearly three-quarters (70%, n = 21) of these behaviors occurred within

    one year of the shooting.

    Considerations

    The high levels27 of pre-attack suicidal ideation — with many appearing within 12 months of the attack — are

    noteworthy as they represent an opportunity for intervention. If suicidal ideation or attempts in particular are

    observed by others, reframing bystander awareness within the context of a mass casualty event may help to empha-

    size the importance of telling an authority figure and getting help for the suicidal person. Without stigmatizing
    those who struggle with thoughts of self-harm, researchers and practitioners must continue to explore those active

    shooters who combined suicide with externalized aggression (including homicidal violence) and identify the

    concurrent behaviors that reflect this shift.

    CONCERNING COMMUNICATIONS
    One useful way to analyze concerning communications is to divide them into two categories: threats/confrontations

    and leakage of intent.

    Threats/Confrontations

    Threats are direct communications to a target of intent to harm and may be delivered in person or by other means

    (e.g., text, email, telephone). For this study, threats need not be verbalized or written; the FBI considered in-person

    confrontations that were intended to intimidate or cause safety concerns for the target as falling under the category

    of threats as well.

    More than half of the 40 active shooters who had a target made threats or had a prior confrontation (55%, n = 22).

    When threats or confrontations occurred, they were almost always in person (95%, n = 21) and only infrequently in

    writing or electronically (14%, n = 3). Two active shooters made threats both in person and in writing/electronically.

    Leakage

    Leakage occurs when a person intentionally or unintentionally reveals clues to a third-party about feelings,

    thoughts, fantasies, attitudes or intentions that may signal the intent to commit a violent act.28 Indirect threats of

    harm are included as leakage, but so are less obvious, subtle threats, innuendo about a desire to commit a violent

    attack, or boasts about the ability to harm others. Leakage can be found not only in verbal communications, but

    27 The National Survey on Drug Use and Health (2015) shows that in 2015: 4% of adults had serious thoughts of suicide, 1.1% made serious plans, and 0.6% attempted suicide

    (https://www.samhsa.gov/data/sites/default/files/NSDUH-DR-FFR3-2015/NSDUH-DR-FFR3-2015.htm)

    28 Meloy, J. R. & O’Toole, M. E. (2011). The concept of leakage in threat assessment. Behavioral Sciences and the Law, 29, 513-527

    25

    also in writings (e.g., journals, school assignments, artwork, poetry) and in online interactions (e.g., blogs, tweets,

    texts, video postings). Prior research has shown that leakage of intent to commit violence is common before attacks

    perpetrated by both adolescents and adults, but is more common among adolescents.29,30,31

    Here, too, leakage was prevalent, with over half of the active shooters leaking intent to commit violence (56%,

    n = 35). In the Phase II sample, 88% (n = 7) of those active shooters age 17 and younger leaked intent to commit

    violence, while 51% (n = 28) of adult active shooters leaked their intent. The leaked intent to commit violence was

    not always directed at the eventual victims of the shootings; in some cases what was communicated was a more

    general goal of doing harm to others, apparently without a particular person or group in mind. For example, one

    active shooter talked to a clerk at a gas station about killing “a family” and another expressed interest in becoming

    a sniper like a character featured in The Turner Diaries. In 16 of the 40 cases (40%) where the active shooter had a

    target, however, the leaked intent to act violently was directly pertaining to that target. In these cases, the leakage

    was generally a statement to a third-party of the intent to specifically harm the target.

    Legacy Tokens

    Finally, the FBI considered whether or not an active shooter had constructed a “legacy token” which has been

    defined as a communication prepared by the offender to claim credit for the attack and articulate the motives
    underlying the shooting.32 Examples of legacy tokens include manifestos, videos, social media postings, or other

    communications deliberately created by the shooter and delivered or staged for discovery by others, usually near in

    time to the shooting. In 30% (n = 19) of the cases included in this study, the active shooter created a legacy token

    prior to the attack.

    Considerations

    Although more than half of the active shooters with pre-attack targets made threats (n = 22), in the majority (65%)

    of the overall cases no threats were made to a target, and the FBI cautions that the absence of a direct threat should

    not be falsely reassuring to those assessing the potential for violence raised by other circumstances and factors. Nor

    should the presence of a threat be considered conclusive. There is a significant amount of research and experience
    to demonstrate that direct threats are not correlated to a subsequent act of targeted violence.33,34,35,36,37,38

    It is important to highlight that in this Phase II study the overwhelming majority of direct threats were verbally

    delivered by the offender to a future victim. Only a very small percentage of threats were communicated via

    writing or electronically. In many ways this is not surprising. Written, directly communicated threats against

    a target (e.g., “I’m going to shoot and kill everyone here on Tuesday”) often spark a predictable response that

    includes a heightened law enforcement presence and the enhancement of security barriers. These responses are

    highly undesirable to an offender planning an active shooting.39 Verbal threats issued directly to another person

    appear to be far more common among the active shooters included in the Phase II study.

    29 Hemple, A., Meloy, J.R., & Richards, T. (1999). Offender and offense characteristics of a nonrandom sample of mass murderers. Journal of the American Academy of Psychiatry and the Law, 27,

    213-225. Meloy, J.R., Hoffman, J., Guldimann, A., & James, D. (2011). The role of warning behaviors in threat assessment: An exploration and suggested typology. Behavioral Sciences and the

    Law, 30,

    256-279.

    30 Meloy, J. R. & O’Toole, M. E. (2011).

    31 Meloy, J.R., Hoffman, J., Guldimann, A., & James, D. (2011). The role of warning behaviors in threat assessment: An exploration and suggested typology. Behavioral Sciences and the Law, 30,

    256-279.

    32 Simons, A., & Tunkel, R. (2014). The assessment of anonymous threatening communications. In J.R. Meloy & J. Hoffman (Eds.), International handbook of threat assessment (pp. 195-213). New

    York: Oxford University Press.

    33 Borum, R., Fein, R. Vossekuil, B., & Berglund, J. (1999). Threat assessment: Defining an approach for evaluating risk of targeted violence. Behavioral Sciences and the Law, 17, 323-337.

    34 Calhoun, F. (1998). Hunters and howlers: Threats and violence against federal judicial officials in the United States, 1789-1993. Arlington, VA: US Marshals Service.

    35 Calhoun T. & Weston, S. (2003).

    36 Dietz, P., Matthews, D., Martell, D., Stewart, T., Hrouda, D., & Warren, J. (1991a). Threatening and otherwise inappropriate letters to members of the United States Congress. Journal of Forensic

    Sciences, 36, 1445-1468.

    37 Dietz, P., Matthews, D., Van Duyne, C., Martell, D., Parry, C., Stewart, T., et al. (1991b). Threatening and otherwise inappropriate letters to Hollywood celebrities. Journal of Forensic Sciences, 36,

    185-209.

    38 Meloy, J.R. (2000). Violence risk and threat assessment. San Diego: Specialized Training Services.

    39 Simons A. & Tunkel, R. (2014)

    26

    Whether verbal or written, concerning communications are challenging as those on the receiving end must assess

    sometimes ominously vague or nebulous verbiage. Such confusion can create doubt in the listener’s mind as to

    the communicator’s true intent toward violence.40 As law enforcement agencies continue to remind bystanders

    if they “see something, say something” it becomes relevant to use this data (particularly regarding leakage

    behaviors) to lower the internal threshold for reporting, even in the face of ambiguous language. It is troubling

    to note that no bystanders reported instances of leakage to law enforcement, perhaps out of a fear of overreacting

    or perhaps due to a lack of understanding as to what law enforcement’s response would be. This suggests that

    more robust efforts need to be made to educate bystanders (especially students and adolescents) on the nature of

    leakage and its potential significance.

    Limitations

    The findings presented in this report reflect a thorough and careful review of the data derived almost exclusively
    from law enforcement records. Nevertheless, there are limitations to the study which should be kept in mind before

    drawing any conclusions based on the findings.

    First, the Phase I study on which the present analysis is based included only a specific type of event. Shootings
    must have been (a) in progress in a public place and (b) law enforcement personnel and/or citizens had the potential

    to affect the outcome of the event based on their responses. The FBI acknowledges there is an inherent element of

    subjectivity in deciding whether a case meets the study criteria. Moreover, while every effort was made to find all
    cases between 2000 and 2013 which met the definition, it is possible that cases which should have been included in
    the study were not identified. Overall, as with the Phase I study, the incidents included in the Phase II study were
    not intended to and did not comprise all gun-related violence or mass or public shootings occurring between 2000

    and 2013.

    Second, although the FBI took a cautious approach in answering protocol questions and limited speculation by

    relying on identifiable data, there was some degree of subjectivity in evaluating which of the original 160 cases had
    sufficient data to warrant inclusion in the study.

    Third, while reliance on official law enforcement investigative files was reasonable based on the study’s objectives,
    the level of detail contained in these files was not uniform throughout and the FBI was not able to definitively
    answer all protocol questions for all subjects.

    This is a purely descriptive study. With the exception of mental health and suicidal behaviors, the FBI did not make

    any comparisons to the general population or to criminals who were not active shooters. Therefore, we cannot

    postulate on the probability as to whether some of the behaviors and characteristics seen here would also have

    been seen in other populations. Furthermore, the FBI cautions readers to not treat the observed behaviors as having

    predictive value in determining if a person will become violent or not, as the findings and observations presented
    herein are not a “checklist” but instead are offered to promote awareness among potential bystanders and for

    consideration in the context of a thorough, holistic threat assessment by trained professionals. Future research may

    benefit from comparisons between those who completed active shooting attacks and those who planned to attack
    but were disrupted prior to the offense, and/or in comparison to those individuals who may have displayed concern-

    ing behaviors but had no true intent to commit an act of targeted violence.

    40 The FBI noted that there were four cases where threats were made and someone notified law enforcement (out of 22 cases where a threat was made, or 14%)

    27

    Conclusion

    The ability to utilize case files (as compared to open-source documents) allowed the FBI to carefully examine
    both the internal issues experienced and the behaviors demonstrated by active shooters in the weeks and months

    preceding their attacks. What emerges is a complex and troubling picture of individuals who fail to successfully

    navigate multiple stressors in their lives while concurrently displaying four to five observable, concerning
    behaviors, engaging in planning and preparation, and frequently communicating threats or leaking indications of

    an intent to attack. As an active shooter progresses on a trajectory towards violence, these observable behaviors

    may represent critical opportunities for detection and disruption.

    The information contained in this Phase II report can be utilized by myriad safety stakeholders. The successful

    prevention of an active shooting frequently depends on the collective and collaborative engagement of varied

    community members: law enforcement officials, teachers, mental health care professionals, family members, threat
    assessment professionals, friends, social workers, school resource officers…and many others. A shared awareness
    of the common observable behaviors demonstrated by the active shooters in this study may help to prompt inquiries

    and focus assessments at every level of contact and every stage of intervention.

    While many dedicated professionals work to thwart active shootings, the FBI suspects that future active shooters

    themselves are looking for ways to avoid detection and maximize damage as they plan and prepare for their acts of

    violence. The prevention of these future attacks will depend on our ability to remain agile and recognize evolving

    pre-attack behaviors. To that end, the FBI continues to study active shooters to better inform all safety stakeholders

    and to support the development of sound threat mitigation strategies.

    As tragically seen from current events, active shootings continue to impact our nation. The FBI hopes that the

    information contained in this Phase II study will help in efforts to promote safety across all communities.

    28

  • Appendix A:
  • STRESSORS

    Abuse of illicit drugs or alcohol: difficulties caused by the effects of drugs/alcohol and/or frustrations related to
    obtaining these substances.

    Civil legal problems: being party to a non-trivial lawsuit or administrative action.

    Conflict with friends/peers: general tension in the relationship beyond what is typical for the active shooter’s age

    or specific instances of serious and ongoing disagreement.

    Conflict with other family members: general tension in the relationship beyond what is typical for the active

    shooter’s age, or specific instances of serious and ongoing disagreement.

    Conflict with parents: general tension in the relationship beyond what is typical for the active shooter’s age, or

    specific instances of serious and ongoing disagreement.

    Criminal legal problems: arrests, convictions, probation, parole.

    Death of friend/relative: death that caused emotional or psychological distress.

    Financial strain: related to job loss, debt collection, potential or actual eviction, inability to pay normal and usual

    daily bills.

    Job-related problems: ongoing conflicts with co-workers or management, pervasive poor performance evaluations,
    or disputes over pay or leave.

    Marital problems/conflict with intimate partner(s)/divorce or separation: difficulties in the relationship
    that were a consistent source of psychological distress and/or which did or were likely to lead to the end of the

    relationship or the desire to end the relationship.

    Mental health problems: symptoms of anxiety, depression, paranoia, or other mental health concerns that have a

    negative effect on daily functioning and/or relationships.

    Other: any other circumstance causing physical, psychological, or emotional difficulties that interfere in a
    non-trivial way with normal functioning in daily life.

    Physical injury: physical condition/injury that significantly interfered with or restricted normal and usual
    activities.

    School-related problems: conflicts with teachers and staff that go beyond single instances of minor discipline;
    pervasive frustration with academic work; inability to follow school rules.

    Sexual stress/frustration: pronounced and ongoing inability to establish a desired sexual relationship.

    29

    Appendix B:

    CONCERNING BEHAVIORS

    Amount or quality of sleep: unusual sleep patterns or noticeable changes in sleep patterns.

    Anger: inappropriate displays of aggressive attitude/temper.

    Change, escalation, or contextually inappropriate firearms behavior: interest in or use of firearms that
    appears unusual given the active shooter’s background and experience with firearms.

    Changes in weight or eating habits: significant weight loss or gain related to eating habits.

    Hygiene or personal appearance: noticeable and/or surprising changes in appearance or hygiene practices.

    Impulsivity: actions that in context appear to have been taken without usual care or forethought.

    Interpersonal interactions: more than the usual amount of discord in ongoing relationships with family,

    friends, or colleagues.

    Leakage: communication to a third-party of the intent to harm another person.

    Mental health: indications of depression, anxiety, paranoia or other mental health concerns.

    Other: any behavior not otherwise captured in above categories that causes more than a minimal amount of

    worry in the observer.

    Physical aggression: inappropriate use of force; use of force beyond what was usual in the circumstances.

    Physical health: significant changes in physical well-being beyond minor injuries and ailments.

    Quality of thinking or communication: indications of confused or irrational thought processes.

    Risk-taking: actions that show more than a usual disregard for significant negative consequences.

    School performance: appreciable decrease in academic performance; unexplained or unusual absences.

    Sexual behavior: pronounced increases or decreases in sexual interest or practices.

    Threats/Confrontations: direct communications to a target of intent to harm. May be delivered in person or by

    other means (e.g., text, email, telephone).

    Use of illicit drugs or illicit use of prescription drugs: sudden and/ recent use or change in use of drugs; use

    beyond social norms that

    interferes with the activities of daily life.

    Use or abuse of alcohol: sudden and/or recent use or changes in use of alcohol; use beyond social norms that

    interferes with the activities of daily life.

    Violent media usage: more than a usual age-appropriate interest in visual or aural depictions of violence.

    Work performance: appreciable decrease in job performance; unexplained or unusual absences.

    U.S. Department of Justice

    Federal Bureau of Investigation

    • Snapshot
    • Findings

    • Health Care Facilities
    • Residences
    • Military and Other Government Properties
    • Open Spaces
    • Education Environments
    • Commerce Areas
    • Houses of Worship
    • Conclusion

      Appendix A:

    U.S. Department of Justice

    Federal Bureau of Investigation

    A STUDY OF THE

    PRE-ATTACK BEHAVIORS

    OF ACTIVE SHOOTERS

    IN THE UNITED STATES
    BETWEEN 2000 AND 201

    3

    JUNE 2018

    2

    Authors

    James Silver, Ph.D., J.D., Worcester State University

    Andre Simons, Supervisory Special Agent, Behavioral Analysis Unit, FBI

    Sarah Craun, Ph.D., Behavioral Analysis Unit, FBI

    This publication is in the public domain. Authorization to reproduce this publication in whole or in part is granted.

    The citation should be: Silver, J., Simons, A., & Craun, S. (2018). A Study of the Pre-Attack Behaviors of Active

    Shooters in the United States Between 2000 – 2013. Federal Bureau of Investigation, U.S. Department of Justice,

    Washington, D.C. 20535.

    3

    A Study of the Pre-Attack Behaviors of
    Active Shooters in the United States
    Between 2000 and 20

    13

    Acknowledgments ……………………………………………………………………………………………………….

    4

    Introduction ………………………………………………………………………………………………………………….

    6

    Key

  • Findings
  • ………………………………………………………………………………………………………………….

    7

    Methodology ………………………………………………………………………………………………………………..

    8

    Findings

    Shooter Demographics ………………………………………………………………………………………………………….

    9

    Planning and Preparation ……………………………………………………………………………………………………13

    Firearms Acquisition …………………………………………………………………………………………………………….

    14

    Stressors ………………………………………………………………………………………………………………………………..1

    5

    Mental Health ………………………………………………………………………………………………………………………

    17

    Concerning Behaviors ………………………………………………………………………………………………………….17

    Primary Grievance ………………………………………………………………………………………………………………..

    21

    Targeting ………………………………………………………………………………………………………………………………

    23

    Suicide: Ideation and Attempts ……………………………………………………………………………………………

    24

    Concerning Communications ……………………………………………………………………………………………..24

    Limitations ………………………………………………………………………………………………………………….

    26

  • Conclusion
  • ………………………………………………………………………………………………………………….

    27

    Appendices …………………………………………………………………………………………………………………

    28

    Click on a link above to jump to a page.

    4

    Acknowledgments

    The authors wish to thank the many dedicated members and former members of the FBI’s Behavioral Analysis

    Unit (BAU) who supported this study, including Crime Analyst Kristen Solik, BAU; Unit Chief John Wyman,

    BAU; Unit Chief Kristen Slater, BAU; Unit Chief Kevin Burton, BAU; Unit Chief Shawn VanSlyke, BAU (ret.);

    Research Coordinator Kristen Lybert, BAU; Supervisory Special Agents (SSAs) Karie Gibson and Adrienne Isom,

    BAU; Mr. Bryan Czako; Mr. Davis Moore; and Mr. James Russell. The authors also offer special thanks and

    gratitude to our colleagues in the BAU’s Behavioral Threat Assessment Center (BTAC).

    Further, the authors express their appreciation to Assistant Director Kerry Sleeper, Section Chief Katherine Schweit

    (ret.), Unit Chief James Green, and Supervisory Intelligence Analyst Deborah Cryan of the FBI’s Office of Partner
    Engagement for their past and ongoing support of this project. Special thanks as well to Visual Information

    Specialist Erin Kim of the FBI’s Office of Public Affairs.

    The authors are exceptionally grateful to our many threat assessment colleagues who have partnered with and

    supported the BAU over several years. These professionals quietly and tirelessly work each day to prevent active

    shootings in our schools, universities, houses of worship, and businesses.

    5

    The authors and researchers from the FBI’s Behavioral Analysis Unit involved in preparing this

    report are aware of the horrific impact these shootings have had on victims, survivors, families,
    and communities. We extend our deepest sympathies to those who have suffered the unimaginable

    tragedy of an active shooting, either personally or as a family member. We know that behind

    the statistics and numbers presented here are thousands of individuals with personal stories of

    grief, bravery, and resilience. In partnership with other law enforcement and threat assessment

    professionals, we remain committed to doing everything possible to prevent future attacks. Although

    much work remains, we present this report as a step towards disrupting those who would seek to

    inflict catastrophic harm.

    6

    Introduction

    In 2017 there were 30 separate active shootings in the United States, the largest number ever recorded by the

    FBI during a one-year period.1 With so many attacks occurring, it can become easy to believe that nothing can

    stop an active shooter determined to commit violence. “The offender just snapped” and “There’s no way that

    anyone could have seen this coming” are common reactions that can fuel a collective sense of a “new normal,”

    one punctuated by a sense of hopelessness and helplessness. Faced with so many tragedies, society routinely

    wrestles with a fundamental question: can anything be done to prevent attacks on our loved ones, our children,

    our schools, our churches, concerts, and communities?

    There is cause for hope because there is something that can be done. In the weeks and months before an attack,

    many active shooters engage in behaviors that may signal impending violence. While some of these behaviors

    are intentionally concealed, others are observable and — if recognized and reported — may lead to a disruption

    prior to an attack. Unfortunately, well-meaning bystanders (often friends and family members of the active

    shooter) may struggle to appropriately categorize the observed behavior as malevolent. They may even resist

    taking action to report for fear of erroneously labeling a friend or family member as a potential killer. Once

    reported to law enforcement, those in authority may also struggle to decide how best to assess and intervene,

    particularly if no crime has yet been committed.

    By articulating the concrete, observable pre-attack behaviors of many active shooters, the FBI hopes to make

    these warning signs more visible and easily identifiable. This information is intended to be used not only by law
    enforcement officials, mental health care practitioners, and threat assessment professionals, but also by parents,
    friends, teachers, employers and anyone who suspects that a person is moving towards

    violence.

    In 2014, the FBI published a report titled A Study of Active Shooter Incidents in the United States Between 2000

    and 2013.2 One hundred and sixty active shooter incidents in the United States occurring between 2000 and 2013

    were included in the sample. In this first report, the FBI focused on the circumstances of the active shooting
    events (e.g., location, duration, and resolution) but did not attempt to identify the motive driving the offender,

    nor did it highlight observable pre-attack behaviors demonstrated by the offender. The 2014 report will be

    referred to as the “Phase I” study.

    The present study (“Phase II”) is the natural second phase of that initiative, moving from an examination of

    the parameters of the shooting events to assessing the pre-attack behaviors of the shooters themselves. This

    second phase, then, turns from the vitally important inquiry of “what happened during and after the shooting”

    to the pressing questions of “how do the active shooters behave before the attack?” and, if it can be determined,

    “why did they attack?” The FBI’s objective here was to examine specific behaviors that may precede an attack
    and which might be useful in identifying, assessing, and managing those who may be on a pathway to deadly

    violence.

    1 https://www.fbi.gov/file-repository/active-shooter-incidents-us-2016-2017 /view

    2 https://www.fbi.gov/file-repository/active-shooter-study-2000-2013-1 /view

    7

    Key Findings of the Phase II Study

    1. The 63 active shooters examined in this study did not appear to be uniform in any way such that they

    could be readily identified prior to attacking based on demographics alone.

    2. Active shooters take time to plan and prepare for the attack, with 77% of the subjects spending a week

    or longer planning their attack and 46% spending a week or longer actually preparing (procuring the

    means) for the attack.

    3. A majority of active shooters obtained their firearms legally, with only very small percentages obtaining a
    firearm illegally.

    4. The FBI could only verify that 25% of active shooters in the study had ever been diagnosed with a

    mental illness. Of those diagnosed, only three had been diagnosed with a psychotic disorder.

    5. Active shooters were typically experiencing multiple stressors (an average of 3.6 separate stressors) in the

    year before they attacked.

    6. On average, each active shooter displayed 4 to 5 concerning behaviors over time that were observable to

    others around the shooter. The most frequently occurring concerning behaviors were related to the active

    shooter’s mental health, problematic interpersonal interactions, and leakage of violent intent.

    7. For active shooters under age 18, school peers and teachers were more likely to observe concerning

    behaviors than family members. For active shooters 18 years old and over, spouses/domestic partners were

    the most likely to observe concerning behaviors.

    8. When concerning behavior was observed by others, the most common response was to communicate

    directly to the active shooter (83%) or do nothing (54%). In 41% of the cases the concerning

    behavior was reported to law enforcement. Therefore, just because concerning behavior was recognized

    does not necessarily mean that it was reported to law enforcement.

    9. In those cases where the active shooter’s primary grievance could be identified, the most common
    grievances were related to an adverse interpersonal or employment action against the shooter (49%).

    10. In the majority of cases (64%) at least one of the victims was specifically targeted by the active shooter.

    *All percentages in this report are rounded to the nearest whole number.

    8

    Methodology

    With the goal of carefully reviewing the pre-attack lives and behaviors of the active shooters, the FBI developed a

    unique protocol of 104 variables covering, among other things:

    ■ Demographics

    ■ Planning and preparation

    ■ Acquisition of firearms in relation to the attack

    ■ Stressors

    ■ Grievance formation

    ■ Concerning pre-attack behaviors and communications

    ■ Targeting decisions

    ■ Mental health

    Whereas Phase I analyzed event circumstances that are typically well documented both in law enforcement

    incident reports and reliable open sources3, this second phase is substantially based on observations of what are

    often nuanced behavioral indicators demonstrated by the active shooter prior to the attack. Given the subtle nature

    of many of the factors relevant to the inquiry, the FBI decided to use data that have been verified to the greatest
    possible extent, relying almost exclusively on information contained in official law enforcement investigative files.4
    For this reason, Phase II includes only those cases where the FBI obtained law enforcement investigative files that
    contained “background” materials (e.g., interviews with family members, acquaintances, neighbors; school or

    employment records; writings generated by the subject) adequate to answer the protocol questions.5 In addition,

    as Phase II focused on identifying pre-attack behaviors of those on a trajectory to violence, active shooting events

    which appeared to be spontaneous reactions to situational factors (e.g., fights that escalated) were excluded. This
    resulted in a final sample of 63 active shooting incidents included in the Phase II study.

    The use of law enforcement investigative case files as the primary source of data makes this study unique in
    comparison to other reports that typically rely upon unverified data derived from open sources. The comprehensive
    evaluation of law enforcement case files for suitability and completeness also contributed to the substantial time it
    has taken to prepare and publish this study.

    The FBI examined whether the 63 cases included in Phase II are representative of the entire Phase I sample

    (N = 160). To identify the differences in the samples between Phase I and Phase II (N = 160 versus N = 63), the

    FBI compared those cases that were only in Phase I (n = 97) to those cases included in Phase II (N = 63), assessing

    potential differences between the active shooters (e.g., race, gender, age, and whether the offender committed

    suicide subsequent to the attack), as well as potential differences in the characteristics of the incidents (number of

    victims killed, number of law enforcement officers killed, location of the incident, active shooter movement during
    the event, and if the event concluded prior to the arrival of law enforcement).

    3 Incident overview (e.g., date, location), incident specifics (weapon(s) used, duration of event), and incident outcome (deaths, injuries, resolution).

    4 For one incident, the study relied on publicly available official reports which were based on the complete law enforcement investigative files.

    5 The investigative files did not contain uniform amounts of subject-related behavioral information, as the depth and breadth of investigations varied based on several factors, including available

    resources, the prospect or not of trial, and the complexity of the event.

    9

    As compared to the 97 cases that were only in Phase I, the 63 cases in Phase II had the following characteristics:

    ■ Had a higher number of victims killed on average during each shooting;

    ■ Were more likely to end before law enforcement arrived;

    ■ Were more likely to include offenders who identified with Asian and Caucasian ethnicity, with active shooters
    identified with African American and Hispanic ethnicity generally underrepresented as compared to Phase I;

    ■ Were more likely to occur in an educational facility or a house of worship; and

    ■ Were more likely to end with the active shooter committing suicide.

    After cases were identified, a three-stage coding process was utilized. First, two researchers read all case materials
    and independently coded each of the cases across all protocol variables. The researchers took a conservative

    approach to coding, declining to definitively answer any question that was not supported by record evidence.
    Second, another experienced coder (the “reviewer”) also read each investigative file. In the final stage, the coders
    and the reviewer met for each of the 63 cases, compared answers, discussed disagreements, and produced a single

    reconciled set of data.

    SHOOTER DEMOGRAPHICS
    The sample comprised individuals who varied widely along a range of demographic factors making it impossible to

    create a demographic profile of an active shooter. Indeed, the findings and conclusions of this study should be consid-

    ered in light of the reality that these 63 active shooters did not appear to be uniform in any way such that they could be

    readily identified prior to attacking based on demographics alone.

    Age:

    The youngest active shooter was 12 years old and the oldest was 88 years old with an average age of 37.8 years.

    Grouping the active shooters by age revealed the following:

    10

    Gender and Race:

    The sample was overwhelmingly male (94%, n = 59), with only four females in the data set (6%, n = 4), and varied

    by race as shown in Figure 2:6

    Highest Level of Education7:

    None of the active shooters under the age of 18 had successfully completed high school, and one (age 12) had not

    yet entered high school. When known, the highest level of education of adults varied considerably, as shown in

    Figure 3:

    6 Descriptors of active shooters’ races were obtained from law enforcement records.

    7 Active shooters under the age of 18 (n=8) were excluded in analyses for those variables not typically pertaining to juveniles (e.g., marital status, higher education).

    11

    Employment:

    The active shooters who were under 18 years old were all students. As featured in Figure 4, nearly equal percent-

    ages of the adult active shooters 18 years or older were employed as were unemployed, and 7% (n = 4) were

    primarily students. The rest of the adults were categorized as retired, disabled/receiving benefits, or other/unknown.

    Military:

    Of the active shooters 18 and older, 24% (n = 13) had at least some military experience, with six having served in

    the Army, three in the Marines, two in the Navy, and one each in the Air Force and the Coast Guard.

    Relationship Status:

    The active shooters included in the Phase II study were mostly single at the time of the offense (57%, n = 36).

    Thirteen percent (n = 8) were married, while another 13% were divorced. The remaining 11% were either partnered

    but not married (n = 7) or separated (6%, n = 4).

    Criminal Convictions and Anti-Social Behavior8:

    Nineteen of the active shooters aged 18 and over (35%) had adult convictions prior to the active shooting event.

    As visualized in Figure 5, the convictions can be categorized as crimes against society, property, or persons. The

    category of “crimes against society” included offenses such as driving under the influence, disorderly conduct and
    the possession of drug paraphernalia. Both the misdemeanor and felony “crimes against property” involved non-vi-

    olent offenses, such as conspiracy to commit theft, theft, possession of stolen property, and criminal mischief. The

    misdemeanor “crimes against persons” were not inherently dangerous, but the felony “crimes against persons”

    involved convictions for criminal sexual assault of a family member, aggravated stalking, and endangering a person

    (although no active shooter was convicted of more than one crime against a person).

    8 The study does not include juvenile adjudications; therefore, we did not run the analyses on those aged 17 and younger.

    12

    In sum, the active shooters had a limited history of adult convictions for violent crime and a limited history of adult

    convictions for crime of any kind.

    Because formal criminal proceedings may not capture the full range of anti-social behaviors in a person’s

    background, the FBI also looked for evidence of behaviors that were abusive and/or violent, but which did not

    result in a criminal charge. For some active shooters, no evidence of these behaviors was found, but given that these

    actions by definition did not involve the formal criminal justice system, it is possible that more violent incidents
    occurred than are reported here.

    We found evidence that 62% (n = 39) of the active shooters had a history of acting in an abusive, harassing, or

    oppressive way (e.g., excessive bullying, workplace intimidation); 16% (n = 10) had engaged in intimate partner

    violence; and 11% (n = 7) had engaged in stalking-related conduct.9

    Considerations

    There were very few demographic patterns or trends (aside from gender) that could be identified, reinforcing the
    concept that there is no one “profile” of an active shooter. Perhaps most noteworthy is the absence of a pronounced
    violent criminal history in an overwhelming majority of the adult active shooters. Law enforcement and threat

    management professionals assessing a potentially violent person may therefore wish to avoid any reliance on

    demographic characteristics or on evidence (or lack thereof) of prior criminal behavior in conducting their

    assessments.

    9 This number may be underrepresented given the high percentage of unknown responses as related to stalking behaviors (68%).

    13

    PLANNING AND PREPARATION
    This study examined two related but separate temporal aspects of the active shooters’ pre-attack lives — total

    time spent planning the attack and total time spent preparing for the attack.10,11,12 The purpose in analyzing these

    chronologies was to establish the broad parameters during which active shooters were moving toward the attack

    and to identify behaviors that may have been common during these time periods.

    In this context, planning means the full range of considerations involved in carrying out a shooting attack. This

    includes the decision to engage in violence, selecting specific or random targets, conducting surveillance, and
    addressing all ancillary practical issues such as victim schedules, transportation, and site access. Planning is

    more specific than a general intent to act violently and involves the thought processes necessary to bring about
    an intended outcome. Since planning may primarily be an internal thought process, it was often difficult to find
    objective, observable indications of an active shooter’s planning. In nearly half of the cases, the total time spent

    planning is unknown. However, this is different than declaring that there was no evidence of planning at all,

    because in every case there was at least some evidence that the active shooter planned the attack; the challenge

    was ascertaining when the planning began.

    In establishing the total duration of planning, the FBI looked for evidence of behaviors that were observable (e.g.,

    conversations, conducting surveillance) as well as in materials that were private to the active shooter (e.g., journals,

    computer hard drives) and likely unknowable to others until after the attack. As demonstrated in Figure 6, there was a

    wide range of planning duration in the 34 cases where the time spent planning could reasonably be determined.

    With regard to specific planning activities, care should be taken in the interpretation of the data. For instance, our
    study indicates that few active shooters overall approached or conducted surveillance on their target (14%, n = 9),

    and fewer still researched or studied the target site where the attack occurred (10%, n = 6). While this could indicate

    that the active shooters were uninterested in knowing about their targets or attack sites in advance or engaged in

    little tactical planning, this is inconsistent with the operational experience of the FBI. The likely reason for this

    finding is that the active shooters often attacked people and places with which they were already familiar. There was

    10 Calhoun, T., & Weston, S., (2003). Contemporary threat management. San Diego: Specialized Training Services;

    11 Fein, R. & Vossekuil, B. (1999). Assassination in the United States: an operational study of recent assassins, attackers, and near-lethal approachers. Journal of Forensic Sciences.

    12 Vossekuil, B., Fein, R., Reddy, M., Borum, R., & Modzeleski, W. (2004). The final report and findings of the safe school initiative: Implications for the prevention of school attacks in the United States.

    Washington, DC: U.S. Secret Service and the U.S. Department of Education.

    14

    a known connection between the active shooters and the attack site in the majority of cases (73%, n = 46), often a

    workplace or former workplace for those 18 and older (35%, n = 19), and almost always a school or former school

    for those younger than 18 (88%, n = 7), indicating that in most cases the active shooter was already familiar with

    both the attack site as well as the persons located at the site. Conversely, those active shooters with no affiliation to
    the targeted site behaved differently. Active shooters with no known connection to the site of their attack were more

    likely to conduct surveillance (p < .05) and research the site (p < .01). With routine contact, pre-attack surveillance

    could presumably be conducted concurrent to normalized activity and eliminate the need for a more formalized or

    detectable reconnaissance of a chosen target.

    The investigative files also demonstrated that only some active shooters researched or studied past attacks by others
    (21%, n = 13). This is not to say that other active shooters were unaware of past attacks — it is difficult to imagine
    that they did not have at least some basic knowledge of prior infamous shootings that received national media

    coverage. The FBI again suspects that this behavior may be underrepresented in the study sample, especially as we

    could not determine if active shooters researched past attacks in 46% of the cases.

    Preparing was narrowly defined for this study as actions taken to procure the means for the attack, typically items
    such as a handgun or rifle, ammunition, special clothing and/or body armor. The focus was on activities that could
    have been noticed by others (e.g., a visit to a gun store, the delivery of ammunition) and which were essential to the

    execution of the plan. The FBI was able to find evidence of time spent preparing in more cases than for time spent
    planning (likely reflecting the overt nature of procuring materials as opposed to the presumably largely internal
    thought process of planning). As Figure 7 demonstrates, in more than half of the cases where the time spent prepar-

    ing was known, active shooters spent one week or less preparing for the attack.

    FIREARMS ACQUISITION
    As part of the review of the active shooter’s preparations, the FBI explored investigative records and attempted to

    identify how each active shooter obtained the firearm(s) used during the attack. Most commonly (40%, n = 25), the

    active shooter purchased a firearm or firearms legally and specifically for the purpose of perpetrating the attack. A
    very small percentage purchased firearms illegally (2%, n = 1) or stole the firearm (6%, n = 4). Some (11%, n = 7)

    borrowed or took the firearm from a person known to them. A significant number of active shooters (35%, n = 22)

    already possessed a firearm and did not appear (based on longevity of possession) to have obtained it for the express
    purpose of committing the shooting.

    15

    Considerations

    Active shooters generally take some time to plan and carry out the attack. However, retrospectively determining

    the exact moment when an active shooter decided to engage in violence is a challenging and imprecise process.

    In reviewing indicators of planning and preparing, the FBI notes that most active shooters (who demonstrated

    evidence of these processes in an observable manner) spent days, weeks, and sometimes months getting ready to

    attack. In fact, in those cases where it could be determined, 77% of the active shooters (n = 26) spent a week or

    longer planning their attack, and 46% (n = 21) spent a week or longer preparing. Readers are cautioned that simply

    because some active shooters spent less than 24 hours planning and preparing, this should not suggest that potential

    warning signs or evidence of an escalating grievance did not exist before the initiation of these behaviors. In the

    four cases where active shooters took less than 24 hours to plan and prepare for their attacks, all had at least one

    concerning behavior and three had an identifiable grievance.

    Perhaps unsurprisingly, active shooters tended to attack places already familiar to them, likely as a result of a personal

    grievance which motivated the attack and/or as a result of operational comfort and access. A unique challenge for

    safety, threat assessment, and security professionals will be to identify “outside” active shooters who are not already

    operating within the target environment. Pre-attack site surveillance by an outsider may be one observable behavior in

    physical or online worlds indicative of planning and preparation activities.

    STRESSORS

    Stressors are physical, psychological, or social forces that place real or perceived demands/pressures on an individual

    and which may cause psychological and/or physical distress. Stress is considered to be a well-established correlate of

    criminal behavior.13 For this study, a wide variety of potential stressors were assessed, including financial pressures,
    physical health concerns, interpersonal conflicts with family, friends, and colleagues (work and/or school), mental
    health issues, criminal and civil law issues, and substance abuse.14

    13 Felson, R.B., Osgood, D.W., Horney, J. & Wiernik, C. (2012). Having a bad month: General versus specific effects of stress on crime. Journal of Quantitative Criminology, 28, 347-363 for a

    discussion of various theories describing the relationship between stress and crime.

    14 See Appendix A.

    16

    The FBI recognizes that most (if not all) people in some way confront similar issues on a regular basis in their daily

    lives, and that most possess adequate personal resources, psychological resiliency, and coping skills to successfully

    navigate such challenges without resorting to violence. Therefore, the FBI focused on identifying stressors that

    appeared to have more than a minimal amount of adverse impact on that individual, and which were sufficiently
    significant to have been memorialized, shared, or otherwise noted in some way (e.g., in the active shooter’s own
    writings, in conversation with family or friends, work files, court records). Given the fluid nature of some (although
    not all) of the stressors, the analysis was limited to the year preceding the attack.

    The variables were treated as binary, that is, either the stressor was present or not, without regard for the number of

    separate circumstances giving rise to the stressor. So, an active shooter who had conflict with one family member

    and a shooter who had conflicts with several family members were both coded as “yes” for “conflict with other
    family members.”

    Overall, the data reflects that active shooters were typically experiencing multiple stressors (an average of 3.6
    separate stressors) in the year before they attacked. For example, in the year before his attack, one active shooter

    was facing disciplinary action at school for abuse of a teacher, was himself abused and neglected at home, and had

    significant conflict with his peers. Another active shooter was under six separate stressors, including a recent arrest
    for drunk driving, accumulating significant debt, facing eviction, showing signs of both depression and anxiety, and
    experiencing both the criminal and civil law repercussions of an incident three months before the attack where he

    barricaded himself in a hotel room and the police were called.

    The only stressor that applied to more than half the sample was mental health (62%, n = 39). Other stressors that

    were present in at least 20% of the sample were related to financial strain, employment, conflicts with friends and
    peers, marital problems, drug and alcohol abuse, other, conflict at school, and physical injury.

    TABLE 1: STRESSORS

    Stressors Number %

    Mental health 39 62

    Financial strain 31 49

    Job related 22 35

    Conflicts with friends/peers 18

    29

    Marital problems 17 27

    Abuse of illicit drugs/alcohol 14

    22

    Other (e.g. caregiving responsibilities) 14 22

    Conflict at school 14 22

    Physical injury 13 21

    Conflict with parents 11

    18

    Conflict with other family members 10 16

    Sexual stress/frustration 8 13

    Criminal problems 7 11

    Civil problems 6 10

    Death of friend/relative 4 6

    None 1 2

    17

    MENTAL HEALTH
    There are important and complex considerations regarding mental health, both because it is the most prevalent

    stressor and because of the common but erroneous inclination to assume that anyone who commits an active

    shooting must de facto be mentally ill. First, the stressor “mental health” is not synonymous with a diagnosis of

    mental illness. The stressor “mental health” indicates that the active shooter appeared to be struggling with (most

    commonly) depression, anxiety, paranoia, etc. in their daily life in the year before the attack. There may be complex

    interactions with other stressors that give rise to what may ultimately be transient manifestations of behaviors and

    moods that would not be sufficient to warrant a formal diagnosis of mental illness. In this context, it is exceedingly
    important to highlight that the FBI could only verify that 25% (n = 16) of the active shooters in Phase II were

    known to have been diagnosed by a mental health professional with a mental illness of any kind prior to the

    offense.15 The FBI could not determine if a diagnosis had been given in 37% (n = 23) of cases.

    Of the 16 cases where a diagnosis prior to the incident could be ascertained, 12 active shooters had a mood disor-

    der; four were diagnosed with an anxiety disorder; three were diagnosed with a psychotic disorder; and two were

    diagnosed with a personality disorder. Finally, one active shooter was diagnosed with Autism spectrum disorder;

    one with a developmental disorder; and one was described as “other.” Having a diagnosed mental illness was

    unsurprisingly related to a higher incidence of concurrent mental health stressors among active shooters.

    Considerations

    It is clear that a majority of active shooters experienced multiple stressors in their lives before the attack. While the

    active shooters’ reactions to stressors were not measured by the FBI, what appears to be noteworthy and of impor-

    tance to threat assessment professionals is the active shooters’ ability to navigate conflict and resiliency (or lack
    thereof) in the face of challenges. Given the high prevalence of financial and job-related stressors as well as conflict
    with peers and partners, those in contact with a person of concern at his/her place of employment may have unique

    insights to inform a threat assessment.

    In light of the very high lifetime prevalence of the symptoms of mental illness among the U.S. population, formally

    diagnosed mental illness is not a very specific predictor of violence of any type, let alone targeted violence.16,17,18

    Some studies indicate that nearly half of the U.S. population experiences symptoms of mental illness over their

    lifetime, with population estimates of the lifetime prevalence of diagnosable mental illness among U.S. adults at

    46%, with 9% meeting the criteria for a personality disorder.19,20 Therefore, absent specific evidence, careful consid-

    eration should be given to social and contextual factors that might interact with any mental health issue before

    concluding that an active shooting was “caused” by mental illness. In short, declarations that all active shooters

    must simply be mentally ill are misleading and unhelpful.

    CONCERNING BEHAVIORS

    Concerning behaviors are observable behaviors exhibited by the active shooter. For this study, a wide variety of

    concerning behaviors were considered, including those related to potential symptoms of a mental health disorder,

    interpersonal interactions, quality of the active shooter’s thinking or communication, recklessness, violent media

    usage, changes in hygiene and weight, impulsivity, firearm behavior, and physical aggression.21 Although these may

    be related to stressors in the active shooter’s life, the focus here was not on the internal, subjective experience of

    15 The number of documented, diagnosed mental illness may be the result of a number of factors, including those related to situational factors (access to health care) as well as those related to

    the study factors (access to mental health records).

    16 Elbogen, E.B., & Johnson, S.C. (2009). The intricate link between violence and mental disorder. Arch Gen Psychiatry,66(2),152-161.

    17 Glied, S.A., and Frank, R.G. (2014). Mental illness and violence: Lessons from the evidence. American Journal of Public Health, 104, e5-e6 doi:10.2015/AJPH.2013.301710

    18 Monahan, J., Steadman, H. J., Silver, E., Applebaum, P.S., Clark Robbins, P., Mulvey, E. P., & Banks, S. (2001). Rethinking Risk Assessment: The MacArthur Study of Mental Disorder and Violence.

    Oxford, UK: Oxford University Press

    19 Kessler, R.C., Berglund, P., Demler, O., Jin, R., Merikangas, K.R., Walters, E.E. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey

    Replication. Arch Gen Psychiatry. 2005:62(6): 593-602.

    20 Lenzweger, M.F., Lane, M.C., Loranger, A.W., Kessler, R.C., DSM-IV personality disorders in the National Comorbidity Survey Replication. Biol Psychiatry. 2007;62(6): 553-564.

    21 See Appendix B.

    18

    the active shooter, but rather on what was objectively knowable to others. So, while the assessment of stressors is

    meant to provide insight into the active shooter’s inner turmoil, the examination of concerning behaviors addresses

    a related but separate issue — the possibility of identifying active shooters before they attack by being alert for

    observable, concerning behaviors. The FBI looked for documented confirmation that someone noticed a facet of
    the shooter’s behavior causing the person to feel a “more than minimal” degree of unease about the well-being and

    safety of those around the active shooter.

    Before examining what behaviors were observable by others, it is useful to address the widespread perception

    that active shooters tend to be cut off from those around them. In general, the active shooters in Phase II were not

    completely isolated and had at least some social connection to another person. While most of the active shooters

    age 18 and older were single/never married (51%, n = 28) or separated/divorced (22%, n = 12) at the time of the

    attack, the majority did live with someone else (68%, n = 43). This percentage was slightly less (64%, n = 35) for

    only those active shooters who were 18 years or older. Most had significant in-person social interactions with at
    least one other person in the year before the attack (86%, n = 54), and more than a quarter of them had significant
    online interactions with another person within a year of the attack (27%, n = 17). All active shooters either: a) lived

    with someone, or b) had significant in-person or online social interactions.

    Since the observation of concerning behaviors offers the opportunity for intervention prior to the attack, this

    study examines not only what was observed, but when the observations were made, who made them, and what

    if anything the person(s) did with regard to these observations. To better serve threat assessment teams, mental

    health professionals, community resources, and law enforcement officials, the FBI expanded the inquiry to capture
    behaviors that may have been observed at any point (in many cases beyond one year) before the attack.

    Overall, active shooters showed concerning behaviors in multiple ways, with an average of 4.7 concerning behav-

    iors per active shooter. Behaviors observed in more than half of the sample were related to the shooter’s mental

    health22, interpersonal interactions, leakage (the communication to a third-party of an intent to harm someone,

    discussed with threats in a separate section), and the quality of the active shooter’s thinking or communication.

    Of note was that contextually inappropriate firearms behavior was noted in approximately one fifth of the active
    shooters, while drug and alcohol abuse figured even less prominently in the sample (for the purposes of the study,
    contextually inappropriate firearms behavior was defined as interest in or use of firearms that appeared unusual
    given the active shooter’s background and experience with firearms).

    TABLE 2: CONCERNING BEHAVIORS

    Concerning Behavior Number %

    Mental health 39 62

    Interpersonal interactions 36 57

    Leakage 35 56

    Quality of thinking or communication 34 54

    Work performance* 11 46

    School performance** 5 42

    Threats/confrontations 22 35

    Anger 21 33

    Physical aggression 21 33

    22 Thirty-nine active shooters were experiencing a mental health stressor, and 39 active shooters showed concerning behaviors related to mental health, but the same 39 active shooters did not

    appear in each category; there were five active shooters who had a mental health stressor but who did not show a concerning behavior, and five other active shooters who showed a mental

    health-related concerning behavior but for whom there was no evidence of mental health stress.

    Continues on next page

    19

    Risk-taking 13 21

    Firearm behavior 13 21

    Violent media usage 12 19

    Weight/eating 8 13

    Drug abuse 8 13

    Impulsivity 7 11

    Alcohol abuse 6 10

    Physical health 6 10

    Other (e.g. idolizing criminals) 5 8

    Sexual behavior 4 6

    Quality of sleep 3 5

    Hygiene/appearance 2 3

    * Based on the 24 active shooters who were employed at the time of the offense

    ** Based on the 12 active shooters who were students at the time of the offense

    When Were the Concerning Behaviors Noticed?

    Since the overwhelming majority of active shooters (all but three) displayed at least two concerning behaviors,

    there are a number of different ways to assess the data. One way is to examine the data by active shooter and to

    observe the first instance that any concerning behavior was noticed (this could not be determined for three active
    shooters). Figure 9 shows this data and helps frame the longest time before a shooting during which others were

    concerned about the active shooter’s behavior.

    Again, this chart shows the first instance of any concerning behavior, and it should be kept in mind that this

    behavior might not have been the type that by itself would cause a reasonable person to be alarmed or to report it to

    others. For example, a co-worker who noticed that an active shooter had more than the normal amount of conflict
    with a supervisor might be unlikely to take any action. Perhaps only after an attack and with the benefit of hindsight
    would this singular behavior be considered to be — in and of itself — troubling or concerning. Yet, on average,

    each active shooter displayed four to five concerning behaviors over time. While it may only be the interaction and

    cumulative effect of these behaviors that would cause alarm, early recognition and detection of growing or interre-

    lated problems may help to mitigate the potential for violence.

    20

    In What Way Were the Concerning Behaviors Noticed?

    Concerning behaviors came to the attention to others in a variety of ways, with some far more common than

    others. The most prevalent way in which concerning behaviors were noticed was verbal communication by the

    active shooter (95%, n = 60), followed by observing the physical actions of the active shooter (86%, n = 54),

    written communication (27%, n = 17), and finally instances where concerning behavior was displayed online
    (16%, n = 10). A large majority of active shooters (89%, n = 56) demonstrated concerning behaviors that were

    noticed in multiple ways.

    Who Noticed the Concerning Behaviors?

    At least one person noticed a concerning behavior in every active shooter’s life, and on average, people from

    three different groups noticed concerning behaviors for each active shooter. As shown below, classmates (for

    those who were students), partners (for those in relationships), family members and friends most frequently

    noticed concerning behavior, followed by co-workers, other, and law enforcement:

    TABLE 3: WHO NOTICED CONCERNING BEHAVIORS

    Who Noticed Number %

    Schoolmate* 11 92

    Spouse/domestic partner** 13 87

    Teacher/school staff* 9 75

    Family member 43 68

    Friend 32 51

    Co-worker 25 40

    Other (e.g. neighbors) 23 37

    Law enforcement 16

    25

    Online individual 6 10

    Religious mentor 3 5

    * Percentage calculated only with those active shooters who were students at the time of the offense

    ** Percentage calculated only with those active shooters who were in a relationship at the time of the offense

    What, If Anything, Did the Concerned Party Do?

    If the person recognizes behaviors as problematic but takes no action, the opportunity for intervention is missed.

    Whether and how a person responds to an active shooter’s concerning behavior is likely influenced by a host of
    personal and situational factors (e.g., whether the behavior is threatening to the observer or others, the relationship

    of the observer and active shooter, avenues for anonymous reporting, and/or confidence in authorities or others to
    address the behavior).

    In this study, even in cases where an active shooter displayed a variety of concerning behaviors that might indicate

    an intent to act violently, the observer(s) of that information did not necessarily pass it along to anyone else. As

    shown above, the people most likely to notice concerning behaviors were those who knew the active shooter best

    — family, friends and classmates. For the very reason they are the people most likely to take note of concerning

    behaviors, they are also people who may feel constrained from acting on these concerns because of loyalty,

    disbelief, and/or fear of the consequences.23

    23 Borum, R. (2013). Informing Lone‐Offender Investigations. Criminology & Public Policy, 12(1), 103-112.

    21

    Again, keeping in mind that active shooters displayed multiple concerning behaviors and those who observed these

    behaviors might have responded in different ways to each, the most common response was to communicate directly

    to the active shooter (83%, n = 52) or do nothing (54%, n = 34). Thus, in many instances, the concern stayed

    between the person who noticed the behavior and the active shooter.

    The next most common responses were: report the active shooter to a non-law enforcement authority (51%, n = 32);

    discuss the concerning behavior with a friend or family member (49%, n = 31); and, report the active shooter to law

    enforcement authority (41%, n = 26).

    Considerations

    The analysis above is not intended to, nor could it, encompass the innumerable ways in which the observer of a

    concerning behavior might react. Nor does it suggest that every concerning behavior warrants assertive intervention;

    many of the concerning behaviors that registered with others likely would not have presaged deadly violence to a

    reasonable person. The FBI is aware that in retrospect certain facts may take on a heightened degree of significance
    that may not have been clear at the time.

    Nevertheless, understanding that there are often opportunities before a shooting to recognize concerning behaviors

    that may suggest progression toward violence, the FBI is highlighting the most common behaviors displayed in the

    sample. There is no single warning sign, checklist, or algorithm for assessing behaviors that identifies a prospective
    active shooter. Rather, there appears to be a complex combination of behaviors and interactions with bystanders

    that may often occur in the days, weeks, and months leading up to an attack. Early recognition and reporting of

    concerning behaviors to law enforcement or threat assessment professionals may initiate important opportunities

    for mitigation.

    PRIMARY GRIEVANCE
    A grievance is defined for this study as the cause of the active shooter’s distress or resentment; a perception — not
    necessarily based in reality — of having been wronged or treated unfairly or inappropriately.24,25,26 More than a

    typical feeling of resentment or passing anger, a grievance often results in a grossly distorted preoccupation with

    a sense of injustice, like an injury that fails to heal. These thoughts can saturate a person’s thinking and foster a

    pervasive sense of imbalance between self-image and the (real or perceived) humiliation. This nagging sense of

    unfairness can spark an overwhelming desire to “right the wrong” and achieve a measure of satisfaction and/or

    revenge. In some cases, an active shooter might have what appeared to be multiple grievances but, where possible,

    the FBI sought to determine the primary grievance. Based on a review of the academic literature and the facts of

    the cases themselves, the FBI identified eight categories of grievances, with an additional category of “other” for
    grievances that were entirely idiosyncratic.

    As shown in the following table, the FBI could not identify a primary grievance for 13 (21%) of the active

    shooters, either because they did not have one or because there was insufficient evidence to determine whether
    one existed. While it may be particularly difficult to understand the motivation(s) for attacks that do not appear
    to be based on identifiable grievances, these active shooters still displayed concerning behaviors, were under
    identifiable stressors, and engaged in planning and preparation activities. For example, for the active shooters
    where no grievance could be identified, all had at least two behaviors (with an average of 5.4 behaviors) that
    were noted to be concerning by others.

    24 Calhoun, T., & Weston, S., (2003).

    25 Fein, R., & Vossekuil, B. (1999).

    26 Vossekuil, B., Fein, R., Reddy, M., Borum, R., & Modzeleski, W. (2004).

    22

    The majority (79%, n = 50) of the active shooters did appear to be acting in accord with a grievance of some kind.

    Of course, the grievance itself may not have been reasonable or even grounded in reality, but it appeared to serve as

    the rationale for the eventual attack, giving a sense of purpose to the shooter. Most of these grievances seem to have

    originated in response to some specific action taken regarding the active shooter. Whether interpersonal, employment,
    governmental, academic, or financial, these actions were (or were perceived to be) directed against the active shooter
    personally. In contrast, grievances driven by more global or broad considerations — such as ideology or hatred of a

    group — account for less than 7% of the overall cases. In general then, active shooters harbored grievances that were

    distinctly personal to them and the circumstances of their daily lives.

    TABLE 4: PRIMARY GRIEVANCE

    Primary Grievance Number %

    Adverse interpersonal action against the shooter 21 33

    Adverse employment action against the shooter 10 16

    Other (e.g. general hatred of others) 6 10

    Adverse governmental action against the shooter 3 5

    Adverse academic action against the shooter 2 3

    Adverse financial action against the shooter 2 3

    Domestic 2 3

    Hate crime 2 3

    Ideology/extremism 2 3

    Unknown 13 21

    Precipitating Events

    Of the 50 active shooters who had an identifiable grievance, nearly half of them experienced a precipitating
    or triggering event related to the grievance (44%, n = 22). Seven active shooters (14%) did not experience a

    precipitating event, and the FBI could not determine whether the remaining 21 (42%) did. Precipitating events

    generally occurred close in time to the shooting and included circumstances such as an adverse ruling in a legal

    matter, romantic rejection, and the loss of a job.

    These precipitating events were of more consequence in the timing of the attack, and while they appear to have

    accelerated the active shooter’s movement on the trajectory to violence, they did not by themselves appear to set

    the course.

    Considerations

    Of course, many people have grievances and never act violently. What caused the active shooters in this study to

    act the way they did cannot be explained simply by the presence of a grievance. There was likely the interaction

    of a variety of operational considerations and psychological stressors that eventually crystallized in the decision

    to ignore non-violent options and choose to attack. However, the types of grievances most commonly experienced

    by the active shooters in this study may be important considerations for the many threat assessment teams and law

    enforcement professionals who work each day to assess a subject’s progression along the pathway to violence.

    23

    TARGETING
    For this study, a target is defined as a person or group of people who were identifiable before the shooting
    occurred and whom the active shooter intended to attack. It was not necessary that the active shooter knew the

    target by name; intending to attack a person holding a position at or affiliated with a business, educational facil-
    ity, or in a governmental agency sufficed. The target could be a group, so long as members of that group could
    have been identified

    prior to the attack.

    In cases where the victims could not reasonably have been identified prior to the shooting, the active shooter was
    deemed to have selected the victims at random. While there is some element of selection in any attack where there

    is more than one potential victim (unless the active shooter literally does not aim at all), the FBI considered victims

    to be random where there was: 1) no known connection between the active shooter and the victims, and 2) the

    victims were not specifically linked to the active shooter’s grievance.

    In many cases, there was a mix of targeted and random victims in the same shooting. The typical circumstance

    occurred when an active shooter went to a location with targets in mind and also shot others who were at the same

    location, either because they presented some obstacle in the attack or for reasons that could not be identified.

    The overall numbers for targeted and random victims are listed below:

    Considerations

    While approximately one-third of active shooters in this sample victimized only random members of the public,

    most active shooters arrive at a targeted site with a specific person or persons in mind. Awareness of targeting
    behaviors can provide valuable insight for threat assessment professionals. Relatedly, the FBI has observed that

    when an active shooter’s grievance generalizes — that is, expands beyond a desire to punish a specific individual
    to a desire to punish an institution or community — this should be considered to be progression along a trajectory

    towards violence and ultimately a threat-enhancing characteristic.

    24

    SUICIDE: IDEATION AND ATTEMPTS
    For this study, “suicidal ideation” was defined as thinking about or planning suicide, while “suicide attempt” was
    defined as a non-fatal, self-directed behavior with the intent to die, regardless of whether the behavior ultimately
    results in an injury of any kind. Although these definitions are broad, the FBI concluded that an active shooter had
    suicidal ideation or engaged in a suicide attempt only when based on specific, non-trivial evidence.

    Nearly half of the active shooters had suicidal ideation or engaged in suicide-related behaviors at some time prior to

    the attack (48%, n = 30), while five active shooters (8%) displayed no such behaviors (the status of the remaining
    28 active shooters was unknown due to a lack of sufficient evidence to make a reasonable determination).

    An overwhelming majority of the 30 suicidal active shooters showed signs of suicidal ideation (90%, n = 27), and

    seven made actual suicide attempts (23%). Nearly three-quarters (70%, n = 21) of these behaviors occurred within

    one year of the shooting.

    Considerations

    The high levels27 of pre-attack suicidal ideation — with many appearing within 12 months of the attack — are

    noteworthy as they represent an opportunity for intervention. If suicidal ideation or attempts in particular are

    observed by others, reframing bystander awareness within the context of a mass casualty event may help to empha-

    size the importance of telling an authority figure and getting help for the suicidal person. Without stigmatizing
    those who struggle with thoughts of self-harm, researchers and practitioners must continue to explore those active

    shooters who combined suicide with externalized aggression (including homicidal violence) and identify the

    concurrent behaviors that reflect this shift.

    CONCERNING COMMUNICATIONS
    One useful way to analyze concerning communications is to divide them into two categories: threats/confrontations

    and leakage of intent.

    Threats/Confrontations

    Threats are direct communications to a target of intent to harm and may be delivered in person or by other means

    (e.g., text, email, telephone). For this study, threats need not be verbalized or written; the FBI considered in-person

    confrontations that were intended to intimidate or cause safety concerns for the target as falling under the category

    of threats as well.

    More than half of the 40 active shooters who had a target made threats or had a prior confrontation (55%, n = 22).

    When threats or confrontations occurred, they were almost always in person (95%, n = 21) and only infrequently in

    writing or electronically (14%, n = 3). Two active shooters made threats both in person and in writing/electronically.

    Leakage

    Leakage occurs when a person intentionally or unintentionally reveals clues to a third-party about feelings,

    thoughts, fantasies, attitudes or intentions that may signal the intent to commit a violent act.28 Indirect threats of

    harm are included as leakage, but so are less obvious, subtle threats, innuendo about a desire to commit a violent

    attack, or boasts about the ability to harm others. Leakage can be found not only in verbal communications, but

    27 The National Survey on Drug Use and Health (2015) shows that in 2015: 4% of adults had serious thoughts of suicide, 1.1% made serious plans, and 0.6% attempted suicide

    (https://www.samhsa.gov/data/sites/default/files/NSDUH-DR-FFR3-2015/NSDUH-DR-FFR3-2015.htm)

    28 Meloy, J. R. & O’Toole, M. E. (2011). The concept of leakage in threat assessment. Behavioral Sciences and the Law, 29, 513-527

    25

    also in writings (e.g., journals, school assignments, artwork, poetry) and in online interactions (e.g., blogs, tweets,

    texts, video postings). Prior research has shown that leakage of intent to commit violence is common before attacks

    perpetrated by both adolescents and adults, but is more common among adolescents.29,30,31

    Here, too, leakage was prevalent, with over half of the active shooters leaking intent to commit violence (56%,

    n = 35). In the Phase II sample, 88% (n = 7) of those active shooters age 17 and younger leaked intent to commit

    violence, while 51% (n = 28) of adult active shooters leaked their intent. The leaked intent to commit violence was

    not always directed at the eventual victims of the shootings; in some cases what was communicated was a more

    general goal of doing harm to others, apparently without a particular person or group in mind. For example, one

    active shooter talked to a clerk at a gas station about killing “a family” and another expressed interest in becoming

    a sniper like a character featured in The Turner Diaries. In 16 of the 40 cases (40%) where the active shooter had a

    target, however, the leaked intent to act violently was directly pertaining to that target. In these cases, the leakage

    was generally a statement to a third-party of the intent to specifically harm the target.

    Legacy Tokens

    Finally, the FBI considered whether or not an active shooter had constructed a “legacy token” which has been

    defined as a communication prepared by the offender to claim credit for the attack and articulate the motives
    underlying the shooting.32 Examples of legacy tokens include manifestos, videos, social media postings, or other

    communications deliberately created by the shooter and delivered or staged for discovery by others, usually near in

    time to the shooting. In 30% (n = 19) of the cases included in this study, the active shooter created a legacy token

    prior to the attack.

    Considerations

    Although more than half of the active shooters with pre-attack targets made threats (n = 22), in the majority (65%)

    of the overall cases no threats were made to a target, and the FBI cautions that the absence of a direct threat should

    not be falsely reassuring to those assessing the potential for violence raised by other circumstances and factors. Nor

    should the presence of a threat be considered conclusive. There is a significant amount of research and experience
    to demonstrate that direct threats are not correlated to a subsequent act of targeted violence.33,34,35,36,37,38

    It is important to highlight that in this Phase II study the overwhelming majority of direct threats were verbally

    delivered by the offender to a future victim. Only a very small percentage of threats were communicated via

    writing or electronically. In many ways this is not surprising. Written, directly communicated threats against

    a target (e.g., “I’m going to shoot and kill everyone here on Tuesday”) often spark a predictable response that

    includes a heightened law enforcement presence and the enhancement of security barriers. These responses are

    highly undesirable to an offender planning an active shooting.39 Verbal threats issued directly to another person

    appear to be far more common among the active shooters included in the Phase II study.

    29 Hemple, A., Meloy, J.R., & Richards, T. (1999). Offender and offense characteristics of a nonrandom sample of mass murderers. Journal of the American Academy of Psychiatry and the Law, 27,

    213-225. Meloy, J.R., Hoffman, J., Guldimann, A., & James, D. (2011). The role of warning behaviors in threat assessment: An exploration and suggested typology. Behavioral Sciences and the

    Law, 30,

    256-279.

    30 Meloy, J. R. & O’Toole, M. E. (2011).

    31 Meloy, J.R., Hoffman, J., Guldimann, A., & James, D. (2011). The role of warning behaviors in threat assessment: An exploration and suggested typology. Behavioral Sciences and the Law, 30,

    256-279.

    32 Simons, A., & Tunkel, R. (2014). The assessment of anonymous threatening communications. In J.R. Meloy & J. Hoffman (Eds.), International handbook of threat assessment (pp. 195-213). New

    York: Oxford University Press.

    33 Borum, R., Fein, R. Vossekuil, B., & Berglund, J. (1999). Threat assessment: Defining an approach for evaluating risk of targeted violence. Behavioral Sciences and the Law, 17, 323-337.

    34 Calhoun, F. (1998). Hunters and howlers: Threats and violence against federal judicial officials in the United States, 1789-1993. Arlington, VA: US Marshals Service.

    35 Calhoun T. & Weston, S. (2003).

    36 Dietz, P., Matthews, D., Martell, D., Stewart, T., Hrouda, D., & Warren, J. (1991a). Threatening and otherwise inappropriate letters to members of the United States Congress. Journal of Forensic

    Sciences, 36, 1445-1468.

    37 Dietz, P., Matthews, D., Van Duyne, C., Martell, D., Parry, C., Stewart, T., et al. (1991b). Threatening and otherwise inappropriate letters to Hollywood celebrities. Journal of Forensic Sciences, 36,

    185-209.

    38 Meloy, J.R. (2000). Violence risk and threat assessment. San Diego: Specialized Training Services.

    39 Simons A. & Tunkel, R. (2014)

    26

    Whether verbal or written, concerning communications are challenging as those on the receiving end must assess

    sometimes ominously vague or nebulous verbiage. Such confusion can create doubt in the listener’s mind as to

    the communicator’s true intent toward violence.40 As law enforcement agencies continue to remind bystanders

    if they “see something, say something” it becomes relevant to use this data (particularly regarding leakage

    behaviors) to lower the internal threshold for reporting, even in the face of ambiguous language. It is troubling

    to note that no bystanders reported instances of leakage to law enforcement, perhaps out of a fear of overreacting

    or perhaps due to a lack of understanding as to what law enforcement’s response would be. This suggests that

    more robust efforts need to be made to educate bystanders (especially students and adolescents) on the nature of

    leakage and its potential significance.

    Limitations

    The findings presented in this report reflect a thorough and careful review of the data derived almost exclusively
    from law enforcement records. Nevertheless, there are limitations to the study which should be kept in mind before

    drawing any conclusions based on the findings.

    First, the Phase I study on which the present analysis is based included only a specific type of event. Shootings
    must have been (a) in progress in a public place and (b) law enforcement personnel and/or citizens had the potential

    to affect the outcome of the event based on their responses. The FBI acknowledges there is an inherent element of

    subjectivity in deciding whether a case meets the study criteria. Moreover, while every effort was made to find all
    cases between 2000 and 2013 which met the definition, it is possible that cases which should have been included in
    the study were not identified. Overall, as with the Phase I study, the incidents included in the Phase II study were
    not intended to and did not comprise all gun-related violence or mass or public shootings occurring between 2000

    and 2013.

    Second, although the FBI took a cautious approach in answering protocol questions and limited speculation by

    relying on identifiable data, there was some degree of subjectivity in evaluating which of the original 160 cases had
    sufficient data to warrant inclusion in the study.

    Third, while reliance on official law enforcement investigative files was reasonable based on the study’s objectives,
    the level of detail contained in these files was not uniform throughout and the FBI was not able to definitively
    answer all protocol questions for all subjects.

    This is a purely descriptive study. With the exception of mental health and suicidal behaviors, the FBI did not make

    any comparisons to the general population or to criminals who were not active shooters. Therefore, we cannot

    postulate on the probability as to whether some of the behaviors and characteristics seen here would also have

    been seen in other populations. Furthermore, the FBI cautions readers to not treat the observed behaviors as having

    predictive value in determining if a person will become violent or not, as the findings and observations presented
    herein are not a “checklist” but instead are offered to promote awareness among potential bystanders and for

    consideration in the context of a thorough, holistic threat assessment by trained professionals. Future research may

    benefit from comparisons between those who completed active shooting attacks and those who planned to attack
    but were disrupted prior to the offense, and/or in comparison to those individuals who may have displayed concern-

    ing behaviors but had no true intent to commit an act of targeted violence.

    40 The FBI noted that there were four cases where threats were made and someone notified law enforcement (out of 22 cases where a threat was made, or 14%)

    27

    Conclusion

    The ability to utilize case files (as compared to open-source documents) allowed the FBI to carefully examine
    both the internal issues experienced and the behaviors demonstrated by active shooters in the weeks and months

    preceding their attacks. What emerges is a complex and troubling picture of individuals who fail to successfully

    navigate multiple stressors in their lives while concurrently displaying four to five observable, concerning
    behaviors, engaging in planning and preparation, and frequently communicating threats or leaking indications of

    an intent to attack. As an active shooter progresses on a trajectory towards violence, these observable behaviors

    may represent critical opportunities for detection and disruption.

    The information contained in this Phase II report can be utilized by myriad safety stakeholders. The successful

    prevention of an active shooting frequently depends on the collective and collaborative engagement of varied

    community members: law enforcement officials, teachers, mental health care professionals, family members, threat
    assessment professionals, friends, social workers, school resource officers…and many others. A shared awareness
    of the common observable behaviors demonstrated by the active shooters in this study may help to prompt inquiries

    and focus assessments at every level of contact and every stage of intervention.

    While many dedicated professionals work to thwart active shootings, the FBI suspects that future active shooters

    themselves are looking for ways to avoid detection and maximize damage as they plan and prepare for their acts of

    violence. The prevention of these future attacks will depend on our ability to remain agile and recognize evolving

    pre-attack behaviors. To that end, the FBI continues to study active shooters to better inform all safety stakeholders

    and to support the development of sound threat mitigation strategies.

    As tragically seen from current events, active shootings continue to impact our nation. The FBI hopes that the

    information contained in this Phase II study will help in efforts to promote safety across all communities.

    28

  • Appendix A:
  • STRESSORS

    Abuse of illicit drugs or alcohol: difficulties caused by the effects of drugs/alcohol and/or frustrations related to
    obtaining these substances.

    Civil legal problems: being party to a non-trivial lawsuit or administrative action.

    Conflict with friends/peers: general tension in the relationship beyond what is typical for the active shooter’s age

    or specific instances of serious and ongoing disagreement.

    Conflict with other family members: general tension in the relationship beyond what is typical for the active

    shooter’s age, or specific instances of serious and ongoing disagreement.

    Conflict with parents: general tension in the relationship beyond what is typical for the active shooter’s age, or

    specific instances of serious and ongoing disagreement.

    Criminal legal problems: arrests, convictions, probation, parole.

    Death of friend/relative: death that caused emotional or psychological distress.

    Financial strain: related to job loss, debt collection, potential or actual eviction, inability to pay normal and usual

    daily bills.

    Job-related problems: ongoing conflicts with co-workers or management, pervasive poor performance evaluations,
    or disputes over pay or leave.

    Marital problems/conflict with intimate partner(s)/divorce or separation: difficulties in the relationship
    that were a consistent source of psychological distress and/or which did or were likely to lead to the end of the

    relationship or the desire to end the relationship.

    Mental health problems: symptoms of anxiety, depression, paranoia, or other mental health concerns that have a

    negative effect on daily functioning and/or relationships.

    Other: any other circumstance causing physical, psychological, or emotional difficulties that interfere in a
    non-trivial way with normal functioning in daily life.

    Physical injury: physical condition/injury that significantly interfered with or restricted normal and usual
    activities.

    School-related problems: conflicts with teachers and staff that go beyond single instances of minor discipline;
    pervasive frustration with academic work; inability to follow school rules.

    Sexual stress/frustration: pronounced and ongoing inability to establish a desired sexual relationship.

    29

    Appendix B:

    CONCERNING BEHAVIORS

    Amount or quality of sleep: unusual sleep patterns or noticeable changes in sleep patterns.

    Anger: inappropriate displays of aggressive attitude/temper.

    Change, escalation, or contextually inappropriate firearms behavior: interest in or use of firearms that
    appears unusual given the active shooter’s background and experience with firearms.

    Changes in weight or eating habits: significant weight loss or gain related to eating habits.

    Hygiene or personal appearance: noticeable and/or surprising changes in appearance or hygiene practices.

    Impulsivity: actions that in context appear to have been taken without usual care or forethought.

    Interpersonal interactions: more than the usual amount of discord in ongoing relationships with family,

    friends, or colleagues.

    Leakage: communication to a third-party of the intent to harm another person.

    Mental health: indications of depression, anxiety, paranoia or other mental health concerns.

    Other: any behavior not otherwise captured in above categories that causes more than a minimal amount of

    worry in the observer.

    Physical aggression: inappropriate use of force; use of force beyond what was usual in the circumstances.

    Physical health: significant changes in physical well-being beyond minor injuries and ailments.

    Quality of thinking or communication: indications of confused or irrational thought processes.

    Risk-taking: actions that show more than a usual disregard for significant negative consequences.

    School performance: appreciable decrease in academic performance; unexplained or unusual absences.

    Sexual behavior: pronounced increases or decreases in sexual interest or practices.

    Threats/Confrontations: direct communications to a target of intent to harm. May be delivered in person or by

    other means (e.g., text, email, telephone).

    Use of illicit drugs or illicit use of prescription drugs: sudden and/ recent use or change in use of drugs; use

    beyond social norms that

    interferes with the activities of daily life.

    Use or abuse of alcohol: sudden and/or recent use or changes in use of alcohol; use beyond social norms that

    interferes with the activities of daily life.

    Violent media usage: more than a usual age-appropriate interest in visual or aural depictions of violence.

    Work performance: appreciable decrease in job performance; unexplained or unusual absences.

    U.S. Department of Justice

    Federal Bureau of Investigation

    • Snapshot
    • Findings

    • Health Care Facilities
    • Residences
    • Military and Other Government Properties
    • Open Spaces
    • Education Environments
    • Commerce Areas
    • Houses of Worship
    • Conclusion

      Appendix A:

    RESEARCH ARTICLE

    The impact of end-demand legislation on sex

    workers’ access to health and sex worker-led

    services: A community-based prospective

    cohort study in Canada

    Elena Argento1,2☯, Shira Goldenberg1,3‡, Melissa Braschel1‡, Sylvia Machat1‡, Steffanie

    A. Strathdee4‡, Kate ShannonID
    1,2☯*

    1 Centre for Gender & Sexual Health Equity, Vancouver, British Columbia, Canada, 2 Faculty of Medicine,

    University of British Columbia, Vancouver, British Columbia, Canada, 3 Faculty of Health Sciences, Simon

    Fraser University, Burnaby, British Columbia, Canada, 4 Department of Medicine, University of California

    San Diego, La Jolla, California, United States of America

    ☯ These authors contributed equally to this work.

    ‡ These authors also contributed equally to this work.

    * dr.shannon@cgshe.ubc.ca

    Abstract

    Background

    Following a global wave of end-demand criminalization of sex work, the Protection of Com-

    munities and Exploited Persons Act (PCEPA) was implemented in Canada, which has impli-

    cations for the health and safety of sex workers. This study aimed to evaluate the impact of

    the PCEPA on sex workers’ access to health, violence, and sex worker-led services.

    Methods

    Longitudinal data were drawn from a community-based cohort of ~900 cis and trans women

    sex workers in Vancouver, Canada. Multivariable logistic regression examined the indepen-

    dent effect of the post-PCEPA period (2015–2017) versus the pre-PCEPA period (2010–

    2013) on time-updated measures of sex workers’ access to health, violence supports, and

    sex worker/community-led services.

    Results

    The PCEPA was independently correlated with reduced odds of having access to health

    services when needed (AOR 0.59; 95%CI: 0.45–0.78) and community-led services (AOR

    0.77; 95%CI: 0.62–0.95). Among sex workers who experienced physical violence/sexual

    violence or trauma, there was no significant difference in access to counseling supports

    post-PCEPA (AOR 1.24; 95%CI: 0.93–1.64).

    Conclusion

    Sex workers experienced significantly reduced access to critical health and sex worker/com-

    munity-led services following implementation of the new laws. Findings suggest end-

    PLOS ONE | https://doi.org/10.1371/journal.pone.0225783 April 6, 2020 1 / 10

    a1111111111

    a1111111111

    a1111111111

    a1111111111

    a1111111111

    OPEN ACCESS

    Citation: Argento E, Goldenberg S, Braschel M,

    Machat S, Strathdee SA, Shannon K (2020) The

    impact of end-demand legislation on sex workers’

    access to health and sex worker-led services: A

    community-based prospective cohort study in

    Canada. PLoS ONE 15(4): e0225783. https://doi.

    org/10.1371/journal.pone.0225783

    Editor: Marina Della Giusta, University of Reading,

    UNITED KINGDOM

    Received: May 31, 2019

    Accepted: November 12, 2019

    Published: April 6, 2020

    Peer Review History: PLOS recognizes the

    benefits of transparency in the peer review

    process; therefore, we enable the publication of

    all of the content of peer review and author

    responses alongside final, published articles. The

    editorial history of this article is available here:

    https://doi.org/10.1371/journal.pone.0225783

    Copyright: © 2020 Argento et al. This is an open

    access article distributed under the terms of the

    Creative Commons Attribution License, which

    permits unrestricted use, distribution, and

    reproduction in any medium, provided the original

    author and source are credited.

    Data Availability Statement: Due to the highly

    criminalized and stigmatized nature of this

    population, anonymized data may be made

    http://orcid.org/0000-0002-6764-5212

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    demand laws may exacerbate and reproduce harms of previous criminalized approaches to

    sex work in Canada. This study is one of the first globally to evaluate the impact of end-

    demand approaches to sex work. There is a critical evidence-based need to move away

    from criminalization of sex work worldwide to ensure full labor and human rights for sex

    workers. Findings warn against adopting end-demand approaches in other cities or

    jurisdictions.

    Introduction

    Global research and evidence demonstrate that criminal policies and punitive enforcement-

    based approaches to sex work continue to undermine the health and human rights of sex

    workers [1–3]. The legal environment has immense potential to shape the wellbeing of those

    most marginalized in society. Substantial evidence demonstrates that the criminalization of

    sex work perpetuates widespread forms of violence, stigma, and discrimination that prevent

    sex workers from seeking or accessing critical health and support services [4–6]. In settings

    where sex work is criminalized, sex workers are at significantly elevated risk of HIV and other

    sexually transmitted infections (STIs) driven by social marginalization and increased exposure

    to workplace violence and abuse [6,7]. The criminalized nature of sex work and related polic-

    ing practices displace sex workers to more isolated and risker locations and reduce the ability

    of sex workers to work together or more formally organize due to fear of arrest and police

    harassment [4,6,8]. Where sex work is criminalized, the ability of sex workers to formally orga-

    nize or work together is restricted. The hindering of collectivization among sex workers

    through criminalization is of critical concern given the central importance of community

    empowerment and enabling sex workers to negotiate safety in the workplace, as well as advo-

    cate for human rights, including access to health and safety.

    Numerous human rights and public health experts and international bodies, such as the

    World Health Organization, UNAIDS, and Amnesty International, along with sex work com-

    munities worldwide, have strongly endorsed full decriminalization of sex work based on well-

    established evidence of the harmful impacts of criminalization and enforcement-based

    approaches [3,9,10]. In 2013, the Supreme Court of Canada struck down three core anti-pros-

    titution laws on the basis that they were a violation of sex workers’ constitutional rights [11];

    however, Canada’s federal government implemented new legislation in 2014, known as the

    “Protection of Communities and Exploited Persons Act” (PCEPA), which has serious implica-

    tions for the health and safety of sex workers. Modeled after laws in Norway, Sweden and a

    number of other European countries, the PCEPA is an end-demand approach that criminal-

    izes new aspects of sex work including communicating for the purpose of selling sex and the

    purchasing and advertising of sexual services, targeting clients and third parties while leaving

    the sale of sex legal [12].

    Research and legal experts and community have expressed serious concerns regarding end-

    demand legislation, as it reproduces the same risks and harms of previous criminalization

    models whereby targeting clients still leads to rushed transactions and improper screening,

    increasing risk of violence and HIV/STIs [7,13]. The PCEPA also targets third party self-adver-

    tising, which has the potential to detrimentally impact sex workers’ health and safety, and con-

    flates sex workers with victims of violence and trafficking. Further, the PCEPA focuses on

    cisgender women sex workers and makes no mention of sex workers who do not identify as cis

    women (i.e., LGBTQ, men) [12], failing to acknowledge gender and sexual diversity of individ-

    uals who sell sex and the unique vulnerabilities faced by gender and sexual minorities [14–16].

    The impact of end-demand laws on sex workers’ access to health and sex worker-led services

    PLOS ONE | https://doi.org/10.1371/journal.pone.0225783 April 6, 2020 2 / 10

    available on request subject to the UBC/

    Providence Health Ethical Review Board, and

    consistent with our funding body guidelines (NIH

    and CIHR). Requests should be directed to

    info@cgshe.ubc.ca.

    Funding: This research is supported by the US

    National Institutes of Health (NIH)

    (R01DA028648), a Canadian Institutes of Health

    Research (CIHR) Foundation Grant, and MacAIDS.

    SG is partially supported by NIH and a CIHR New

    Investigator Award. KS is partially supported by a

    Canada Research Chair in Global Sexual Health and

    HIV/AIDS, NIH, and Michael Smith Foundation for

    Health Research. EA is supported by a CIHR

    Doctoral Award. SAS is supported by a NIDA

    MERIT Award (R37DA019829). The study funders

    had no role in the study design, data collection,

    analysis, interpretation, writing of the report, or

    decision to submit the paper for publication.

    Competing interests: The authors have declared

    that no competing interests exist.

    https://doi.org/10.1371/journal.pone.0225783

    mailto:info@cgshe.ubc.ca

    One of the explicit goals of end-demand approaches is to increase access to services and

    supports for sex workers, yet scientific and legal evidence suggest that criminalization may

    impede access to services [1,2,9,10]. There remains a paucity of empirical research and evi-

    dence on the impacts of end-demand approaches globally. Therefore, this study aimed to lon-

    gitudinally evaluate the impact of the PCEPA on sex workers’ access to health, violence, and

    sex worker/community-led services and supports in Vancouver, Canada.

    Methods

    Longitudinal data (2010–2017) were drawn from a community-based, prospective open cohort

    of over 900 women sex workers in Metro Vancouver known as AESHA (An Evaluation of Sex

    Workers Health Access). Participants were recruited using time-location sampling [17], with

    day and late-night outreach to outdoor sex work locations (i.e., streets, alleyways), indoor sex

    work venues (i.e. massage parlors, micro-brothels, in-call locations), and online. Participatory

    mapping strategies were conducted to identify work venues, and a weekly mobile van has

    reached over 100 sex work venues across the city. AESHA includes a diverse experiential team

    of both current and former sex workers represented across interviewer, outreach, nursing, and

    coordinator staff since its inception in 2010. AESHA also has a Community Advisory Board of

    over 15 women’s health, sex work and HIV agencies, as well as representatives from health

    authorities and policy experts.

    Eligibility criteria for participants include cis or trans women, 14 years of age or older, who

    exchanged sex for money within the last 30 days. After providing written informed consent,

    participants completed interviewer-administered questionnaires and voluntary HIV/STI/

    HCV serology testing at enrollment and biannually. The questionnaires and clinical compo-

    nents were completed at one of two study offices or at a safe location identified by participants.

    The main interview questionnaire elicits responses related to socio-demographics (e.g., sexual

    identity, ethnicity, housing), the work environment (e.g., access to services, safety, policing,

    incarceration), client characteristics (e.g., types/fees of services, condom use), intimate part-

    ners (e.g., cohabitation, financial support), experiences of violence (e.g., childhood abuse,

    exposure to intimate partner and workplace violence), and drug use patterns. The clinical

    questionnaire relates to overall physical, mental, and emotional health, and HIV testing and

    treatment experiences to support education, referral, and linkages with care. The study holds

    ethical approval through Providence Health Care/University of British Columbia Research

    Ethics Board. As in previous studies, we have held ethical approval since 2004 to include self-

    supporting youth aged 14–18 years who are not living with a parent or guardian under the

    emancipated minor clause, given the critical importance of understanding the needs of vulner-

    able youth. All participants received an honorarium of $40 CAD at each bi-annual visit for

    their time, expertise and travel.

    Measures

    The main outcomes of interest were time-updated variables for having access to health care

    when needed and sex worker/community-led services and supports in the last six months.

    Having access to health services when needed was defined as>75% of the time (responding

    ‘Usually (over 75% of the time)’ or ‘Always (100% of the time)’ to the question ‘How often can

    you get health care services when you need it?’). Utilization of sex worker/community-led ser-

    vices was defined as responding ‘yes’ to using any sex worker/community-led health or sup-

    port services, including outreach programs. Access to counseling support for violence/trauma

    was also examined as an outcome variable among participants who had ever experienced any

    physical and/or sexual violence and/or lifetime trauma, defined as responding ‘yes’ to

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    experiencing any barriers to counseling or therapy for sexual abuse or other trauma or

    violence.

    The primary exposure variable was the post-PCEPA time period (April 2015-August 2017

    vs. 2010–2013). Given that the PCEPA was introduced in January 2014 and not officially

    passed until the end of the year, the year 2014 was dropped from the analyses in order to

    reduce any potential effects on the outcomes of interest due to variation in the ways in which

    the laws may have been enforced during this phase. The first three months of 2015 were also

    excluded to account for outcome measures referring to the preceding six months. Approxi-

    mately half (53%, n = 452) of participants were interviewed in the pre-PCEPA time period

    (2010–2013) only, and 14% (n = 117) were interviewed in the post-PCEPA time period (2015–

    2017) only. One-third (33%, n = 285) of participants were interviewed in both pre- and post-

    PCEPA time periods. Various other socio-demographic and structural-environmental vari-

    ables were considered as potential confounders based on the literature and available data col-

    lected for the AESHA cohort. Time-fixed variables included gender and/or sexual minority

    (LGBTQ) and Indigenous ancestry (inclusive of First Nations, Metis, and Inuit). Participant

    age was updated based on age at baseline and interview date. Primary place of soliciting clients

    (e.g., street/public spaces, indoor venues/in-call, independent off-street/online), workplace

    physical and/or sexual violence by clients, police harassment without arrest, any injection and

    non-injection drug use, and being on any opioid substitution therapy (OST) were considered

    time-varying and were updated to reflect their occurrence within the last six months.

    Statistical analyses

    Descriptive statistics at baseline were calculated for the primary independent variable, the

    post-PCEPA period, and all potential confounders, stratified by the outcomes of interest. Cate-

    gorical variables were assessed using Pearson’s chi-square test (or Fisher’s exact test for small

    cell counts), and the Wilcoxon rank sum test was used for continuous variables. The relation-

    ships between the post-PCEPA period and access to health care and sex worker/community-

    led supports were examined using bivariate and multivariable logistic regression with general-

    ized estimating equations (GEE) and an exchangeable correlation matrix. Separate multivari-

    able confounder models were fitted to assess the independent relationship between the post-

    PCEPA period and the outcomes of interest. All analyses were restricted to observations where

    participants reported engaging in sex work in the last six months; the model for accessing vio-

    lence supports was further restricted to those who had ever experienced physical and/or sexual

    violence. A sub-analysis was conducted to examine whether physical and/or sexual workplace

    violence was affected by the PCEPA; however, these results were not found to be significant.

    Full models included all hypothesized confounders and were subjected to a manual stepwise

    approach, whereby variables that altered the association of interest by<5% were systematically

    removed [18]. Remaining variables were retained as confounders in the final multivariable

    models. A complete case analysis was used such that observations with any missing data were

    removed. Two-sided p-values and unadjusted and adjusted odds ratios (ORs and AORs) with

    95% confidence intervals (95%CI) for the associations between the post-PCEPA period and

    the outcomes of interest were generated. All statistical analyses were performed using SAS soft-

    ware version 9.4 (SAS Institute, Cary, NC, USA).

    Results

    Of a total 854 participants who completed the baseline questionnaire, 14% (n = 118) reported

    not having access to health services when needed at baseline and 29% (n = 247) reported not

    having access at some point during the study. At baseline, 59% (n = 501) reported using a sex

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    worker/community-led health service (70%, n = 596 used these services at some point during

    the study period). Of a total 683 participants who reported ever experiencing physical and/or

    sexual violence and/or trauma, 11% (n = 77) reported experiencing barriers to accessing

    counseling support for violence/trauma at baseline and 31% (n = 209) experienced barriers at

    some point during the study period. Baseline characteristics among women who had access to

    health care, sex worker/community-led services and supports, and violence supports are dis-

    played in Tables 1, 2 and 3.

    The median age at baseline was 35 years (interquartile range [IQR] = 28–42). At baseline,

    36% (n = 310) identified as a gender or sexual minority and 39% (n = 332) as Indigenous,

    highlighting the overrepresentation of gender and sexual minorities and Indigenous women

    among sex workers in Vancouver. Among the restricted sample of participants who had ever

    experienced violence or trauma, 44% (n = 299/683) identified as a gender or sexual minority

    and 47% (n = 320/683) as Indigenous, and a significantly higher proportion of Indigenous

    women reported experiencing barriers to counseling (p = 0.016).

    Unadjusted and adjusted odds ratios for the associations between the post-PCEPA time

    period and access to health care, sex worker/community-led services and supports, and counsel-

    ing for violence/trauma are displayed in Table 4. In final separate multivariable confounder

    models, the post-PCEPA period was independently associated with significantly reduced odds

    of having access to health services when needed (AOR 0.59; 95%CI: 0.45–0.78) and sex worker/

    community-led services and supports (AOR 0.77; 95%CI: 0.62–0.95). Among sex workers who

    experienced violence or trauma, there was no significant difference in access to counseling sup-

    ports following implementation of the new laws (AOR 1.24; 95%CI: 0.93–1.64; p = 0.140).

    Discussion

    Despite one of the explicit goals of end-demand criminalization approaches being to increase

    access to services and supports for sex workers, this study found no statistically significant

    Table 1. Baseline socio-structural characteristics of sex workers who had access to health services when needed in the last 6 months, compared to those who did not

    (N = 852).

    Characteristic Had access to health services when needed N = 734

    (86%)

    Did not have access to health services when needed N = 118

    (14%)

    p-value

    Post-PCEPA 96 (13.1) 21 (17.8) 0.167

    Age (median, IQR) 35 (28–42) 35 (28–43) 0.747

    Gender/sexual minority 270 (36.8) 39 (33.1) 0.428

    Indigenous 288 (39.2) 43 (36.4) 0.556

    Used non-injection drugs† 501 (68.3) 66 (55.9) 0.007

    Used injection drugs† 310 (42.2) 36 (30.5) 0.016

    Workplace violence† 285 (38.8) 48 (40.7) 0.752

    On opioid substitution therapy
    No 257 (35.0) 41 (34.8)

    Yes 204 (27.8) 14 (11.9)

    N/A (never used opioids) 268 (36.5) 59 (50.0) <0.001

    Primary place to solicit clients†

    Street/public space 384 (52.3) 48 (40.7)

    Indoor/in-call venue 194 (26.4) 51 (43.2)

    Independent/self-

    advertising

    148 (20.2) 19 (16.1) 0.001

    † In the last 6 months.

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    increase in access to health or sex worker/community-led support services following imple-

    mentation of the PCEPA in Vancouver, Canada. Rather, findings suggest that after implemen-

    tation of the new laws, sex workers had reduced access to health and sex worker/community-

    led supports. To our knowledge, this study is the first to longitudinally evaluate the impact of

    end-demand legislation on access to health services and supports for sex workers in Canada.

    Table 2. Baseline socio-structural characteristics of sex workers who utilized sex worker/community-led health and support services in the last 6 months, compared

    to those who did not (N = 854).

    Characteristic Used community services N = 501 (59%) Did not use community services N = 353 (41%) p-value

    Post-PCEPA 60 (12.0) 57 (16.2) 0.081

    Age (median, IQR) 35 (28–42) 35 (28–42) 0.658

    Gender/sexual minority 229 (45.7) 81 (23.0) <0.001

    Indigenous ancestry 263 (52.5) 69 (19.6) <0.001

    Used non-injection drugs† 443 (88.4) 125 (35.4) <0.001

    Used injection drugs† 291 (58.1) 55 (15.6) <0.001

    Workplace violence† 257 (51.3) 79 (22.4) <0.001

    On opioid substitution therapy
    No 231 (46.1) 67 (19.0)

    Yes 177 (35.3) 42 (11.9)

    N/A (never used opioids) 86 (17.2) 242 (68.6) <0.001

    Primary place to solicit clients†

    Street/public space 357 (71.3) 76 (21.5)

    Indoor/in-call venue 31 (6.2) 215 (60.9)

    Independent/self-advertising 109 (21.8) 58 (16.4) <0.001

    † In the last 6 months.

    https://doi.org/10.1371/journal.pone.0225783.t002

    Table 3. Baseline socio-structural characteristics of sex workers who experienced barriers to receiving counseling for trauma in the last 6 months, compared to

    those who did not (N = 683)�.

    Characteristic Experienced barriers to support N = 77 (11%) Did not experience barriers to support N = 606 (89%) p-value

    Post-PCEPA 12 (15.6) 84 (13.9) 0.682

    Age (median, IQR) 32 (28–40) 35 (28–42) 0.159

    Gender/sexual minority 33 (42.9) 266 (43.9) 0.863

    Indigenous ancestry 46 (59.7) 274 (45.2) 0.016

    Used non-injection drugs† 68 (88.3) 486 (80.2) 0.054

    Used injection drugs† 41 (53.3) 293 (48.4) 0.418

    Workplace violence† 40 (52.0) 280 (46.2) 0.302

    On opioid substitution therapy
    No 35 (45.5) 258 (42.6)

    Yes 23 (29.9) 188 (31.0)

    N/A (never used opioids) 17 (22.1) 153 (25.3) 0.808

    Primary place to solicit clients†

    Street/public space 50 (64.9) 372 (61.4)

    Indoor/in-call venue 6 (7.8) 96 (15.8)

    Independent/self-advertising 20 (26.0) 132 (21.8) 0.161

    �Restricted to workers who reported sexual and/or physical violence or trauma in lifetime.
    † In the last 6 months.

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    Findings from this study support global calls for full decriminalization of sex work as a criti-

    cal and necessary structural intervention to improve health and human rights for sex workers

    and reduce transmission of HIV and other STIs [2,3,7,10]. Existing data suggests that end-

    demand criminalization that targets clients and third parties, but not sex workers, has been

    shown to reproduce the risks and harms associated with previous laws criminalizing sex work.

    For example, a recent study from France found that end-demand laws had detrimental effects

    on sex workers’ safety, health and overall living conditions–worse than the previous laws

    against soliciting [13]. Qualitative research in Vancouver elucidated the ways in which policing

    practices that target clients recreate vulnerability to violence by hindering the ability of work-

    ers to properly screen clients [7]. Further, the evidence is unequivocal that sex workers who

    experience physical or sexual violence are less able to negotiate the terms of their transactions

    and are more likely to experience client condom refusal, significantly increasing risk of HIV/

    STI transmission [8,19–23]. Marginalized sex workers who experience violence face consider-

    able barriers to accessing counselling for trauma support. The present analysis demonstrates

    that there was no change in experiencing barriers to accessing counselling for violence or

    trauma post-PCEPA. This lack of change suggests that end-demand criminalization has failed

    to address such barriers and may potentially exacerbate the physical and psychological burden

    among sex workers, especially given that one of the explicit goals of end-demand legislation is

    to increase access to services and supports for sex workers. Future qualitative work would help

    to shed more light on sex workers’ experiences of barriers to accessing these services pre- vs.

    post-PCEPA.

    Interventions aimed at promoting community empowerment and social cohesion among

    sex workers can have powerful influences on women’s health and safety, as evidenced in lower

    and middle-income countries [24–26]. However, criminalization, stigma, and a lack of fund-

    ing to support sex worker-led programs continue to impede collectivization among sex work-

    ers [1,24]. Akin to the US PEPFAR anti-prostitution pledge, the PCEPA reduces access to

    community-led services and jeopardizes funding for and development of critical sex worker-

    led supports, in addition to further conflating sex work with trafficking [6,10,27,28]. Legislative

    reform to sex work laws in New Zealand and parts of Australia exemplify the benefits of

    decriminalizing all aspects of sex work for enabling safer occupational conditions for sex work-

    ers, with demonstrated impacts on increased access to health services and improved workplace

    safety [29–31]. Structural and legal interventions should therefore be guided by the large and

    growing body of evidence demonstrating that punitive approaches to sex work, including end-

    demand criminalization such as the PCEPA recently implement in Canada, do not improve

    health, safety, or access to services for sex workers.

    Table 4. Unadjusted and adjusted odds ratios for the effect of the post-PCEPA period (2015–2017 vs. 2010–2013) on sex workers’ access to health and sex worker/

    community-led services and supports in the last 6 months.

    Health Access Outcomes Unadjusted Odds Ratio (95%

    CI)

    p-value Adjusted Odds Ratio (95%

    CI)

    p-value

    Accessed health services when needed 0.60 (0.47–0.76) <0.001 0.59 (0.45–0.78)� <0.001

    Utilized community-driven sex work health and support services 0.73 (0.63–0.85) <0.001 0.77 (0.62–0.95)�� 0.014

    Experienced barriers to accessing counseling for sexual abuse, trauma or other

    violence†
    1.10 (0.86–1.40) 0.465 1.24 (0.93–1.64)��� 0.140

    † Restricted to workers who reported sexual and/or physical violence or trauma in lifetime.

    � Adjusted for workplace violence, non-injection drug use, and opioid substitution therapy.

    �� Adjusted for age, Indigeneity, place of solicitation, workplace violence, injection and non-injection drug use, and opioid substitution therapy.

    ���Adjusted for age, Indigeneity, place of solicitation, workplace violence and non-injection drug use.

    https://doi.org/10.1371/journal.pone.0225783.t004

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    Strengths and limitations

    A major strength of this study is prospective design and use of GEE analyses, which increased

    statistical power. Sex workers’ access to health and support services is likely influenced by a

    complex set of socio-structural variables, and not all potential confounders could be controlled

    for in this study. Among the sample restricted to women who experienced violence/trauma,

    experiencing barriers to counseling may have been underestimated due to the fact that baseline

    questionnaires prior to September 2014 only asked about sexual violence and not physical vio-

    lence or trauma. Data were self-reported, which introduces the potential for social desirability

    and reporting biases, and events that occurred in the past may be subject to recall bias. Given

    that interviews were conducted in safe and comfortable spaces, alongside the community-

    based nature of the study represented by experiential interviewers (including current and for-

    mer sex workers), the likelihood of some biases may have been reduced. Findings may not be

    generalizable to other sex work populations and settings; however, the study included a wide

    representation of sex workers from both street and off-street work environments. Women

    who work more independently (e.g., escorts, online) may have been underrepresented. Com-

    munity mapping and time-location sampling likely helped to minimize selection bias and

    ensure a more representative sample of sex workers.

    Conclusions

    Findings demonstrate no increase in access to health, violence, and sex worker-led support ser-

    vices post-PCEPA, and rather a reduction in odds of accessing sex worker/community-led

    supports and health services when needed. End-demand approaches to criminalize sex work

    may not only reproduce the harms of previous criminalized approaches to sex work in Canada,

    but may further exacerbate barriers to accessing health and community-led services that have

    been proven to be key contributors of better health outcomes. There is a critical evidence-

    based need to move away from criminalized approaches to sex work to ensure full labor and

    human rights for sex workers, including access to health, social, and legal support services.

    Findings warn against adopting end-demand approaches in other cities or jurisdictions.

    Acknowledgments

    We thank all those who contributed their time and expertise to this project, particularly partic-

    ipants, AESHA community advisory board members and partner agencies, and the AESHA

    team, including: Jennifer Morris, Jane Li, Minshu Mo, Sherry Wu, Emily Leake, Anita Dhanoa,

    Meaghan Thumath, Alka Murphy, Jenn McDermid, Tave Cole, Jaime Adams, Roisin Heather,

    Anna Mathen, Bridget Simpson, Nadina Morin, Desire Tibashoboka, Carly Glanzberg and

    Maya Henriquez. We also thank Abby Rolston, Peter Vann, Erin Seatter, Jill Chettiar, and

    Megan Bobetsis for their research and administrative support.

    Author Contributions

    Conceptualization: Elena Argento, Shira Goldenberg, Steffanie A. Strathdee, Kate Shannon.

    Formal analysis: Elena Argento, Shira Goldenberg, Melissa Braschel.

    Funding acquisition: Kate Shannon.

    Investigation: Elena Argento, Melissa Braschel, Sylvia Machat, Kate Shannon.

    Methodology: Elena Argento, Melissa Braschel, Steffanie A. Strathdee, Kate Shannon.

    Software: Melissa Braschel.

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    Supervision: Shira Goldenberg, Steffanie A. Strathdee, Kate Shannon.

    Writing – original draft: Elena Argento.

    Writing – review & editing: Elena Argento, Shira Goldenberg, Melissa Braschel, Sylvia

    Machat, Steffanie A. Strathdee, Kate Shannon.

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    International Journal of

    Environmental Research

    and Public Health

    Systematic Review

    Sex Worker Health Outcomes in High-Income Countries of
    Varied Regulatory Environments: A Systematic Review

    Jessica McCann 1,* , Gemma Crawford 1,2 and Jonathan Hallett 1,2

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    Citation: McCann, J.; Crawford, G.;

    Hallett, J. Sex Worker Health

    Outcomes in High-Income Countries

    of Varied Regulatory Environments:

    A Systematic Review. Int. J. Environ.

    Res. Public Health 2021, 18, 3956.

    https://doi.org/10.3390/ijerph18083956

    Academic Editor: Paul B. Tchounwou

    Received: 18 February 2021

    Accepted: 31 March 2021

    Published: 9 April 2021

    Publisher’s Note: MDPI stays neutral

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    Copyright: © 2021 by the authors.

    Licensee MDPI, Basel, Switzerland.

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    distributed under the terms and

    conditions of the Creative Commons

    Attribution (CC BY) license (https://

    creativecommons.org/licenses/by/

    4.0/).

    1 Curtin School of Population Health, Curtin University, Kent Street, Bentley, WA 6102, Australia;
    g.crawford@curtin.edu.au (G.C.); j.hallett@curtin.edu.au (J.H.)

    2 Collaboration for Evidence, Research and Impact in Public Health, Curtin School of Population Health,
    Curtin University, Kent Street, Bentley, WA 6102, Australia

    * Correspondence: jessica.mccann@postgrad.curtin.edu.au

    Abstract: There is significant debate regarding the regulation of the sex industry, with a complex
    range of cultural, political and social factors influencing regulatory models which vary considerably
    between and within countries. This systematic review examined the available evidence on the
    relationship between different approaches to sex industry regulation in high-income countries, and
    associated effects on sex worker health status. Objectives included identification of sex worker health
    outcomes, including sexual health, substance use and experience of stigma and violence. A search
    was performed electronically in eight scholarly databases which yielded 95 articles which met the
    criteria for inclusion. Findings suggested that sex workers in legalised and decriminalized countries
    demonstrated greater health outcomes, including awareness of health conditions and risk factors.

    Keywords: sex work; regulation; legislation; public health

    1. Introduction

    Sex workers are a priority population for public health [1] and there is growing
    support for occupational health and safety approaches to support sex worker health [2–4].
    Sex workers may experience vulnerability for a number of health issues, including those
    related to mental health, sexual health, substance use and interpersonal violence [5]. A
    recent study found higher rates of alcohol use, illicit drug use, and experiences of violence
    amongst sex workers compared to the general population [5]. Similar outcomes have
    been noted in other research, with concerns raised for the human rights of sex workers in
    response to increasing rates of violence [6,7] alcohol [8,9] and drug use [10]. Health issues
    in this population are exacerbated by the experience of discrimination and stigma, leading
    to reduced health service seeking behaviour [11,12].

    Regulatory models for sex work are varied; shaped by social, cultural and political
    influences [13–15]. Historically, criminalisation was the favoured regulatory model in
    many high-income countries [16]. More recently, societal perspectives towards the sex
    industry have shifted, resulting in regulation that is increasingly diverse within and
    between countries [17]. For example, in Australia, regulations differ by jurisdiction, and
    include partial criminalisation in WA, decriminalization in New South Wales (NSW),
    and legalisation with licensing regulation in Victoria (VIC) [5]. In comparison, sex work
    is decriminalized in New Zealand [18]. Sex work is illegal in all states in the United
    States of America (USA) except in certain counties in Nevada, where licensed brothels
    are permitted [19]. In contrast, sex work is legal in Denmark, however it is illegal for a
    third-party, such as a brothel, to profit from sex work [20].

    Recent literature has demonstrated an association between legislation and sex
    worker health outcomes [21]. Public preference is increasingly growing in favour of de-
    criminalization [6,8,14,22,23], and evidence continues to support the effectiveness of decrimi-
    nalization as a regulatory model for improving sex worker health outcomes [4,5,18,22,24–28].

    Int. J. Environ. Res. Public Health 2021, 18, 3956. https://doi.org/10.3390/ijerph18083956 https://www.mdpi.com/journal/ijerph

    https://www.mdpi.com/journal/ijerph

    https://www.mdpi.com

    https://orcid.org/0000-0003-0722-8086

    https://orcid.org/0000-0002-4426-2833

    https://orcid.org/0000-0003-0136-5426

    https://doi.org/10.3390/ijerph18083956

    https://doi.org/10.3390/ijerph18083956

    When we share, everyone wins

    https://creativecommons.org/licenses/by/4.0/

    https://creativecommons.org/licenses/by/4.0/

    https://doi.org/10.3390/ijerph18083956

    https://www.mdpi.com/journal/ijerph

    https://www.mdpi.com/article/10.3390/ijerph18083956?type=check_update&version=1

    Int. J. Environ. Res. Public Health 2021, 18, 3956 2 of 16

    Findings to date have demonstrated the benefits of decriminalization at a study level [18,29]
    and multiple jurisdictions, including in Australia, are considering reform to sex indus-
    try legislation [30–32]. This systematic review aimed to identify and critically appraise
    global findings on sex worker health outcomes within high-income countries of differing
    regulatory environments.

    2. Materials and Methods

    The review was performed in accordance with the Preferred Reporting Items for
    Systematic Reviews and Meta-Analyses (PRISMA) criteria [33] and registered with the In-
    ternational Prospective Register of Systematic Reviews (PROSPERO), registration number:
    CRD42018109964.

    2.1. Study Eligibility

    This systematic review included available, English language, full-text, peer-reviewed
    primary research using quantitative (experimental and epidemiological) methods which
    were conducted in high-income countries and published between 1978 and 2019. High-
    income countries were defined by the World Bank as countries with a Gross National
    Income (GNI) per capita of USD 12,056 and above for the year 2017 [34]. The review
    included studies with a focus on adult sex workers (over 18 years) and excluded child
    prostitution and trafficking. The legal age of adulthood and consent to sell sex varies
    globally within and between countries and cultures [35]. While application of a universal
    demarcation (e.g., 18 years) has been critiqued for its ethnocentrism [36], for comparative
    and pragmatic purposes and to reduce the likelihood of children being included as part of
    study populations, the authors defined adulthood as per the United Nations Convention
    on the Rights of the Child [37]. Articles in which sex workers had been trafficked, or
    the consent to sex work was ambiguous, were excluded. Articles from 1978 onwards
    were included in the literature search given in part the lasting impacts upon sex industry
    legislation resulting from the emergence of the HIV epidemic in the late 1970′s [13,18]. Due
    to the complex nature of sex work, many articles were noted that involved vulnerable
    population groups such as people who use drugs, people experiencing homelessness,
    incarcerated individuals, transgender people, people experiencing mental health disorders
    and individuals who had experienced physical or sexual abuse. Such articles were excluded
    if the primary focus was not sex work, or if sex work was utilised as an outcome measure
    rather than as a population descriptor. This approach was chosen to ensure that clarity of
    the research population was maintained.

    2.2. Information Sources

    Peer reviewed articles related to sex worker health and sex industry legislation were
    obtained electronically from the following academic databases: PubMed, ProQuest, Sco-
    pus, Current Contents Connect and Ovid (including Medline, Embase, PsycINFO and
    Global Health). Databases were selected through consultation with the university librarian,
    covering a broad set of clinical, social science and public health literature.

    2.3. Search Strategy and Study Selection

    A combination of keyword and subject heading/MESH heading terms were identified
    that included varied terminology for the population group, high-income countries and
    quantitative outcomes. This was to ensure that articles related to health outcomes and
    legislation were encompassed in the search. The search terms are listed in Table 1.

    Int. J. Environ. Res. Public Health 2021, 18, 3956 3 of 16

    Table 1. Database search terminology.

    Database Subject Headings/MESH Terms Keywords

    PubMed
    Sex work

    Sex workers
    Developed countries

    (1) (prostitut* OR “sex work*” OR “sex industry” OR
    “sexual service” OR escort OR brothel OR “sex
    trade*”)

    (2) results AND (mean OR median OR outcome OR
    “standard error” OR “standard deviation” OR “odds
    ratio” OR prevalence OR cohort OR cross-section OR
    “cross section” OR “case control” OR prospective OR
    retrospective OR trial OR size OR quant* OR amount
    OR number OR survey* OR questionnaire)

    (3) (Andorra or “Antigua and Barbuda” or Argentin* or
    Aruba or Australia* or Austria* or Bahamas or
    Bahrain* or Barbados or bilge* or Bermuda or “British
    Virgin Island*” or Brunei or Canad* or “Cayman
    Island*” or “Channel Island*” or Chile* or Croatia* or
    Curaçao or Cyprus or “Czech Republic” or Denmark
    or Estonia or “Faroe Island*” or Finland or France or
    “French Polynesia” or Germany or Gibraltar or “Great
    Britain” or Greece or Greenland or Guam or “Hong
    Kong” or Hungar* or Iceland* or Ireland or “Isle of
    Man” or Israel* or Ital* or Japan* or Korea* or Kuwait
    or Latvia* or Liechtenstein or Lithuania or
    Luxembourg* or Macao or Malta or Monaco or
    Netherlands or “New Caledonia” or “New Zealand”
    or “Northern Mariana Island*” or Norw* or Oman or
    Palau or Panama or Poland or Portug* or “Puerto
    Ric*” or Qatar or “San Marino” or “Saudi Arabia*” or
    Scotland or Seychelles or Singapore* or “Sint marten”
    or “Slovak Republic” or Slovenia or Spain or “Saint
    Kitts and Nevis” or “Saint Martin” or Swed* or
    Switzerland or Taiwan* or Trinidad or Tobago or
    “Turks and Caicos” or “United Arab Emirates” or
    “United Kingdom” or “United States” or Uruguay or
    “Virgin Island*” or Wales)

    ProQuest

    Scopus

    Current Contents Connect

    Medline
    Sex work

    Sex workers
    Developed countries

    Embase
    Sex worker
    Prostitution

    Developed country

    PsycINFO

    Prostitution
    Developed countries

    Global Health

    Sex workers
    Prostitutes

    Prostitution
    Developed countries

    Terms were searched in the title and abstract of articles, with peer review selected as a
    filter for databases that supported this feature. Searches were conducted by the primary
    researcher (JM) and audited for consistency and accuracy by the other members of the
    research team Figure 1. presents the process undertaken for the review.

    Articles were managed and stored using the citation management software, EndNote
    (version X8.2) (Clarivate Analytics, Philadelphia, PA, USA). Article titles and abstracts
    were reviewed to remove duplicate entries and to exclude clearly irrelevant articles from
    initial search results (e.g., those not related to sex work or reporting on qualitative findings).
    Article titles and abstracts were screened against the inclusion criteria by JM who met
    with the research team to discuss sample article including those which were unclear or
    ambiguous before proceeding to final review of full text articles against the inclusion
    criteria. Reasons for exclusion at full-text review included: unclear consent to sex work
    (n = 7), inability to extract data on high income countries (n = 10), sex workers aged 18 years
    and above (n = 130), and qualitative results only (n = 49) and availability of conference
    abstracts only (n = 26).

    Int. J. Environ. Res. Public Health 2021, 18, 3956 4 of 16Int. J. Environ. Res. Public Health 2021, 18, x 4 of 17

    Figure 1. Database search strategy.

    Articles were managed and stored using the citation management software, EndNote
    (version X8.2) (Clarivate Analytics, Philadelphia, PA, USA). Article titles and abstracts
    were reviewed to remove duplicate entries and to exclude clearly irrelevant articles from
    initial search results (e.g., those not related to sex work or reporting on qualitative find-
    ings). Article titles and abstracts were screened against the inclusion criteria by JM who
    met with the research team to discuss sample article including those which were unclear
    or ambiguous before proceeding to final review of full text articles against the inclusion
    criteria. Reasons for exclusion at full-text review included: unclear consent to sex work (n
    = 7), inability to extract data on high income countries (n = 10), sex workers aged 18 years
    and above (n = 130), and qualitative results only (n = 49) and availability of conference
    abstracts only (n = 26).

    2.4. Data Extraction and Quality Appraisal
    Joanna Briggs Institute (JBI) critical appraisal checklists were utilised to assess the

    quality of extracted articles [38]. Quality assessment included review of study methodol-
    ogy, design, execution and consideration of bias. On completion of the quality appraisal,
    23 articles were excluded from the analysis. Reasons for exclusion at full text review were:
    unclear methodologies of exposure and/or evaluation (n = 10), limited sample size (n = 6),
    insufficiently matched cases and controls (n = 5) and significant lost to follow up rates (n
    = 1). Rationale for exclusion based on quality appraisal was reviewed and verified by a
    member of the research team experienced in systematic review methodology.

    A standardised data extraction table was developed based on those used in previous
    reviews by the research team [39,40]. The following data were extracted: overview (au-
    thors, location, aim); study characteristics (study design, recruitment, sample size, re-
    sponse rate); participant characteristics (mean age, sex/gender, other); ethical approval;
    evaluation design and measures; and study findings.

    For articles where legislation was not described, this information was sought from
    government sources. Articles that did not describe recruitment in standard terminology
    were assigned one of the following terms for analysis purposes: convenience sampling

    Figure 1. Database search strategy.

    2.4. Data Extraction and Quality Appraisal

    Joanna Briggs Institute (JBI) critical appraisal checklists were utilised to assess the
    quality of extracted articles [38]. Quality assessment included review of study methodology,
    design, execution and consideration of bias. On completion of the quality appraisal,
    23 articles were excluded from the analysis. Reasons for exclusion at full text review were:
    unclear methodologies of exposure and/or evaluation (n = 10), limited sample size (n = 6),
    insufficiently matched cases and controls (n = 5) and significant lost to follow up rates
    (n = 1). Rationale for exclusion based on quality appraisal was reviewed and verified by a
    member of the research team experienced in systematic review methodology.

    A standardised data extraction table was developed based on those used in previous
    reviews by the research team [39,40]. The following data were extracted: overview (authors,
    location, aim); study characteristics (study design, recruitment, sample size, response rate);
    participant characteristics (mean age, sex/gender, other); ethical approval; evaluation
    design and measures; and study findings.

    For articles where legislation was not described, this information was sought from
    government sources. Articles that did not describe recruitment in standard terminology
    were assigned one of the following terms for analysis purposes: convenience sampling
    (assigned to articles that described recruitment at brothels, sexual health clinics or sex work
    venues); time-location sampling (assigned to articles that specified recruitment at a specific
    time and location); and snowball sampling (assigned to articles that stated recruitment by
    peers). Articles that used terminology such as “women” and “men” without specifying
    reference to either gender or biological sex have been interpreted as female and male
    gender, respectively.

    Platt and colleagues [21] have proposed a typology of sex work legislative models
    which was broadly used to categorise studies in this review as follows:

    • Full criminalization: Legislation whereby all aspects of sex work and sex work loca-
    tions and/or establishments are prohibited.

    • Partial criminalization: Organisation of sex work is prohibited (e.g., involvement of
    third parties or running a brothel).

    • ‘Nordic model’: Criminalization of purchase of sex and third parties.

    Int. J. Environ. Res. Public Health 2021, 18, 3956 5 of 16

    • Legal: Regulatory models whereby sex work and sex work locations and/or establish-
    ments are legal (e.g., using a licencing or registration model).

    • Decriminalization: Legislation whereby sex work and sex work locations and/or estab-
    lishments are decriminalized. Criminal law may remain surrounding safe sex practices.

    3. Results

    Articles were collated and synthesised based on emerging themes in the review.
    Ninety-five studies met the criteria for inclusion.

  • Results
  • were subsequently categorised
    into the following domains: study location; legislation; participant demographics; sam-
    pling; study design; and health outcomes.

    3.1. Study Location

    Included articles captured data from a range of high-income countries. Four or more
    studies were conducted in the following countries: Argentina [41–46], Australia [27,29,47–64],
    Canada [65–69], Hong Kong [70–77], Italy [78–81], Japan [82–86], Singapore [87–90], Spain [91–99],
    The Netherlands [100–107] and the USA [108–115]. Two studies were found in each of
    the following countries: England [116,117], New Zealand [118,119], Portugal [120,121]
    and Scotland [122,123]. One study was conducted in each of the following countries: Bel-
    gium [124], Chile [125], Czech Republic [126], Denmark [127], Estonia [128], Hungary [129],
    Panama [130], Puerto Rico [131], South Korea [132], and Switzerland [133]. Some studies
    were multi-jurisdictional for example Australian studies that compared three or more
    states [27,53–56].

    3.2. Legislation

    Sex work legislation varied across the studies, with the largest proportion of studies conducted
    in countries with partial criminalization [41–47,62,63,66–99,101,102,105,116,117,119–124,127,128].
    A summary of the legal status of sex work activity in included studies is described in
    Table 2 [134]. A more comprehensive summary of included studies can be found in
    Supplementary Materials (Tables S1–S6) reported by legislative framework: criminalized
    (Table S1: n = 10); partially criminalized (Table S2: n = 56); Nordic model (Table S3: n = 1);
    legalized (Table S4: n = 18; decriminalized (Table S5: n = 5) and multi-jurisdictional with
    differing legal statuses (Table S6: n = 5).

    Table 2. Summary of sex work legal status by study location and year of data collection.

    Legal Status Location of Included Studies (n)

    Criminalized Puerto Rico (n = 1); South Korea (n = 1); USA (n = 8)

    Partial criminalization

    Argentina (n = 6); Australia, WA (n = 3); Australia, QLD (prior to 1999) (n = 1); Australia, SA
    (n = 1); Belgium (n = 1); Canada (prior to 2014) (n = 4); Denmark (n = 1); England (n = 2);
    Estonia (n = 1); Hong Kong (n = 8); Italy (n = 4); Japan (n = 5); Netherlands (prior to 2000)
    (n = 3); New Zealand (prior to 2003) (n = 1); Portugal (n = 2); Scotland (n = 2); Singapore (n = 4);
    Spain (n = 9)

    Nordic Canada (from 2014) (n = 1)

    Legal Australia, QLD (from 1999) (n = 5); Australia, VIC (n = 11); Chile (n = 1); Czech Republic
    (n = 1); Hungary (n = 1); Netherlands (from 2000) (n = 5); Panama (n = 1); Switzerland (n = 1)

    Decriminalization Australia, NSW (n = 9); New Zealand (from 2003) (n = 1)

    Note: Not included here is indirect criminalization of migrant sex workers who face additional challenges relating to citizenship in
    otherwise legal or decriminalized settings (see for example Selvey and colleagues [63]). Some studies included multiple jurisdictions and
    therefore appear in this table in multiple categories.

    The second largest group of studies were those which focused on locations where
    sex work was legal [48,49,51,52,59–61,64,100,103,104,106,107,125,126,129,130,133] followed
    by criminalized [108–115,131,132]. Five studies were included where sex work was de-
    criminalized [29,50,57,58,118] and one study was conducted in a setting with the Nordic

    Int. J. Environ. Res. Public Health 2021, 18, 3956 6 of 16

    model [65]. Five studies included multiple jurisdictions with legal, criminalized and
    partially criminalized settings [27,53–56].

    3.3. Participant Characteristics

    The mean age of participants for all studies ranged from 23.0 to 39.3 years of age.
    Most studies featured only female participants [27,29,42,45–48,50–53,57–61,64,67,68,70–90,
    92–97,99–105,107,109,112,113,115,116,119,122,124–128,130–133]. Eight studies had all male
    participants [54–56,69,91,111,117,121], whilst a smaller proportion of studies featured both
    male and female participants [49,66,110,123,129]. Twelve studies included transgender
    participants [41,43,44,62,63,65,98,106,108,114,118,120], three of which focused solely on
    transgender sex workers [41,44,108]. The remainder included transgender participants
    in addition to cisgender male and/or female participants [43,62,63,65,98,106,114,118,120].
    This review included all types of transactional sex, with commercial sex trading comprising
    the largest proportion of articles [27,29,41–68,70–74,76,78–105,108–114,116–130,132,133].
    A smaller proportion of studies focused on opportunistic sex trading (such as survival
    sex and sex for drugs) [69,77,115,131]. For example, two studies focused on the role of
    unfavourable living conditions in opportunistic sex work [69,77].

    3.4. Study Design

    Convenience sampling was the most common participant recruitment method [27,29,
    41,42,46–51,54–56,58,60,61,64,65,70–72,74–76,78–80,82–86,88,90–94,96,97,99–106,108,110–112,
    115–118,120,121,126,127,129,131,132]. Some studies used other non-probability sam-
    pling methods, such as snowball sampling [43,44,62,63,69,77,89,119,123], purpo-
    sive sampling [45,52,53,57,59,65–67,73,98,100,107,108,113,118,124] and time-location
    sampling [68,81,87,114,122,125,130]. Additional recruitment methods found by one
    study each include cluster sampling [109], convenience stratified sampling [95],
    non-proportional quota sampling [133], and respondent driven sampling [128].

    The majority of studies reviewed were cross-sectional studies and prevalence
    studies [27,29,41–44,46–51,53–68,70–81,85,86,90,91,93,95,97–100,103–112,114,115,118–123,125,
    126,128–133]. There were a smaller number of case-control studies [82–84,94,116,117,127],
    cohort studies [69,89,92,96,101,102,124] and quasi-experimental studies [45,87,88] as well
    as one randomised intervention trial [113] evaluating a HIV behavioural intervention
    conducted in the USA with drug involved female sex workers (n = 597) and STI clinical
    audit [52] conducted in Melbourne, Australia with female sex workers operating in a
    regulated environment (n = 388).

    Most studies collected data through the use of questionnaires [27,29,45,47,50,51,
    55,60–63,65,66,68–72,74,76,77,81,88,90,98,99,103,108,114,115,118,119,121,125,129,133]. Less
    frequently used data collection methods included structured interviews [100,113,123] and
    self-completed diaries reporting on sex practices [54] and drug and alcohol use [56]. Twenty
    four studies utilised a combination of clinical testing and questionnaire data [41,42,44,46,
    48,67,75,79,80,85,87,89,91,105,106,109–112,120,127,130–132]. Sixteen studies utilised clini-
    cal testing data alone [43,73,78,82–84,86,92,94–96,101,104,124,126,128]. Nine studies used
    epidemiological data [49,52,53,57–59,107,116,117]. Three studies included both clinical test-
    ing and structured interview data [93,97,122]. Epidemiological data were combined with
    self-report STI diagnosis data reported by questionnaire [102] and with clinical laboratory
    STI testing [64] for two studies.

    Fifty-two studies confirmed the approval of their research by a Human Research
    Ethics Committee (HREC) [27,29,41,43,44,46,48–51,53–66,68,71,72,76,77,87,93,94,96–99,103,
    104,106,108,109,113,118,120,121,123,125,128,130,132,133]. Three articles stated that HREC
    approval was not required for their research objectives [52,107,129]. The remainder did not
    report on ethical approval.

    Int. J. Environ. Res. Public Health 2021, 18, 3956 7 of 16

    3.5. Health Outcomes

    Studies reported a range of health outcomes. Mental health issues were most fre-
    quently reported [29,41–46,48–50,52–54,56–61,64–86,88–112,115–117,120–124,126–131,133].
    This included: higher distress levels compared to non-sex workers in the USA (n = 176) [115],
    social isolation reported by Asian sex workers in Western Australia (n = 94) [63] and high
    rates of mental health disorders experienced by sex workers in Switzerland (n = 193) [133].
    Experience of violence [41,46,47,77,98,108,114,133], stigma [27,44,51,63,118], drug
    use [29,41,56,66,80,98,110,123,129,131], rates of sexually transmissible infections (STIs) and
    bloodborne viruses (BBVs) [41–44,48,49,52,53,57,61,64,67,69,73,75,78–80,82–86,88,89,91–97,100–102,
    104–107,109–113,116,117,120–124,126–128,130,132] and use of health services [27,29,45,47,48,55,65,
    71,72,76,77,102,113,116,117,119,125] were also reported. Two of the five studies that reported
    experiences of stigma as a health outcome also noted experience of stigma as a risk factor
    for reduced usage of health services by sex workers [27,118]. For example, the study by
    Abel found that sex workers frequently did not disclose their profession to health care
    providers due to fears of stigmatization, leading to less comprehensive health reviews [118].

    Studies from settings where sex work was criminalized and partially criminalized
    frequently reported epidemiological data such as prevalence of STIs and BBVs, vaccina-
    tion rates and drug use [78–80,82–86,109,111,112,122,123]. However, it was noted that
    epidemiological data for partially criminalized studies was more often reported in the
    context of social influences such as experience of violence [41,46], stigma [44] and sex-
    ual risk behaviours [66,67,69,88,89,101,105,121,127]. Studies in settings where sex work
    was legalized commonly reported on legislation effects upon the improvement of sexual
    health [52,61] and mental health outcomes [60,103]. Studies in settings where sex work
    was decriminalized showed sex workers were likely to engage in health service seeking
    behaviour [18,29,57]. These findings were contrasted by a number of studies which identi-
    fied issues of access to and usage of health services in the other contexts including partially
    criminalized [45,72,116,117,119], criminalized [113,114] and “Nordic model” settings [65].
    A study explicitly comparing health service access between decriminalized, legalized and
    partially criminalized jurisdictions in Australia found that sex workers in partially criminal-
    ized settings experienced the poorest health and safety outcomes, with greater availability
    of public sexual health clinics in legalized jurisdictions and most significant investment in
    health promotion programs and occupational health and safety measures in decriminalized
    and regulated settings [27,102].

    Drug use was more frequently reported in studies from criminalized and partially
    criminalized settings [80,102,108,110,115,131]. One study from NSW in Australia (decrimi-
    nalized), reported a reduction in drug use [29]. Studies from decriminalized and legalized
    locations mostly displayed consistent and improved condom usage [29,50,57,58,106], in
    comparison with studies from criminalized and partially criminalized settings that showed
    higher rates of poor condom usage [46,62,90,108,132]. The study from a Nordic model set-
    ting found higher prevalence of unmet health care needs, including poor mental health [65],
    Studies in partially criminalized settings noted both high STI prevalence [73,86,93,94,124]
    and low STI prevalence [79,97]. However, a study of multiple jurisdictions in Australia
    including legalized, decriminalized and partially criminalized settings, found significantly
    greater gonorrhea diagnoses in partially criminalized settings; attributed to increased
    policing of condom use [53].

    4. Discussion

    This review aimed to synthesize the available evidence on sex worker health in
    the context of different approaches to sex industry regulation in high-income countries.
    Ninety-five articles were identified for inclusion, published since 1978. Most studies were
    cross-sectional, using convenience sampling.

    Cross-sectional design was common (n = 69) and a majority of articles used con-
    venience sampling (n = 60) which may have led to measurement error [135]. The high
    proportion of self-report data and convenience sampling methods also introduces recall

    Int. J. Environ. Res. Public Health 2021, 18, 3956 8 of 16

    and self-selection bias [136,137]. Such methodologies however are an accepted method
    for use with hard-to-reach populations such as sex workers, where recruitment can be
    impacted by fears of stigma or incrimination [138]. A large proportion of studies (n = 59)
    failed to adequately describe recruitment methodology and instead listed the location/s
    where recruitment occurred. Further limitations include the lack of information on the
    use of standardised and validated questionnaires as an evaluation method. As such the
    reliability and validity of these data is unclear. Almost half the included studies did not
    report ethical approval (n = 40). Three quarters of these (n = 30) were published prior
    to the year 2006. This correlates with changes in reporting requirements, as increased
    transparency in reporting HREC approval has been mandated in recent times [139]. There
    is a call to action for high-quality, robust studies with ethical oversight given the inher-
    ent challenges relating to power and coercion particularly where legality intersects with
    experiences of marginalization.

    Sex workers in legalized and decriminalized contexts demonstrated greater aware-
    ness of health conditions and health risk behaviours, in comparison with criminalized
    jurisdictions. Studies in criminalized settings reported a higher proportion of drug
    use [56,108,122,129] associated with depression [131] distress [115] and reduced condom
    use [108]. This review found that criminalization of sex work increased risk of poorer social
    and health outcomes [108,109,114,115,131]; a finding which is consistent with the existing
    literature [5,18]. The literature identifies concomitant factors such as homelessness [140]
    and incarceration [141] which may also have impacts upon sex worker health outcomes.
    While only one of the included studies in this review used the Nordic model, this approach
    has been criticized for spatial displacement of sex workers and increasing risk to sex work-
    ers in their negotiation with clients [142]. Given the relatively few empirical studies of the
    impact of the Nordic Model on workers in the literature [143] and its increasing popularity
    across many high-income countries, there is an urgent need for additional research to test
    underlying assumptions of the model that suggest it reduces sex work numbers and harms.

    Greater condom usage was seen in legalized and decriminalized contexts. For example,
    the study by Van Veen et al. reported consistent condom use in 81% of participants [106].
    Lower condom use in in some criminalized jurisdictions, may be in part influenced by
    the use of carrying condoms as evidence of criminal activity by law enforcement, creating
    barriers to carrying or using condoms [144,145]. This may also account for some of the
    higher STI prevalence rates reported in partially criminalized settings [67,69]. For example,
    studies in these settings found that sex workers experienced greater pressure from clients
    to have unprotected sex [67] and offers for higher payments to have condomless sex [66].
    Levy and colleagues [142] also note low provision of condoms in Sweden via designated
    prostitution units, due in part to perception that provision of condoms facilitated sex work,
    which was inconsistent with the state aims of Sweden’s abolitionism.

    For those studies published in the early 1990s, the impacts of the HIV epidemic on
    research practices throughout this time became evident. Studies from this decade were
    largely epidemiological, with a focus on HIV prevalence and the role of sex workers as a vec-
    tor for transmission [97,101,105,110,111,122,123,131]. Community and political responses
    to the emerging Australian HIV epidemic resulted in significant law reforms within the
    sex industry, with changes in sex practices and policies emerging in this time [146]. From
    1998 onwards, there was a shift away from an HIV focus in the included studies. This
    aligns with the availability of HIV treatments and subsequent changes in health priority
    areas as the burden of disease from HIV decreased in high-income countries [147]. Al-
    though this finding is not a reflection of the current laws, it does highlight the impacts
    of HIV upon high-income countries. Sex workers are a priority population group for
    HIV prevention strategies for both higher and lower income countries [46,67,79,87,106].
    It is therefore of value to understand how social and environmental characteristics of sex
    work and sex work legislation have been shaped from the historical and current context
    of HIV prevention strategies and policies. There is great need and opportunity for future
    research to include sex workers in peer-based roles. Findings suggest that peer researchers

    Int. J. Environ. Res. Public Health 2021, 18, 3956 9 of 16

    facilitate sex worker support and increase research impacts [148]. For example, a study by
    Selvey et al. including peer-based researchers found that peer outreach and support was
    beneficial for improvement of sexual health and education, particularly for sex workers
    from culturally and linguistically diverse backgrounds [63].

    Sex workers may have greater accessibility to health promotion programs including
    access to free and anonymous testing [27] and other health services in locations where
    brothels are not criminalized. Research from NSW has found greater usage of health
    promotion programs by sex workers in decriminalized cities [27]. Other authors have
    observed high rates of voluntary sexual health checks in decriminalized jurisdictions and
    suggest that mandatory testing schemes have not been a feature of successful intervention
    strategies despite political saliency [149]. Some studies in criminalized and partially
    criminalized jurisdictions also showed the effectiveness of health promotion programs
    for improving use of health services [45,113], and reducing health risk behaviours [87,88].
    The sort of program highlighted as effective were peer to peer education [27] and sexual
    health education programs focused on STI prevention and condom usage [42,88,100].
    These findings highlight the critical role that health promotion programs should and do
    play in health education and awareness among sex workers in countries where sex work
    is currently criminalized. Despite stated need amongst participants, research by Levy
    and colleagues highlighted poor harm reduction coverage and conditionality in service
    provision within the Swedish context [142]. Investment in resources and funding for
    sex work advocacy groups and non-governmental organisations is needed to ensure the
    continuation of valuable health promotion programs regardless of legal context.

    This review found experiences of stigma, discrimination and marginalization across
    countries of varying legislation, with experience of stigma associated with reduced use of
    health services. For example, findings from NSW indicate an improvement in the health
    and safety of the sex industry, in addition to reduced financial burden on the criminal
    justice system, since introduction of decriminalization in 1995 [22]. It is also argued that
    decriminalization has the potential to normalize the role of sex work, thereby reducing
    the stigma and discrimination experienced amongst sex workers [26] and increasing the
    accessibility of health services [5]. Previous studies have suggested that experience of
    social issues such as stigma, marginalization and discrimination may remain for some
    time post legislative reform [18,24]. This could account for presence of stigma in countries
    with decriminalization and legalization, where systemic and historic marginalization has
    impacted upon access to and use of health services [103,118,119]. This finding suggests
    that sex workers’ experience of discrimination and stigma may take time to improve post
    decriminalization. Established cultural norms, including societal attitudes and behaviours
    towards sex work can be slow to change, particularly given the historical context of
    criminalisation [13]. This highlights the pervasive nature of stigma [150] which requires
    further investigation through more robust study designs that include analysis of the
    political, social and cultural factors that shape experience of stigma and discrimination.
    Specific interventions and policies in addition to legislation are required to improve this
    social health outcome.

    This review had a number of strengths and limitations. The review provides a com-
    prehensive 40-year picture of the literature. The use of eight databases provided expanded
    scope. To increase rigour, the review followed an established protocol registered with the
    PROSPERO International Prospective Register of Systematic Reviews. The review was
    restricted to articles published in English. Inclusion of papers in languages other than
    English may have yielded relevant information and a broader range of data. Given the
    heterogeneity in culture and health care systems among high-income countries making
    comparisons should be approached with caution.

    We recognize that important information may be located in the non-peer reviewed
    literature including from authors who do not have the resources to publish findings in
    peer reviewed journals. The lack of inclusion of grey literature may have led to publication
    bias. Inclusion criteria review was only performed by one researcher, however a small

    Int. J. Environ. Res. Public Health 2021, 18, 3956 10 of 16

    sub-section of articles was reviewed by the research team, to assist with standardisation of
    the review process. The breadth of inclusion criteria increased the heterogeneity of results,
    consequently no meta-analysis was conducted.

    Finally, it is noted that use of search terms “sex work/ers” may increase selection
    bias towards articles in which individuals identify with this term as a profession. It is
    understood that not all individuals who engage in transactional sex consider themselves to
    be a sex worker. Although inclusion criteria did not specify type of transactional sex, it is
    considered that the larger volume of articles pertaining to commercial sex work is explained
    by the search terminology utilised. It is possible that individuals who identify with sex
    work as a profession may have better health outcomes and differing socioeconomic factors
    than those who do not, although more research is required to support this suggestion.

    5. Conclusions

    Sex work laws are highly variable at a global and national level, with regulation
    influenced by political, social and cultural factors. There is growing evidence to support
    decriminalization as an approach to improve sex worker health and safety. Findings from
    this review highlight that criminalization of sex work increased risk of poorer social and
    health outcomes. Experiences of stigma, discrimination and marginalization is seen across
    countries of varying legislation and is associated with reduced use of health services.
    The review provides insights into the health and legal status of sex workers in high-
    income countries and calls for action to improve research design, address stigma and
    discrimination, and improve health education delivery.

    Supplementary Materials: The following are available online at https://www.mdpi.com/article/10
    .3390/ijerph18083956/s1, Table S1: summary of studies in criminalized jurisdictions (n = 10), Table S2:
    summary of studies in partially criminalized jurisdictions (n = 56), Table S3: summary of studies in
    ‘Nordic model’ jurisdictions (n = 1), Table S4: summary of studies in legalized jurisdictions (n = 18),
    Table S5: summary of studies in decriminalized jurisdictions (n = 5), Table S6: summary of studies
    involving multiple jurisdictions with different regulatory approaches (n = 5).

    Author Contributions: J.H. conceptualized the study and was responsible for coordinating the
    contribution of all authors to the paper. J.H., J.M. and G.C. designed the study protocol. J.M. served
    as the primary author of the initial manuscript. G.C. and J.H. have performed critical evaluation
    and editing of the manuscript. All authors read and approved the final version for submission. All
    authors have read and agreed to the published version of the manuscript.

    Funding: This research received no external funding.

    Institutional Review Board Statement: Not applicable.

    Informed Consent Statement: Not applicable.

    Data Availability Statement: The data presented in this study are available in Supplementary
    Materials Tables S1–S6.

    Acknowledgments: We would like to thank the Curtin University Faculty Librarian for technical
    support provided in the use of database search methods and strategies.

    Conflicts of Interest: The authors declare no conflict of interest.

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    • Introduction
    • Materials and Methods
    • Study Eligibility

      Information Sources

      Search Strategy and Study Selection

      Data Extraction and Quality Appraisal

      Results

      Study Location

      Legislation

      Participant Characteristics

      Study Design

      Health Outcomes

    • Discussion
    • Conclusions
    • References

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