4.3: Intentional Injuries - Violence

There are many forms of intentional injury, or violence. The CDC approaches violence using the “Social-Ecological Model: a Framework for Prevention”. The framework encourages viewing violence and violence prevention as a multifaceted interconnected dynamic including the individual, their relationships, their community, and our society.

• The Individual
  • Individuals factors such as age, education, income, substance use, or history of abuse impact the risk of violence. A focus on attitudes, beliefs, behaviors, along with training on conflict resolution, safe dating, and healthy relationship may positively impact their risk of violence.
• Relationships
  • A person’s closest social circle-peers, partners and family members-influences their behavior and contribute to their experience. Parenting, mentors, effective communication, and problem solving may support effective relationships to prevent violence.
• Community
  • Where a person lives, works, or goes to school can impact their risk of violence. Creating safe physical and social environments may reduce violence in the community.
• Societal
  • A focus on society asks us to understand and look at how our society either encourages or inhibits violence, for example how social or cultural norms use violence to resolve conflicts or how wealth and health inequalities impact violence risk.

Community Violence

Community violence is interpersonal violence generally outside the home that is perpetrated by individuals who are not intimately related to the victim and who may or may not know each other. Examples include assaults, homicides, fights among groups, and shootings in public places, such as schools and on the streets. Acts of community violence include but are not limited to riots, sniper attacks, gang wars, drive-by shootings, bullying, workplace assaults, terrorist attacks, torture, bombings, war, ethnic cleansing, and widespread sexual, physical, and emotional abuse.

Young people are disproportionately impacted by violence in their communities, including firearm injuries and deaths. Violence is a leading cause of death and nonfatal injuries among adolescents and young adults; over half of US homicides in 2019 occurred among those ages 15 to 34. Unfortunately, data show significant increases in homicide rates in 2020 compared to 2019.

People’s health outcomes are influenced by the conditions in which they live, work, play, and learn. These conditions are called social determinants of health. Systemic racism, bias, and discrimination; economic instability; concentrated poverty; and limited housing, education, and healthcare access drive health inequities, such as violence. Communities of color often disproportionately experience these negative conditions, placing residents at greater risk for poor health outcomes. For example, Black or African American, American Indian, and Alaskan Native, and Hispanic or Latino persons have higher homicide rates than other racial and ethnic demographic groups. Research indicates that youth and young adults (ages 10-34), particularly those in communities of color, are disproportionately impacted.

Community violence can cause significant physical injuries and mental health conditions such as depression, anxiety, and post-traumatic stress disorder (PTSD). Living in a community experiencing violence is also associated with increases in risk of developing chronic diseases, as concerns about violence may prevent someone from engaging in healthy behaviors, such as walking, bicycling, using parks and recreational spaces, and accessing healthy food outlets. Violence scares people out of participating in neighborhood activities; limits business growth and prosperity; strains education, justice, and medical systems; and slows community progress.

The Division of Violence Prevention (DVP) at the Centers for Disease Control and Prevention (CDC) is focused on preventing community violence by identifying and implementing science-based programs, policies, and practices with partners and communities to disseminate, implement, and scale-up strategies based on the best available evidence to create safer communities, such as:

• Changing social norms through street outreach/violence interruption programs.
• Changing the physical environment through Crime Prevention Through Environmental Design (CPTED).
• Preventing future risk and lessening the harms of violence exposure through hospital-community partnerships, and treatment services such as Trauma-Focused Cognitive Behavior Therapy ®(TF-CBT) and Multisystemic Therapy® (MST).
• Strengthening economic supports through job training and summer jobs programs.
• Strengthening youth’s skills through universal school-based programs to help youth develop skills to prevent violence and engage in healthy behaviors.
• Connecting youth to caring adults and activities such as mentoring and after-school programs.

Intimate and Partner Violence

Intimate partner violence (IPV) is abuse or aggression that occurs in a romantic relationship. “Intimate partner” refers to both current and former spouses and dating partners. IPV is common. It affects millions of people in the United States each year and often starts early and continues throughout life. When IPV occurs in adolescence, it is called teen dating violence (TDV). About 1 in 4 women and nearly 1 in 10 men have experienced contact sexual violence, physical violence, and/or stalking by an intimate partner during their lifetime and reported some form of IPV-related impact. About 11 million women and 5 million men who reported experiencing contact sexual violence, physical violence, or stalking by an intimate partner in their lifetime said that they first experienced these forms of violence before the age of 18. Youth from groups that have been marginalized, such as sexual and gender minority youth, are at greater risk of experiencing sexual and physical dating violence.

IPV can vary in how often it happens and how severe it is and might include:

• Physical violence is when a person hurts or tries to hurt a partner by hitting, kicking, or using another type of physical force.
• Sexual violence is forcing or attempting to force a partner to take part in a sex act, sexual touching, or a non-physical sexual event (e.g., sexting) when the partner does not or cannot consent.
• Stalking is a pattern of repeated, unwanted attention and contact by a partner that causes fear or concern for one’s own safety or the safety of someone close to the victim.
• Psychological aggression is the use of verbal and non-verbal communication with the intent to harm another partner mentally or emotionally and/or to exert control over another partner.

IPV Prevention includes:

Teach safe and healthy relationship skills

• Social-emotional learning programs for youth
• Healthy relationship programs for couples

Engage influential adults and peers

• Men and boys as allies in prevention
• Bystander empowerment and education
• Family-based programs

Disrupt the developmental pathways toward partner violence

• Early childhood home visitation
• Preschool enrichment with family engagement
• Parenting skill and family relationship programs
• Treatment for at-risk children, youth and families

Create protective environments

• Improve school climate and safety
• Improve organizational policies and workplace climate
• Modify the physical and social environments of neighborhoods

Strengthen economic supports for families

• Strengthen household financial security
• Strengthen work-family supports

Support survivors to increase safety and lessen harms

• Victim-centered services
• Housing programs
• First responder and civil legal protections
• Patient-centered approaches
• Treatment and support for survivors of IPV, including TDV
• Workplace Injuries

Sexual Violence

Sexual violence is sexual activity when consent is not obtained or freely given. It is a serious public health problem in the United States that affects millions of people each year in the United States and profoundly impacts lifelong health, opportunity, and well-being. Researchers know the numbers underestimate this problem because many cases are unreported. Victims may be ashamed, embarrassed, or afraid to tell the police, friends, or family about the violence. Victims may also keep quiet because they have been threatened with further harm if they tell anyone or do not think anyone will help them.

Sexual violence impacts every community and affects people of all genders, sexual orientations, and ages. Anyone can experience or perpetrate sexual violence. The perpetrator of sexual violence is usually someone the victim knows, such as a friend, current or former intimate partner, coworker, neighbor, or family member. Sexual violence can occur in person, online, or through technology, such as posting or sharing sexual pictures of someone without their consent, or non-consensual sexting.

The data shows:

• Sexual violence is common. More than 1 in 3 women and 1 in 4 men have experienced sexual violence involving physical contact during their lifetimes. Nearly 1 in 5 women and 1 in 38 men have experienced completed or attempted rape, and 1 in 14 men was made to penetrate someone (completed or attempted) during his lifetime.
• Sexual violence starts early. One in 3 female rape victims experienced it for the first time between 11-17 years old and 1 in 8 reported that it occurred before age 10. Nearly 1 in 4 male rape victims experienced it for the first time between 11-17 years old and about 1 in 4 reported that it occurred before age 10.
• Sexual violence is costly. Recent estimates put the lifetime cost of rape at $122,461 per victim, including medical costs, lost productivity, criminal justice activities, and other costs.

Sexual Violence Prevention includes:

Promote Social Norms that Protect Against Violence

• Bystander approaches
• Mobilizing men and boys as allies

Teach Skills to Prevent Sexual Violence

• Social-emotional learning
• Teaching healthy, safe dating and intimate relationship skills to adolescents
• Promoting healthy sexuality
• Empowerment-based training

Provide Opportunities to Empower and Support Girls and Women

• Strengthening economic supports for women and families
• Strengthening leadership and opportunities for girls

Create Protective Environments

• Improving safety and monitoring in schools
• Establishing and consistently applying workplace policies
• Addressing community-level risks through environmental approaches

Support Victims/Survivors to Lessen Harms

• Victim-centered services
• Treatment for victims of SV
• Treatment for at-risk children and families to prevent problem behavior including sex offending

Firearm Violence

A firearm injury is a gunshot wound or penetrating injury from a weapon that uses a powder charge to fire a projectile. Weapons that use a power charge include handguns, rifles, and shotguns. Injuries from air- and gas-powered guns, BB guns, and pellet guns are not considered firearm injuries as these types of guns do not use a powder charge to fire a projectile.

Firearm violence is a serious public health problem that impacts the health and safety of Americans. Important gaps remain in our knowledge about the problem and ways to prevent it. Addressing these gaps is an important step toward keeping individuals, families, schools, and communities safe from firearm violence and its consequences.

Firearm injuries are a serious public health problem. In 2020, there were 45,222 firearm-related deaths in the United States, that’s about 124 people dying from a firearm-related injury each day. More than half of firearm related deaths were suicides and more than 4 out of every 10 were firearm homicides.

More people suffer nonfatal firearm-related injuries than die. More than seven out of every 10 medically treated firearm injuries are from firearm-related assaults. Nearly 2 out of every 10 are from unintentional firearm injuries. There are few intentionally self-inflicted firearm-related injuries seen in hospital emergency departments. Most people who use a firearm in a suicide attempt, die from their injury.

Firearm injuries affect people in all stages of life. In 2020, firearm-related injuries were among the 5 leading causes of death for people ages 1-44 in the United States.

Some groups have higher rates of firearm injury than others. Men account for 86% of all victims of firearm death and 87% of nonfatal firearm injuries. Rates of firearm violence also vary by age and race/ethnicity. Firearm homicide rates are highest among teens and young adults 15-34 years of age and among Black or African American, American Indian or Alaska Native, and Hispanic or Latino populations. Firearm suicide rates are highest among adults 75 years of age and older and among American Indian or Alaska Native and non-Hispanic white populations.

There are many types of firearm injuries, which can be fatal or nonfatal:

• Intentionally self-inflicted
  • Includes firearm suicide or nonfatal self-harm injury from a firearm
• Unintentional
  • Includes fatal or nonfatal firearm injuries that happen while someone is cleaning or playing with a firearm or other incidents of an accidental firing without evidence of intentional harm
• Interpersonal violence
  • Includes firearm homicide or nonfatal assault injury from a firearm
• Legal intervention
  • Includes firearm injuries inflicted by the police or other law enforcement agents acting in the line of duty
    • For example, firearm injuries that occur while arresting or attempting to arrest someone, maintaining order, or ensuring safety
  • The term legal intervention is a commonly used external cause of injury classification. It does not indicate the legality of the circumstances surrounding the death.
• Undetermined intent
  • Includes firearm injuries where there is not enough information to determine whether the injury was intentionally self-inflicted, unintentional, the result of legal intervention, or from an act of interpersonal violence.

It is important to store all firearms safely when not in use. Putting a firearm out of sight or out of reach is not safe storage and not enough to prevent use by children or unauthorized adults.

Drug Overdose

Drug overdoses are now the leading cause of injury deaths in the United States, and most overdoses involve opioids. More than 932,000 people have died since 1999 from a drug overdose. In 2020, 91,799 drug overdose deaths occurred in the United States. The age-adjusted rate of overdose deaths increased by 31% from 2019 (21.6 per 100,000) to 2020 (28.3 per 100,000). Opioids, mainly synthetic opioids (other than methadone), are currently the main driver of drug overdose deaths. 82.3% of opioid-involved overdose deaths involved synthetic opioids. Research shows that people who have had at least one overdose are more likely to have another. In 2020, an estimated 41.1 million Americans needed substance use disorder treatment, but only 2.6 million people with a substance use disorder in the past year received treatment.

Prevention Startegies include:

• Increase and maximize use of prescription drug monitoring programs, which are state-run databases that track prescriptions for controlled substances and can help improve opioid prescribing, inform clinical practice, and protect those at risk.
• Learn about the risks of prescription opioids and about the help and resources that are available for someone who may be struggling with opioid use disorder.
• Treat opioid use disorder by increasing access to substance use disorder treatment services, including Medication-Assisted Treatment (MAT) and Medications for Opioid Use Disorder (MOUD).
• Reverse overdose by expanding access to naloxone, a drug used to reverse overdose, for community members (family members and neighbors) and service providers (i.e., first responders).

Child Abuse and Neglect

Child abuse and neglect are serious public health problems that can have long-term impact on health, opportunity, and wellbeing. At least 1 in 7 children have experienced child abuse or neglect in the past year in the United States. however this is likely an underestimate because many cases are unreported. In 2020, 1,750 children died of abuse and neglect in the United States. Experiencing poverty can place a lot of stress on families, which may increase the risk for child abuse and neglect. Rates of child abuse and neglect are 5 times higher for children in families with low socioeconomic status. In the United States, the total lifetime economic burden associated with child abuse and neglect was about $592 billion in 2018. This economic burden rivals the cost of other high-profile public health problems, such as heart disease and diabetes.

This issue includes all types of abuse and neglect of a child under the age of 18 by a parent, caregiver, or another person in a custodial role (such as a religious leader, a coach, a teacher) that results in harm, the potential for harm, or threat of harm to a child. There are four common types of abuse and neglect:

• Physical abuse is the intentional use of physical force that can result in physical injury. Examples include hitting, kicking, shaking, burning, or other shows of force against a child.
• Sexual abuse involves pressuring or forcing a child to engage in sexual acts. It includes behaviors such as fondling, penetration, and exposing a child to other sexual activities.
• Emotional abuse refers to behaviors that harm a child’s self-worth or emotional well-being. Examples include name-calling, shaming, rejecting, withholding love, and threatening.
• Neglect is the failure to meet a child’s basic physical and emotional needs. These needs include housing, food, clothing, education, access to medical care, and having feelings validated and appropriately responded to.

Risk Factors for Victimization include

Individual Risk Factors

• Children younger than 4 years of age
• Children with special needs that may increase caregiver burden (e.g., disabilities, mental health issues, and chronic physical illnesses)

Risk Factors for Perpetration

• Caregivers with drug or alcohol issues
• Caregivers with mental health issues, including depression
• Caregivers who don’t understand children’s needs or development
• Caregivers who were abused or neglected as children
• Caregivers who are young or single parents or parents with many children
• Caregivers with low education or income
• Caregivers experiencing high levels of parenting stress or economic stress
• Caregivers who use spanking and other forms of corporal punishment for discipline
• Caregivers in the home who are not a biological parent
• Caregivers with attitudes accepting of or justifying violence or aggression

Family Risk Factors

• Families that have household members in jail or prison
• Families that are isolated from and not connected to other people (extended family, friends, neighbors)
• Families experiencing other types of violence, including relationship violence
• Families with high conflict and negative communication styles

Community Risk Factors

• Communities with high rates of violence and crime
• Communities with high rates of poverty and limited educational and economic opportunities
• Communities with high unemployment rates
• Communities with easy access to drugs and alcohol
• Communities where neighbors don’t know or look out for each other and there is low community involvement among res
• dents
• Communities with few community activities for young people
• Communities with unstable housing and where residents move frequently
• Communities where families frequently experience food insecurity

Prevention Strategies include:

Strengthen economic supports to families

• Strengthening household financial security
• Family-friendly work policies

Change social norms to support parents and positive parenting

• Public engagement and education campaigns
• Legislative approaches to reduce corporal punishment

Provide quality care and education early in life

• Preschool enrichment with family engagement
• Improved quality of child care through licensing and accreditation

Enhance parenting skills to promote healthy child development

• Early childhood home visitation
• Parenting skill and family relationship approaches

Intervene to lessen harms and prevent future risk

• Enhanced primary care
• Behavioral parent training programs
• Treatment to lessen harms of abuse and neglect exposure
• Treatment to prevent problem behavior and later involvement in violence

Suicide

Suicide is death caused by injuring oneself with the intent to die. A suicide attempt is when someone harms themselves with any intent to end their life, but they do not die as a result of their actions.

Suicide rates increased 30% between 2000–2018, and declined in 2019 and 2020. Even with the decline in 2020, Suicide was still a leading cause of death in the United States, with nearly 46,000 deaths in 2020. This is about one death every 11 minutes. In 2020, suicide was among the top 9 leading causes of death for people ages 10-64 and was the second leading cause of death for people ages 10-14 and 25-34. The number of people who think about or attempt suicide is even higher. In 2020, an estimated 12.2 million American adults seriously thought about suicide, 3.2 million planned a suicide attempt, and 1.2 million attempted suicide.

Americans with higher than average rates of suicide are veterans, people who live in rural areas, and workers in certain industries and occupations like mining and construction. Young people who identify as lesbian, gay, or bisexual have higher rates of suicidal thoughts and behavior compared to their peers who identify as heterosexual. People who have experienced violence, including child abuse, bullying, or sexual violence have a higher suicide risk.

Suicide and suicide attempts cause serious emotional, physical, and economic impacts. People who attempt suicide and survive may experience serious injuries that can have long-term effects on their health. They may also experience depression and other mental health concerns. The good news is that more than 90% of people who attempt suicide and survive never go on to die by suicide.

Suicide and suicide attempts affect the health and well-being of friends, loved ones, co-workers, and the community. When people die by suicide, their surviving family and friends may experience shock, anger, guilt, symptoms of depression or anxiety, and may even experience thoughts of suicide themselves.

Being connected to family and community support and having easy access to health care can decrease suicidal thoughts and behaviors.

Suicide Prevention strategies include:

• Strengthen economic supports
  • Strengthen household financial security
  • Housing stabilization policies
• Strengthen access and delivery of suicide care
  • Coverage of mental health conditions in health insurance policies
  • Reduce provider shortages in underserved areas
  • Safer suicide care through systems change
• Create protective environments
  • Reduce access to lethal means among persons at risk of suicide
  • Organizational policies and culture
  • Community-based policies to reduce excessive alcohol use
• Promote connectedness
  • Peer norm programs
  • Community engagement activities
• Teach coping and problem-solving skills
  • Social-emotional learning programs
  • Parenting skill and family relationship programs
• Identify and support people at risk
  • Gatekeeper training
  • Crisis intervention
  • Treatment for people at risk of suicide
  • Treatment to prevent re-attempts
• Lessen harms and prevent future risk
  • Postvention
  • Safe reporting and messaging about suicide

Need help? Know someone who does?

Contact the National Suicide Prevention Lifeline

• Call 1-800-273-TALK (1-800-273-8255)
• Use the online Lifeline Crisis Chatexternal icon

Both are free and confidential. You’ll be connected to a skilled, trained counselor in your area.

For more information, visit the National Suicide Prevention Lifelineexternal icon.

You can also connect 24/7 to a crisis counselor by texting the Crisis Text Line.external icon Text HOME to 741741.