A two-year-old child riding a tricycle dies, the random victim of a drive-by shooting. A pregnant woman is hit by a stray bullet in East Los Angeles. Street gang members storm the emergency department of an urban hospital to “finish off ” a rival gang member. Are these random acts confined to the inner city? Is this media sensationalization, racial stereotyping or a realistic depiction of a major adolescent health epidemic sweeping U.S. cities and towns?

Several recent publications examine this public health problem, debunk some of the myths and move beyond the now commonplace stereotype of a gang member—a tattooed teenager in baggy pants, high-top sneakers and an athletic jacket. Important questions are raised. What is the connection between street gangs and violence? Who is at greatest risk? What role might family physicians and parents play in preventing gang violence?

Epidemiology

Street gangs have a presence in 94 percent of all U.S. cities with populations greater than 100,000.¹ Los Angeles has over 950 different gangs with more than 100,000 members.² One study³ performed in Chicago showed that 5 percent of elementary school children were affiliated with street gangs, as were 35 percent of high school dropouts. Gangs have upset school systems nationwide, as demonstrated by the now common use of dress codes, metal detectors and security guards. Gangs are not limited to inner-city ghettos but are active in over 800 cities nationwide. Alarmingly, nearly 100 cities with populations less than 10,000 report active street gangs.¹

It is the relationship of gangs to homicide that make this concern a pressing adolescent health problem. Gunshot wounds are the eighth leading cause of death in the United States.⁴ It is estimated that firearms are used in 80 to 95 percent of gang-related homicides.^5,6 Membership in a street gang increases one's risk of violent death by 60 percent.⁶ This increased risk of mortality, as well as the proliferation of street gangs, should be of grave concern to health care professionals.

Historic Perspective

Street gangs have been described as an aggregation of youths who perceive themselves as distinct, who are viewed as distinct by their community and who call forth a consistently negative image of themselves through their actions.¹ American street gangs have historically been ethnically based. Early American street gangs were Irish, Polish or Italian. In the 1950s and 1960s, African-American, Mexican and Puerto Rican gangs became prominent. While gangs have traditionally been male dominated, female involvement in gangs and all-female gangs are not uncommon.

During the past decade, African-American, Mexican, Hmong, Vietnamese, Chinese, and white gangs have been common; in recent years, Russian and American Indian gangs have been reported. Ethnic gangs develop their own gang culture and identity, which includes specialized nicknames, nonverbal communication, tattoos, style of dress, mannerisms and vocabulary (Table 1). Mass media images, specifically pop music culture and television, have propagated many of these outward trappings, which have been adopted to a large extent by mainstream adolescent culture. In many cases, media images have sensationalized gang life and furthered racial stereotypes, complicating society's understanding of the real nature of the problem.

Characteristics of Gangs

Gangs have traditionally been territorially organized around a specific neighborhood, school or housing project. This geographic orientation has been at the root of intergang violence, and the function of the gang as a mode of protection has evolved. Terms such as “turf,” “hood” and “barrio” describe the territorial basis of gangs.¹ In-fighting is frequent between competing gangs of the same ethnicity. In fact, the majority of gang-related homicides are intra-racial.⁶

Negative gang activities vary widely, ranging from truancy, fighting and vandalism to burglary, assault, homicide and extortion. The drug-gang connection is often cited, but many researchers believe this activity is overstated.² While gangs form a continuum from groups of disgruntled adolescents to organized crime syndicates, most street gangs are not efficient or sophisticated drug distributors.¹

Gang membership is driven in part by the function of street gangs. Gangs are perceived as a source of protection in a violent world. Two major predictors of gang membership include residence in a gang-infested neighborhood and the presence of an older sibling who is already in a gang.¹ Individual risk factors include status and identity needs, poverty, unemployment, dysfunctional families, ethnic segregation and inadequate education opportunities.¹ Gangs function to give adolescents a much-needed sense of belonging and self-esteem in the transition to adulthood. Gangs may be viewed as a failure of society to socialize a segment of its youth.¹

Prevention Strategies

Prevention strategies focus on these risk factors and begin with an understanding of root causes, specifically, the breakdown of traditional family and community structures, lack of economic opportunity, racism and limited role models. Citizens and physicians may intervene by promoting active parenting and community organization. Parents must be taught to recognize signs of gang involvement in children, as well as constructive ways to respond (Tables 2 and 3).

Examples of successful community programs include “Mothers Against Gangs,” an organization that mobilizes parents in preventing school delinquency. In addition to providing training in parenting skills, initiatives include computer literacy, homework tutors, youth entrepreneurship initiatives and legislative advocacy. Another program called “Youth Struggling for Survival” recognizes that gang life is organized around destructive rituals. Founded by a former gang member, this program attempts to bring at-risk youth together and to substitute new rituals, such as African traditions and Native American sweat lodges.

Alternative activities such as supervised evening sports programs have been implemented in many communities. “Cops in the Classroom” programs have been used as a method of making the initial contact with law enforcement a positive one. All of these interventions have had some success but must be implemented in ways that will not inadvertently increase gang cohesiveness.¹ Factors that make gangs appear more visible, organized and relevant may have the undesired effect of attracting new gang members.

Family physicians also have a key role in working with school officials, law enforcement, social services and the local health department in efforts of community organization. In addition, physicians are in the unique position of treating individual adolescents in the context of the family, which in some cases has been functionally replaced by the gang.

Like domestic violence, gang involvement often will not be revealed unless it is actively sought. Adolescent screening should take place in the context of understanding local gang patterns. Screening should focus on high-risk behaviors such as drug and alcohol use, access to handguns, self-esteem issues, school delinquency and having a sibling involved in a gang (Table 4). Initiating counseling and support services for at-risk children is important, although counseling alone is unlikely to be beneficial without concurrent changes in the home and socioeconomic environments. A recent article on adolescent preventive services in American Family Physician reviews some of these strategies.⁷

Other useful interventions include referral to parenting skills classes, providing gun safety information, tattoo removal programs and emergency department crisis response teams. Understanding the significance of tattoos and providing laser tattoo removal when appropriate may change lives. A hospital-community response team with trained crisis counselors who are available for immediate intervention with gang members and their families may be developed and may help prevent retaliation crimes.

Final Comment

The proliferation of street gangs in America, as well as the violence associated with gang activity, is alarming. Family physicians are in a unique position to focus community awareness on this major health problem of adolescence. The medical community would lead a huge public outcry if an infectious agent caused morbidity and mortality comparable to that of gang violence. We should demand nothing short of a national policy on violent street gangs⁸ with an appropriate commitment of public health resources. Our children deserve no less.