Discrimination, Sexual Violence, Depression, Post-traumatic Stress Disorder, and Social Support among Black Women.

BACKGROUND: Black Americans face significant discrimination associated with mental health disorder, which may be exacerbated among sexually victimized people. Social support may buffer that relationship. METHODS: Cross-sectional data from a retrospective cohort study were analyzed to examine if discrimination and sexual victimization overlap to exacerbate symptoms of depression and post-traumatic stress disorder (PTSD) and to determine the extent to which social support moderated that association among Black women living in Baltimore, Maryland [138 non-abused (no physical/sexual victimization) and 98 abused (sexually victimized) since age 18]. RESULTS: Symptoms of depression and PTSD were independently associated with discrimination. Multilinear regression showed social support from friends moderated the association between discrimination and depressive symptoms among sexually abused participants only. CONCLUSION: Discrimination may exacerbate symptoms of depression and PTSD more for sexually victimized Black women, but sources of informal social support may attenuate adverse effects of discrimination on depressive symptoms among members of that group.

An examination of the association between forced sex history and reproductive coercion experiences among Black women attending STD clinics in Baltimore, MD, USA.

BACKGROUND: Reproductive coercion victimization (RCV) is a significant public health issue that negatively affects women's sexual and reproductive health outcomes. Less is known about reproductive coercion perpetration (RCP). Few studies have examined these phenomena among representative samples of Black women. METHODS: Retrospective data of women (n = 298) attending STD clinics in Baltimore, MD were analyzed. We calculated lifetime and 12-month prevalence reports of reproductive coercion, and reported values stratified by forced sex history. Binomial logistic regression models were used to examine the association between forced sex history and RCV, accounting for other types of violence typologies. RESULTS: Lifetime and past 12-month RCV and RCP prevalence were higher among women with forced sex experiences than their counterparts (Lifetime RCV: 46.9% versus 17.5%; past 12-month RCV: 19.4% versus 8.5%. Lifetime RCP: 24.5% versus 17%; past 12-month RCP: 13.3% versus 10.5%). Adjusted models, lifetime reproductive coercion: Women reporting forced sex had a 3.58 times higher odds of having had experienced RCV compared to women not reporting forced sex (AOR 3.58; 95% CI 2.00, 6.46). Women reporting forced sex had a 3.66 times higher odds of having ever experienced pregnancy coercion compared to their counterparts (AOR 3.66; 95% CI 1.93, 7.03) and 4.30 times higher odds of having ever experienced condom manipulation (AOR 4.30; 95% CI 2.15, 8.86). Adjusted models, past 12-month reproductive coercion: Women reporting forced sex had a 2.72 times higher odds of having had experienced past 12-month RCV compared to women not reporting forced sex (AOR 2.72; 95% CI 1.27, 5.91). Women reporting forced sex had a 3.25 times higher odds of having experienced past 12-month pregnancy coercion compared to their counterparts (AOR 3.25; 95% CI 1.38, 7.83) and 3.41 times higher odds of having experienced past 12-month condom manipulation (AOR 3.41; 95% CI 1.14, 10.98). CONCLUSIONS: Participants in our study reported high rates of RCV. Our novel exploration revealed significantly high rates of co-occurring forced sex experiences and RCV and initial prevalence report of RCP. Agencies have a unique opportunity to intervene by implementing screening protocols and referrals for supportive services. These findings may inform future intervention research efforts aimed at improving reproductive health outcomes among Black women.

Risks of Severe Assault and Intimate Partner Homicide among Transgender and Gender Diverse Intimate Partner Violence Survivors: Preliminary Findings from Community Listening Sessions.

Intimate partner violence (IPV) is an epidemic among transgender and gender diverse (TGD) people. However, intimate partner homicide (IPH) among TGD people is under researched. Thus, thematic content analysis was used to describe and examine antecedents of severe assault and IPH among TGD adults who have experienced IPV (N = 13), via community listening sessions. While some themes resembled known severe assault and IPH risks among cisgender women, several themes were unique to TGD people and should be considered when safety planning with TGD individuals or adapting IPV screening tools for this population.

Discrimination, resilience, and HIV testing frequency among black women seeking services from STD clinics.

RATIONALE: In the United States, Black women are disproportionately affected by HIV, accounting for most new HIV infections diagnosed among women. Socio-structural barriers to HIV testing include stigma and discrimination but may be mitigated by resilience. OBJECTIVE: We aimed to examine the effect of discrimination and resilience on HIV testing behaviors among Black women. METHODS: Between 2016 and 2018, we conducted The ESSENCE Project, a retrospective cohort study on the role of physiological and environmental factors on the association between sexual assault and HIV risk among Black women in Baltimore, Maryland, USA. Black women aged 18-44 were recruited from public health STD clinics and completed an audio-computer-assisted self-interview survey. Hierarchical multiple negative binomial regression models were used to examine the associations of everyday discrimination (subtle and overt) and resilience on HIV testing frequency; resilience and its subscales (relational maintenance, personal fortitude, positive coping, independence and insight) were also examined as moderators. RESULTS: Among 236 Black women reporting HIV testing history, the median number of lifetime HIV tests was 4 (IQR = 2, 6). Mean everyday discrimination was 2.3 (SD = 1.2). Mean resilience was 5.3 (SD = 0.8). Everyday discrimination and its subscales (overt and subtle) were negatively associated with lifetime HIV testing frequency, while overall resilience was not associated with lifetime HIV testing frequency. Accounting for demographics, overall resilience moderated the association of subtle discrimination and lifetime HIV testing frequency. For the resilience subscales, more specifically: (1) associations of subtle discrimination and HIV testing frequency were significant at the lowest relational maintenance and lowest positive coping resilience; and (2) the association of subtle discrimination and HIV testing frequency was significant at the highest resilience for all four subscales. CONCLUSIONS: These findings highlight the need for provider- and community-level interventions addressing the deleterious effects of everyday discrimination and more specifically subtle everyday discrimination to encourage HIV testing.

Assessing knowledge, attitudes and beliefs of nurses about LGBTQ older adults using a documentary video.

BACKGROUND: Statistics reveal that lesbian, gay, bisexual, transgender, and queer (LGBTQ) older adults experience health disparities and barriers to accessing healthcare because of discrimination and fear of disclosing sexual orientation. Nurses receive limited education on LGBTQ health issues and even less information specifically about LGBTQ older adults. This study exposed novice nurses to the documentary, Gen Silent, which details LGBTQ older adult experiences. OBJECTIVES: The objective of the study was to increase participants' understanding of LGBTQ older adult health disparities and experiences. DESIGN: A one-group, pre-/post-test design was conducted to test the effect of the documentary on knowledge and attitudes about LGBTQ older adult issues. SETTINGS: The project was set in five academic and community-based hospitals located in the mid-Atlantic region. PARTICIPANTS: A total of 379 nurses attending a nurse residency program participated in the study. METHODS: A questionnaire including a 16-item standardized scale and an open-ended question asking how participants would change their practice was administered before and immediately after the intervention. We assessed change in pre- and post-test knowledge scores using Wilcoxon Sign Rank test and summarized themes of the open-ended question. RESULTS: Findings revealed statistically significant increases in 9 of the 16 items on the scale showing an increase of knowledge and inclusive attitude. Answers to the open-ended question revealed that most participants would ask patients for preferred pronouns and take steps to increase their own understanding of LGBTQ patients and their needs. CONCLUSION: This research supports the use of a documentary as an intervention to facilitate education related to LGBTQ older adults. Further research is needed exposing healthcare professionals of varied experience in diverse healthcare settings to LGBTQ education.

Approach and avoidant coping among black transgender women who have experienced violence: A qualitative analysis.

Black transgender women face nearly universal exposure to violence. Coping behaviors among cisgender women who have survived violence are well delineated; however, there are relatively few studies examining coping strategies for transgender women. The purpose of this qualitative study was to identify and characterize coping behaviors employed by Black transgender women (from Baltimore, MD and Washington, DC metropolitan areas) following an experience of violence. Secondary qualitative data analysis was conducted using framework analysis to explore narratives of 19 Black transgender women. Themes regarding avoidant and approach coping behaviors were developed within the context of existing literature. Approach coping behavior themes included: Help-Seeking, Seeking Guidance and Support, Self-Protecting Behavior, Positive Reappraisal, Self-Affirmation, Self-Care, Connection to a Higher Power, and Acceptance. Avoidant coping behavior themes included: Cognitive Avoidance, Substance, Alcohol, and Tobacco Use, Emotional Discharge, and Seeking Alternative Rewards. Participants employed similar coping behaviors as seen among cisgender women survivors of violence. However, several unique applications of approach coping mechanisms were identified including self-protecting behavior and self-affirming behavior. Culturally informed application of the identified coping behaviors can be taught and integrated into trauma-informed mental health interventions to promote strength and resilience among Black transgender women. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Greenness and the Potential Resilience to Sexual Violence: "Your Neighborhood Is Being Neglected Because People Don't Care. People With Power Don't Care".

There is increasing evidence that green space in communities reduces the risk of aggression and violence, and increases wellbeing. Positive associations between green space and resilience have been found among children, older adults and university students in the United States, China and Bulgaria. Little is known about these associations among predominately Black communities with structural disadvantage. This study explored the potential community resilience in predominately Black neighborhoods with elevated violent crime and different amounts of green space. This embedded mixed-methods study started with quantitative analysis of women who self-identified as "Black and/or African American." We found inequality in environments, including the amount of green space, traffic density, vacant property, and violent crime. This led to 10 indepth interviews representing communities with elevated crime and different amounts of green space. Emergent coding of the first 3 interviews, a subset of the 98 in the quantitative analysis, led to a priori coding of barriers and facilitators to potential green space supported community resilience applied to the final 7 interview data. Barriers were a combination of the physical and social environment, including traffic patterns, vacant property, and crime. Facilitators included subjective qualities of green space. Green spaces drew people in through community building and promoting feelings of calmness. The transformation of vacant lots into green spaces by community members affords space for people to come together and build community. Green spaces, a modifiable factor, may serve to increase community resilience and decrease the risk of violence.

LGBTQ+ health education for nurses: An innovative approach to improving nursing curricula.

BACKGROUND: Lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI+) people experience high rates of discrimination in healthcare settings worldwide, which have been linked to poor health outcomes and delays in seeking care. In the United States (US), nurses report a lack of awareness regarding LGBTQI+ health needs and nursing faculty report a lack of knowledge and confidence to teach LGBTQI+ health content to students. On average, baccalaureate nursing programs in the US only cover 2.12 h of LGBTQI+ content over the course of an entire program. This significant nursing education deficit merits timely dissemination of a logic model to guide LGBTQI+ health content integration. OBJECTIVES: Johns Hopkins School of Nursing (JHSON) LGBTQI+ Health Initiative (LHI) was established to develop a strategic, innovative response to the gaps in LGBTQI+ health education among faculty and nursing students. RESULTS: The process resulted in a pragmatic interdisciplinary approach to nursing curriculum development focused on the integration of LGBTQI+ health. Specifically, a logic model, including product development, assessment, implementation, and evaluation, was developed to guide JHSON LHI efforts and act as a guide for LGBTQI+ health integration into nursing curricula. CONCLUSIONS: Prompt dissemination of the JHSON LHI logic model will expedite process sharing and reduce redundancies among nursing schools pursuing similar initiatives.

Residential Greenness Positively Associated with the Cortisol to DHEA Ratio among Urban-Dwelling African American Women at Risk for HIV.

As ecosystems that support human health, societies, and civilization change in the era of the Anthropocene, individuals with disproportionate balance of salivary hormones may be at greatest risk of morbidity and mortality. Vulnerable communities, in particular, are overburdened by inequities in features of built environments linked to health disparities. This study examined the cross-sectional association of greenness in the built environment with the ratio of cortisol to dehydroepiandrosterone (DHEA) in an urban-dwelling high-risk community sample of African American women (n = 84, age 18-44 years). Saliva samples, collected across 2 consecutive days, were assayed for cortisol and DHEA. Controlling for sexual violence, perceived stress, education, and income, as well as crime, traffic density, and vacant properties, we observed a significant positive cross-sectional association between greenness and the cortisol to DHEA ratio, (ß = 7·5, 95% CI: 0.89, 14.19). The findings highlight environmental influence on stress response at waking when there is the greatest individual variation. Implications for advancing our understanding of the waking ratio of cortisol to DHEA as a potential marker of physiological resilience are discussed.

Polyvictimization and Substance Use Among Sexual Minority Cisgender Women.

BACKGROUND: Violent victimization and substance use are higher among sexual minority cisgender women (SMCW) than heterosexual cisgender women. Unknown, however, is how polyvictimization-experiencing multiple types of violent victimization-affects substance use among SMCW. Purpose/Objectives: This study explores the relationship between polyvictimization and substance use among a small sample of SMCW. Methods: An exploratory secondary data analysis was conducted on data from a convenience sample of 115 SMCW currently in relationships (70.4% lesbian, 73.9% non-Hispanic white) via a cross-sectional survey. Lifetime physical, sexual, and crime-related violent victimization were measured via the Trauma History Questionnaire. Past-year substance use was measured via the Drug Abuse Screening Test (DAST-10). Mann-Whitney U testing and linear regression modeling were used to examine differences in substance use by victimization status (victimized/non-victimized) and the association between polyvictimization and substance use. Results: Lifetime prevalence of violent victimization was high with 60.9% of the sample reporting at least one type of victimization: 10.4% experienced physical, 22.6% experienced sexual, and 22.6% experienced crime-related violent victimization. Substance use was significantly greater for victimized participants than non-victimized participants. Modeling showed that as violent victimization increased by one unit, substance use scores increased by .30 units. Conclusion/Importance: Preliminary evidence suggests that increase in violent victimization was associated with increased substance use among SMCW. Findings indicate a need for additional confirmatory research with more representative samples and longitudinal data. Behavioral health practitioners are urged to consider the implications of these findings and assess for past cumulative violence and current risk of substance use disorder, to appropriately facilitate treatment planning.

Examining Recidivism in a Prostitution Diversion Program.

Street-based sex work is criminalized throughout much of the U.S. Diversion programs have shown mixed results. This study examined the effect a quasi-experimental intervention (prostitution diversion program, n = 149) had on prostitution rearrest compared with a waitlist control group (n = 77) among N = 226 individuals arrested for prostitution in Baltimore. In both groups, n = 64 (28.32%) were rearrested for prostitution over 30 months. Tests of differences compared groups with a significant difference in gender only. A Cox proportional hazard model examined differences in survival time (to recidivist prostitution arrest) between individuals in the control and intervention groups at 6, 12, 18, 24, and 30 months. Results indicate that participation in the intervention did not have a significant effect on decreasing prostitution arrests over time. History of prior prostitution arrest was a significant predictor (hazard ration [HR] = 1.12, p = .02) of rearrest.Lack of program success suggests that barriers to exiting prostitution are substantial, despite availability of supportive services, and that diversion programs may not be the best intervention strategy for all sex workers. Future research should identify motivators for exiting and how to reduce exiting barriers.

Adverse childhood experiences (ACEs) are associated with forced and very early sexual initiation among Black women accessing publicly funded STD clinics in Baltimore, MD.

PURPOSE: To examine the association between adverse childhood experiences (ACEs) and early sexual initiation. METHODS: We analyzed retrospective data of (n = 241) Black women recruited from public STD clinics in Baltimore, MD. Multinomial logistic and linear regression models estimated associations between ACEs and early sexual initiation; contextual variables at initiation were examined as mediators. RESULTS: Twelve percent of our sample reported very early sexual initiation (11-12 years) and 29% reported early sexual initiation (13-14 years). Each additional ACE reported was associated with greater risk of very early sexual initiation (RRR = 1.49; 95%CI:1.23,1.80). Specifically, emotional abuse (RRR = 3.71; 95%CI:1.55,8.89), physical abuse (RRR = 9.45; 95%CI:3.56,25.12), sexual abuse (RRR = 8.60; 95%CI:3.29,22.51), witnessing maternal abuse (RRR = 5.56; 95%CI:2.13,14.52), and household substance misuse (RRR = 3.21; 95%CI:1.38,7.47) at or before the age of 18 were associated with very early sexual initiation. As for context of initiation, age at sexual initiation was younger if the man at initiation was a non-partner (ß = -0.88; 95%CI:-1.36,-0.40), was ≥3 years older (ß = -1.30; 95%CI:-1.82,-0.77), had pressured or forced sexual intitiation (ß = -1.09; 95%CI:-1.58,-0.59), and was under the influence of drugs/alcohol (ß = -0.97; 95%CI:-1.62,-0.32). Contextual variables at first sex, including being pressured or forced, and the man being ≥3 years older fully mediated the association between ACEs and early sexual initiation. CONCLUSIONS: This study highlights the critical need to develop interventions that reduce the impact of ACEs on women's health and delay age at sexual initiation. Health education efforts are needed for clinicians and parents to identify and prevent childhood abuse and to identify and report sexual coercion and abuse for girls and adolescents.

Physiological Changes from Violence-Induced Stress and Trauma Enhance HIV Susceptibility Among Women.

PURPOSE OF REVIEW: This theoretical review identifies physiological mechanisms by which violence against women (VAW) may increase women's susceptibility to HIV through trauma, stress, and immune dysfunction. RECENT FINDINGS: Research documents systemic and local immune responses are related to stress and trauma from abuse across the life course (i.e., childhood, IPV, adulthood re-victimization). Findings are interpreted within a theoretical framework grounded in the Social Stress Theory and the concept of toxic stress, and highlight the current state of the science connecting: (1) VAW to the physiological stress response and immune dysfunction, and (2) the physiological stress response and inflammation to HIV susceptibility and infection in the female reproductive tract. Despite a dearth of research in human subjects, evidence suggests that VAW plays a significant role in creating a physiological environment conducive to HIV infection. We conclude with a discussion of promising future steps for this line of research.

Friends, family, and boyfriends: An analysis of relationship pathways into commercial sexual exploitation.

BACKGROUND: The commercial sexual exploitation of children (CSEC) is a major global issue that affects over two million children each year (Polaris Project, 2014). Large metropolitan cities, such as Las Vegas, have high rates of child prostitution (Shared Hope International, 2009). OBJECTIVE: The purpose of the current study is to elucidate to what extent interpersonal relationships and contextual factors (e.g. abuse within the home, substance abuse, etc.) influence commercial sexual exploitation. PARTICIPANTS AND SETTING: Participants for this study include 26 CSEC survivors located within the state of Nevada. METHODS: The current study utilizes a qualitative content analysis approach to analyze interview transcripts gathered from CSEC survivors. Three stages of analysis were conducted to assess the relationships that influenced the participants' sexual exploitation, as well as the contextual factors shared by the participants. RESULTS: Analyses indicated that three types of relationships led to commercial sexual exploitation: friends, family, and boyfriends. Of the three relationship typologies, friends were the most common (n = 14). As for contextual factors, it was common for participants to have been abused within their home (n = 15) or to have run away from home (n = 20). CONCLUSIONS: The narratives provided in this study show that CSEC survivors do not often willingly engage in trading sex; rather this decision is influenced by a need to escape familial abuse or they are forced to trade sex by someone whom they share a relationship.

The Effect of Intimate Partner Violence and Probable Traumatic Brain Injury on Mental Health Outcomes for Black Women.

Severe intimate partner violence (IPV) including loss of consciousness from head injuries and/or strangulation can result in traumatic brain injury (TBI), a brain pathology characterized by altered brain function, cognitive impairment, and mental health disorders, including depression and posttraumatic stress disorder (PTSD). This study examines the prevalence of probable TBI (defined as loss of consciousness from a blow to the head and/or strangulation) and its association with comorbid PTSD and depression among Black women, who experience both higher rates of IPV and greater mental health burden than White and Latina women. Data come from a retrospective cohort study of 95 Black women with abuse history including IPV, forced sex, and childhood maltreatment. About one-third of women (n=32) had probable TBI. Among them, 38% (n=12) were hit on the head, 38% (n=12) were strangled to unconsciousness, and 25% (n=8) were strangled and hit on the head. Women with IPV history and probable TBI had significantly greater odds of various physical injuries including those that required medical care compared to other abused women. Probable TBI significantly increased comorbid PTSD and depression by 8.93 points (SE=3.40), after controlling for past violence (F (4, 90)=3.67, p<.01). Findings from this study reinforce the need to screen women who lost unconsciousness due to IPV for TBI and facilitate referrals to IPV interventions and mental health treatment.

Examining Trauma and Readiness to Change among Women in a Community Re-Entry Program.

BACKGROUND: Posttraumatic stress disorder (PTSD) and co-occurring substance use disorders (SUDs) are common among women who are incarcerated. OBJECTIVE: The purpose of this study was to examine the relationship between trauma and readiness to change substance use behaviors. METHODS: This study used data from 103 participants enrolled in a residential re-entry program for women with SUDs and trauma history. Women reporting clinically elevated Trauma Symptom Inventory (TSI) subscale scores were compared to those without elevated scores on the University of Rhode Island Change Assessment (URICA) readiness to change instrument. Primary analyses included t-tests and ANCOVA to control for age and ethnicity. RESULTS: In general, women with clinically elevated trauma scores also reported greater readiness to change. The analyses revealed significant differences on the URICA Readiness to Change scores between women who had elevated Defensive Avoidance and Impaired Self-Reference according to the TSI. Results approached significance for women who had elevated TSI subscale scores for Sexual Concerns and Dissociation. CONCLUSIONS: These results point to a need to further understand links between trauma and readiness to change, particularly, the role of posttraumatic growth and psychological distress. This study has implications for social workers and clinicians delivering evidence-based treatment. Women who had high trauma symptoms were more willing to address change. Findings also suggest a need to tailor interventions to include motivational components that are also trauma-informed.

Childhood Maltreatment and Child Protective Services Involvement Among the Commercially Sexually Exploited: A Comparison of Women Who Enter as Juveniles or as Adults.

A risk for commercial sexual exploitation is childhood maltreatment. It's unknown whether juveniles in commercial sexual exploitation experience more childhood maltreatment than adults or how involved child protective services is in investigating maltreatment, a focus of this study. Women (N = 96) who sold sex commercially completed a cross-sectional questionnaire. Descriptive statistics, t tests, chi-squares, and odds ratios were used to examine differences in background, childhood maltreatment, and child protective services involvement by juvenile or adult entry. Although 93% of participants experienced child maltreatment, juveniles had increased odds of parent/caregiver sexual abuse, being left alone, being kicked out, and running away from a parent/caregiver. There were no differences in cumulative childhood maltreatment resulting in an investigation or removal, indicating that juveniles not investigated or removed by child protective services had as much childhood maltreatment as juveniles who were investigated or removed by child protective services. Results highlight the need for child welfare staff to recognize childhood maltreatment as risks for commercial sexual exploitation.

The Girl Is Mine: Reframing Intimate Partner Violence and Sex Work as Intersectional Spaces of Gender-Based Violence.

Intimate partner violence (IPV) and sex work have been primarily constructed as mutually exclusive phenomena within scholarly literature, though both can be situated under the umbrella of gender-based violence and traced to male sexual proprietariness. Specialized research has resulted in deeper understanding of nuanced categorizations of sub-phenomena within both IPV and sex work, with parallel constructions along a spectrum of increasing danger. However, the scholarly construction of these continua as parallel-and thus unrelated-disguises the systemic nature of each form of violence and potentially pits victims against each other in the struggle for legitimacy. We propose a more systemic approach to understanding and researching IPV and sex work and provide examples of research already moving in this direction.

Examining the Relationship between Psychological Functioning, Childhood Trauma, and Types of Perceived Coercion Among Drug Court Enrollees: Results from A Pilot Study.

BACKGROUND: Drug court interventions produce positive results-especially among mandated populations. Many criminal justice-involved persons, including drug court enrollees, have cooccurring substance abuse and childhood trauma disorders associated with psychological dysfunction. Given the coercive nature of mandated drug court treatment, it is important to understand whether childhood trauma and psychological functioning influence perceived coercion to enter treatment. OBJECTIVES: The purpose of this study was to describe the degree to which adverse childhood trauma and psychological functioning were associated with six domains of perceived coercion- self, family, legal, financial, health, and work-among a population of drug court enrollees. METHODS: Data from 54 enrollees in a drug court pilot study were used to examine the relationship between childhood trauma, psychological functioning, and perceived coercion. RESULTS: The pilot study data showed that psychological dysfunction and traumatic experiences in childhood were associated with higher perceived coercion to treatment, explaining 29% of the variance in coercion, controlling for gender and pre-arrest alcohol and drug use. Results indicated that the associations between psychological dysfunction and trauma were driven by non-legal types of coercion. In particular, childhood trauma was correlated with family (r = .32), financial (r = .32), and health (r = .47) types of coercion. CONCLUSIONS: Based on these preliminary findings, drug court practitioners are urged to assess perceived coercion, in addition to the behavioral health and childhood trauma of their clients, and to utilize non-legal types of coercion such as family, health, and financial impact to enhance treatment engagement.

Exhaust All Measures: Ethical Issues in Pediatric End-of-Life Care.

The death of a child may have a profound impact on parents, family members, and health care providers who provided care for the child. Unique challenges are faced by parents of seriously ill children as they must serve as the legal authority for health care decisions of children under age 18, although the child's wishes must also be considered. Social workers must balance core social work values, bioethical values, and psychosocial issues presented by such situations. While studies have been conducted with physicians and nurses regarding ethical issues in pediatric end-of-life care settings, little is known about how social workers experience these conflicts. This article utilizes two vignettes to illustrate potential ethical issues in this setting and applies the National Association of Social Workers Standards for Palliative and End of Life Care (NASW, 2004 ) to explore options for their resolution. These vignettes provide descriptions of possible reactions in this setting and can be used as a basis for further exploration of ethics in pediatric end-of-life care from a social work perspective.