Cross-Cultural Validity of Sexual Recidivism Risk Assessments Using Static-99R, STABLE-2007, and the VRS-SO.

PURPOSE OF REVIEW: The overrepresentation of certain racial/ethnic groups in criminal legal systems raises concerns about the cross-cultural application of risk assessment tools. We provide a framework for conceptualizing and measuring racial bias/fairness and review research for three tools assessing risk of sexual recidivism: Static-99R, STABLE-2007, and VRS-SO. RECENT FINDINGS: Most cross-cultural research examines Static-99R and generally supports its use with Black, White, Hispanic, and Asian men. Preliminary research also supports STABLE-2007 with Asian men. Findings are most concerning for Indigenous men, where Static-99R and STABLE-2007 significantly predict sexual recidivism, but with significantly and meaningfully lower accuracy compared to White men. For the VRS-SO and the combined Static-99R/STABLE-2007 risk levels, predictive accuracy was not significantly lower for Indigenous men, for which we discuss several possible explanations. We offer considerations for risk scale selection with Indigenous men and highlight recent guidance produced for cross-cultural risk assessment.

Effectiveness of substance use disorder treatment as an alternative to imprisonment.

INTRODUCTION: Drug courts are criminal justice programs to divert people with substance use disorders from incarceration into treatment. Drug courts have become increasingly popular in the US and other countries. However, their effectiveness in reducing important public health outcomes such as recidivism and substance-related health harms remains ambiguous and contested. We used nationwide register data from Sweden to evaluate the effectiveness of contract treatment sanction, the Swedish version of drug court, in reducing substance misuse, adverse somatic and mental health outcomes, and recidivism. METHODS: In this prospective cohort study, two quasi-experimental designs were used: difference-in-differences and the within-individual design. In the latter, we compared the risk of outcomes during time on contract treatment to, 1) parole after imprisonment and, 2) probation. RESULTS: The cohort included 11,893 individuals (13% women) who underwent contract treatment. Contract treatment was associated with a reduction of 7 percentage points (95% CI: -.088, -.055) in substance misuse, 5 percentage points (-.064, -.034) in adverse mental health events, 9 percentage points (-.113, -.076) in adverse somatic health events, and 3 fewer charges (-3.16, -2.85) for crime in difference-in-differences analyses. Within-individual associations suggested that the same individual had longer times-to-event for all outcomes during contract treatment than on parole or on probation. CONCLUSIONS: Contract treatment is an effective intervention from both public health and criminal justice perspective. Our findings suggest that it is a superior alternative to incarceration in its target group. Further, we find that an implementation approach that is less punitive and more inclusive than what is typical in the US can be successful.

The Association Between Prior Mental Health Service Utilization and Risk of Recidivism among Incarcerated Ontario Residents.

BACKGROUND: There is mixed evidence on the link between mental health and addiction (MHA) history and recidivism. Few studies have examined post-release MHA care. Our objective was to examine the association between prior (pre-incarceration) MHA service use and post-release recidivism and service use. METHODS: We conducted a population-based cohort study linking individuals held in provincial correctional institutions in 2010 to health administrative databases. Prior MHA service use was assigned hierarchically in order of hospitalization, emergency department visit and outpatient visit. We followed up individuals post-release for up to 5 years for the first occurrence of recidivism and MHA hospitalization, emergency department visit and outpatient visit. We use Cox-proportional hazards models to examine the association between prior MHA service use and each outcome adjusting for prior correctional involvement and demographic characteristics. RESULTS: Among a sample consisting of 45,890 individuals, we found that prior MHA service use was moderately associated with recidivism (hazard ratio (HR): 1.20-1.50, all P < 0.001), with secondary analyses finding larger associations for addiction service use (HR range: 1.34-1.54, all P < 0.001) than for mental health service use (HR range: 1.09-1.18, all P < 0.001). We found high levels of post-release MHA hospitalization and low levels of outpatient MHA care relative to need even among individuals with prior MHA hospitalization. DISCUSSION: Despite a high risk of recidivism and acute MHA utilization post-release, we found low access to MHA outpatient care, highlighting the necessity for greater efforts to facilitate access to care and care integration for individuals with mental health needs in correctional facilities.

A scalable empathic supervision intervention to mitigate recidivism from probation and parole.

Incarceration is a pervasive issue in the United States that is enormously costly to families, communities, and society at large. The path from prison back to prison may depend on the relationship a person has with their probation or parole officer (PPO). If the relationship lacks appropriate care and trust, violations and recidivism (return to jail or prison) may be more likely to occur. Here, we test whether an "empathic supervision" intervention with PPOs-that aims to reduce collective blame against and promote empathy for the perspectives of adults on probation or parole (APPs)-can reduce rates of violations and recidivism. The intervention highlights the unreasonable expectation that all APPs will reoffend (collective blame) and the benefits of empathy-valuing APPs' perspectives. Using both within-subject (monthly official records for 10 mo) and between-subject (treatment versus control) comparisons in a longitudinal study with PPOs in a large US city (NPPOs = 216; NAPPs =∼20,478), we find that the empathic supervision intervention reduced collective blame against APPs 10 mo postintervention and reduced between-subject violations and recidivism, a 13% reduction that would translate to less taxpayer costs if scaled. Together, these findings illustrate that very low-cost psychological interventions that target empathy in relationships can be cost effective and combat important societal outcomes in a lasting manner.

Six-month post-release outcomes for inmates with traumatic brain injury in supported community programming.

OBJECTIVE: The goal of this study is to examine the effectiveness of case management services for a population of justice-involved individuals with TBI history. METHODS: Two thousand three hundred and eighty-nine records from statewide behavioral health and brain injury program databases were used in two studies. RESULTS: Participants with a reported TBI history were more likely to have experienced trauma and to have a behavioral health diagnosis relative to incarcerated persons without TBI. Six months after release, 56.8% of participants with a history of TBI were still receiving community treatment, 27.8% were not in treatment, and 3.4% had completed treatment. There was a high attrition rate; 70% of people referred for case management failed to maintain contact. CONCLUSIONS: For those that did receive services, these data suggest that it prevented an escalation of psychosocial needs. There were no differences in community participation as measured by the Mayo Portland Adaptability Index's Participation Index (M2PI) scores (t24 = .497, p = 0.624) at intake and after 6 months of case management. This study confirms that case management confers a benefit to persons with TBI who are released from the criminal justice system. Further, recidivism rates for this vulnerable group were no different from the larger population of returning citizens.

The role of ethnicity in the admission process of male juvenile released offenders: Examining risk and readiness to change in the Israeli Shushan centers.

INTRODUCTION: Disparities in evaluating readiness to change and recidivism risk across diverse cultural groups can profoundly affect rehabilitation program efficacy. This study examines readiness to change and recidivism risk disparities between Israeli-Arabs and Israeli-Jews entering a re-entry program by the Prisoner Rehabilitation Authority postrelease. METHOD: The University of Rhode Island Change Assessment Scale questionnaire gauged readiness to change, whereas the Ohio Youth Assessment System-Residential tool assessed recidivism risk. The sample included 151 participants: 98 Israeli-Arabs and 53 Israeli-Jews. Mean differences in change readiness and recidivism risk were statistically assessed through t tests. RESULTS: Significant differences emerged in change readiness levels between Israeli-Arabs and Jews upon rehabilitation program entry, with Israeli-Jews exhibiting higher readiness. Additionally, a noteworthy divergence in recidivism risk was noted, indicating elevated average risk for Israeli-Jews. CONCLUSIONS: Findings underscore the vital need for cultural sensitivity during admission. Bias potential in assessing risk for Arab participants emphasizes the necessity of a comprehensive culturally sensitive approach. While focusing on admission, the Risk-Need-Responsivity model application could enhance risk evaluation and guide culturally tailored treatments.

A tailored approach in cholesteatoma surgery.

PURPOSE: In recent years, new techniques have been added to cholesteatoma surgery, and established microsurgical approaches are being reconsidered. This study aims to present the importance of individualized decision-making for the selection of an intact canal wall (CWU) or canal wall down (CWD) surgical procedure for each patient. METHODS: Using the "ChOLE" classification we categorized 264 operations retrospectively. 162 CWU and 102 CWD surgeries were performed. We focus to determine why a CWD procedure was chosen quite frequently despite some low-stage cases. Furthermore, we evaluated recidivism and hearing outcomes. RESULTS: Smaller cholesteatomas (Ch-stage 1a, 1b & 2a) were found in 182 patients (70%), ossicular chain status feasible for straightforward reconstruction (O-stage 0, 1 & 2) was present in 186 patients (70%), minor complications due to the cholesteatoma (L-stage 1) were infrequent with 28 cases (11%) and a well-pneumatized mastoid was found in 144 cases (55%). Recidivism rates were low (7%) without any difference in both groups and a mean follow-up time of 4 years and 8 months. In primary surgeries there was a significant difference (p < 0.05) in postoperative mean air-bone gap (ABG) between CWU (17dB) and CWD (27dB). CONCLUSION: The main goals of cholesteatoma surgery remain the avoidance of recidivism and optimal hearing rehabilitation. We recommend a tailored approach in the treatment of cholesteatomas and not a dogmatic one. Surgeons should not hesitate to perform a CWD procedure if required. Performed correctly it results in a dry ear and CWD surgery should remain in the skill set of the otologic surgeon.

The associations between social determinants of health, mental health, substance-use and recidivism: a ten-year retrospective cohort analysis of women who completed the connections programme in Australia.

BACKGROUND: Women with substance-use issues are overrepresented in prison. Research on women's recidivism often focuses on offending behaviour rather than the health and social circumstances women are experiencing when reimprisonment occurs. This study examines the relationship between social determinants of health (SDOH), mental health, substance-use and recidivism among women exiting prison with histories of substance-use. METHODS: A retrospective cohort study of women exiting prison who completed the transitional support programme "Connections" between 2008 and 2018. Recidivism was measured up to two years post-release. Women's support needs were measured at baseline (4 weeks pre-release) and follow-up (four weeks post-release). Ongoing needs in relation to well-established SDOH were calculated if: (1) at baseline women were identified as having a re-entry need with housing, employment, finances, education, domestic violence, child-custody and social support and (2) at follow-up women reported still needing help in that area. Women's self-reported substance-use and mental health since release were captured at follow-up. Descriptive statistics were calculated for all measures. Associations between SDOH, mental health, substance-use and recidivism were estimated by multiple logistic regression, adjusting for potential confounders. We also evaluated the mediating effects of mental health on the relationship between SDOH and substance-use. RESULTS: Substance-use was associated with increased odds of recidivism (adjusted odds ratio (AOR) 1.8, 95% confidence interval (CI) 1.1-2.9; p = 0.02). Poor mental health (AOR 2.9, 95% CI 1.9-4.6; p = < 0.01), ongoing social support (AOR 3.0, 95% CI 1.9-5.0; p = < 0.01), child-custody (AOR 1.9, 95% CI 1.0-3.3 p = 0.04), financial (AOR 2.0, 95% CI 1.3-3.2; p = < 0.01) and housing (AOR 1.8, 95% CI 1.1-2.9; p = 0.02) needs were individually associated with increased odds of substance-use. Mediation analysis found mental health fully mediated the effects of ongoing housing (beta efficiency (b) = - 033, standard error (SE) 0.01; p = 0.05), financial (b = 0.15, SE 0.07; p = 0.05), child-custody (b = 0.18, SE 0.01; p = 0.05) and social support (b = 0.36, SE 0.1; p = 0.05) needs onto substance-use, and partially mediated the effects of domestic violence (b = 0.57, SE 0.23; p = 0.05) onto substance-use. CONCLUSION: This study underscores the critical importance of addressing the interplay between SDOH, mental health, substance-use and recidivism. An approach that targets SDOH holds the potential for reducing mental distress and substance-use, and related recidivism.

Therapeutic and risk relevance of psychopathy and general criminal attitude change in an institutional sexual offense treatment program.

We examined the interrelationships between psychopathy, changes in general criminal attitudes, and community recidivism in a sample of 212 men who attended an institutional sexual offense treatment program (SOTP) and were followed for an average of 12.73 years post-release. The men completed a self-report measure of general criminal attitudes, the Criminal Sentiments Scale, as part of routine SOTP service delivery, Psychopathy Checklist-Revised (PCL-R) ratings were completed via file review, and recidivism data were obtained from official criminal records. Criminal attitude endorsement and criminal attitude change had clinically meaningful, but differential, associations with the antisocial and interpersonal features of psychopathy. Further, positive changes in criminal attitudes-particularly tolerance of law violations (i.e., rationalizations for criminal behavior)-were significantly predictive of reductions in community violent and general recidivism after controlling for PCL-R score. Results demonstrate that general criminal attitude change has risk relevance in the treatment of high psychopathy persons with sexual offense histories.

The Risk, Need, and Responsivity Relevance of Working Alliance in a Sexual Offense Treatment Program: Its Intersection With Psychopathy, Diversity, and Treatment Change.

The current study examined the self-reported working alliance of men attending a high intensity sexual offense treatment program and its associations with psychopathy, sexual violence risk, treatment change, and recidivism, in a Canadian sample of 317 incarcerated men followed up an average of approximately 10 years post release. Working Alliance Inventory (WAI; Horvath & Greenberg, 1989) self-reported total, Task, Bond, and Goal scores were positively correlated with treatment related changes in risk, and inversely associated with Psychopathy Checklist-Revised (PCL-R; Hare, 1991; Wang & Hare, 2003) scores. The Affective facet of the PCL-R, representing the callous-unemotional features of the syndrome, uniquely predicted lower Bond and Goal scores controlling for the other facets. Cox regression survival analyses demonstrated that sexual violence risk predicted increased sexual recidivism while change predicted decreased sexual recidivism controlling for PCL-R total score; however, WAI scores (particularly the Goal component) were also unexpectedly associated with increased sexual recidivism. For violent recidivism, psychopathy, risk, and change incremented the prediction of general violence, while the WAI was not significantly associated with this outcome. A set of parallel analyses, stratified by Indigenous ethnocultural heritage, demonstrated some continuity, but also potential areas of difference, in substantive findings. Risk, need, responsivity implications of the working alliance for the treatment of high psychopathy correctional clientele, and how this may intersect with Indigenous heritage, are discussed.

Intellectual Ability and Sexual Recidivism Risk Assessment: Comparing Predictive Accuracy in an Incarcerated U.S. Sample.

While studies indicate that individuals with intellectual disabilities (ID) and borderline intellectual functioning (BIF) are overrepresented among those incarcerated for sexual offenses, there is a paucity of research with respect to risk assessment for this population, particularly among incarcerated U.S. samples. This gap is concerning given that individuals perceived as high risk may be denied bail, given harsher sentences, or subject to civil confinement. The present study examined the predictive validity of the Static-99 and Static-99R, which rely on historical predictors, and the MnSOST-R, which includes a dynamic subscale. Archival records were used to compare individuals with (n = 459) and without (n = 459) ID/BIF released from New Jersey state prisons between 1996 and 2007, with an average follow-up period of 5.7 years. All three instruments demonstrated good predictive validity for those without ID/BIF, while only the MnSOST-R produced a significant AUC value for those with ID/BIF. Reincarceration rates for those with ID/BIF within high-risk groups ranged from 0% to 8%, similar to the overall recidivism base rate of 4%. Results highlight the need for additional research to determine which risk factors should be considered for those with ID/BIF.

Explaining the Unexplainable: Balancing Responsibility, Expectations, and Identity in Narratives of Sexual Recidivism.

When someone is caught and punished for a sexual offense, recidivism prevention is of high priority. While a growing body of qualitative research has investigated the desistance process of those who have sexually offended, few studies have examined the narratives of individuals who have sexually recidivated in order to understand how they make sense of their reoffending. This study aims to fill this gap in the literature by exploring the recidivism process and broader life stories of 16 imprisoned men through semi-structured interviews. The results demonstrate how these men explain their recent "failures," the obstacles they face when doing so, and how they attempt to overcome these obstacles in their narratives. Thus, the analysis in this study is both thematic and narrative. Finally, the findings' practical implications are discussed to show how ambiguity in narratives can be a powerful tool in correctional and clinical interventions.

Understanding the Risk of Sexual Reoffending in Adult Men: A Network-Based Model.

The predominant approach to understand dynamic risk factors of sexual reoffending has been referred to as the Propensities Model (Thornton, 2016). According to this model, dynamic risk factors can be conceptualized as latent constructs whose change alters the risk of sexual reoffending. Despite its strengths and contributions to research, this model does not offer answers to the question of how dynamic risk factors contribute to the risk of sexual reoffending, or of how sustained change in risk might take place. In this paper we introduce the Network-Based Model of Risk of Sexual Reoffending (NBM-RSR), which addresses several limitations and constraints of the Propensities Model and offers empirically testable propositions regarding the nature and development of the risk of sexual reoffending. The NBM-RSR considers risk of sexual reoffending to involve a self-sustaining network of causally connected dynamic risk factors. Consistent with this, an increased risk of sexual reoffending is characterized through a network that contains more and stronger interconnected dynamic risk factors with a higher strength. Sustained change in risk of sexual reoffending occurs when activity in the network exceeds a critical point resulting in a new self-sustaining network. Propositions based on the NBM-RSR are introduced and translated into testable hypotheses. These propositions revolve around (a) risk of sexual reoffending resulting from the construction of a network of causally connected dynamic risk factors, (b) network stability, sudden changes, and critical transitions, and (c) dynamic risk factors' relative influence on risk of sexual reoffending.

Structural barriers explain the link between negative community re-entry experiences and motives for illegal behavior in street-identified Black men and women.

This study examines how the re-entry process is related to structural barriers in the community and to motives for engaging in illegal behavior-two key risk factors for recidivism. We analyzed survey data collected on perceptions of community re-entry, employment opportunities, neighborhood violence, and illegal behavior motives from 379 formerly incarcerated and street-identified Black-American community members residing in Wilmington, Delaware (Mage = 32.3/8.9 years old; 77.0% men; 100% Black) by employing Street Participatory Action Research (Street PAR) methodology. We found that negative perceptions of re-entry correlated positively with (i) hardship caused by structural barriers in the community, specifically blocked employment opportunities and neighborhood violence, and (ii) motives for engaging in illegal behavior. Notably, the link between negative perceptions of re-entry and motives for illegal behavior became significantly weaker when the influence of structural barriers on these individual-level factors was included in a multivariate model. Results suggest negative views of the re-entry process reflect the resource-scarce and stressful environments people are living in, and structural barriers can account for the relationship between negative re-entry experiences and why individuals are motivated to engage in illegal behavior. Findings underscore the importance of improving the economic conditions of communities with high numbers of returning citizens.

Examining the Past Injustices Suffered by Those in Corrections and the General Public: A New Therapeutic Approach May Be Necessary.

One under-researched area within corrections is the connection among (a) past adverse events, particularly in the form of injustices against those who now are incarcerated, (b) crimes committed and then (c) healing from the effects of that past adversity of injustice. Might those who have experienced severe injustices against them develop an anger or a hatred that then is displaced onto others, leading to arrest, conviction and imprisonment? This is not to imply that societies condone illegal behaviour but instead to assist in the healing from the adversity so that future crime is reduced. As a first step in this sequence, the study here examined in detail the kinds of injustices suffered by men in a maximum-security correctional institution (N = 103) compared with men in a medium-security environment (N = 37) and in the general public (N = 96). Findings indicated differences between those in the general public and those in the two correctional contexts. The latter two groups had (a) a higher severity of injustices against them (rated by a panel of researchers), (b) a more negative current impact that past injustices are having on them (also rated by a panel of researchers), (c) more reports that the injustices contributed to their choices to harm others, (d) more serious types of hurt (such as sexual abuse), (e) a stronger degree of self-reported hurt and (f) more injustices from family members. Implications for correctional rehabilitation to reduce the negative psychological effects caused by the injustices of others are discussed.

Mixed methods evaluation of a jail diversion program: Impact on arrests and functioning.

This mixed methods study had two aims: (1) to examine the effectiveness of a jail diversion program in reducing recidivism and promoting educational and employment outcomes; and (2) to qualitatively explore mechanisms through which the program was effective. Participants were 17 individuals arrested for drug offenses who participated in an intensive, law enforcement-based jail diversion program, and 17 individuals in a comparison group. Arrests were extracted from police records, and education and employment were extracted from program data. Four intervention participants completed qualitative interviews. Arrest rates in the intervention group decreased significantly postintervention, and arrest rates in the intervention group were numerically lower than those in the comparison group. Participants experienced significant increases in employment and driver's license status. Participants also identified mechanisms through which the program was effective. This jail diversion program shows promise in reducing recidivism and promoting adaptive functioning. Jail diversion programs that include mentorship, peer support, and removal of barriers to success may be particularly effective.

[Theory and Practice of Empowerment for Family Members of Patients Under Custodial Protection Sentence].

Empowerment not only benefits patients but also provides support and assistance to their family members, especially in cases when patients are subject to custodial protection sentences. The positive effects of empowerment on patients' family members may be summarized into three main aspects, including: enhancing their engagement in healthcare, alleviating their anxiety, and enhancing their caregiving skills. With regard to enhancing engagement in healthcare, family members receive health education that provides an overview of the illness, treatment options, prognosis, and key nursing points and allows them to better understand the patient's condition and actively participate in decision-making. With regard to alleviating anxiety, patients under custodial protection sentences are involved in legal problems, which results in higher levels of stress for family members compared to their peers caring for general patients. Through emotional support and active listening, nurses provide opportunities for family members to express their concerns and offer comfort and encouragement, helping them cope with difficulties and pressures. With regard to enhancing caregiving skills, the purpose of custodial protection sentences is to prevent recidivism, and family members bear significant responsibility for caregiving after discharge. Nurses can share similar caregiving experiences from their ward, educate family members about observing symptoms, and provide guidance, thereby strengthening their caregiving capabilities. In addition, with regard to the disposition of patients, nurses assist family members to understand the medical process and provide necessary guidance, ensuring family members have a clear understanding and are respected during the preparations for discharge. Based on related theoretical frameworks and practical experiences, this research highlights the positive role of empowerment in enhancing the caregiving abilities and satisfaction of the family members of patients, particularly those subject to custodial protection sentences.

Schema therapy for violent PD offenders: a randomized clinical trial.

BACKGROUND: Violent criminal offenders with personality disorders (PD's) can cause immense harm, but are often deemed untreatable. This study aimed to conduct a randomized clinical trial to test the effectiveness of long-term psychotherapy for rehabilitating offenders with PDs. METHODS: We compared schema therapy (ST), an evidence-based psychotherapy for PDs, to treatment-as-usual (TAU) at eight high-security forensic hospitals in the Netherlands. Patients in both conditions received multiple treatment modalities and differed only in the individual, study-specific therapy they received. One-hundred-three male offenders with antisocial, narcissistic, borderline, or paranoid PDs, or Cluster B PD-not-otherwise-specified, were assigned to 3 years of ST or TAU and assessed every 6 months. Primary outcomes were rehabilitation, involving gradual reintegration into the community, and PD symptoms. RESULTS: Patients in both conditions showed moderate to large improvements in outcomes. ST was superior to TAU on both primary outcomes - rehabilitation (i.e. attaining supervised and unsupervised leave) and PD symptoms - and six of nine secondary outcomes, with small to moderate advantages over TAU. ST patients moved more rapidly through rehabilitation (supervised leave, treatment*time: F(5308) = 9.40, p < 0.001; unsupervised leave, treatment*time: F(5472) = 3.45, p = 0.004), and showed faster improvements on PD scales (treatment*time: t(1387) = -2.85, p = 0.005). CONCLUSIONS: These findings contradict pessimistic views on the treatability of violent offenders with PDs, and support the effectiveness of long-term psychotherapy for rehabilitating these patients, facilitating their re-entry into the community.

Potentially Inappropriate Medications are Associated With Geriatric Trauma Recidivism.

INTRODUCTION: The American Geriatric Society has identified polypharmacy and categories of potentially inappropriate medication (PIM) that should be avoided in the elderly. These medications can potentially cause an increased risk of falls and traumatic events. MATERIALS AND METHODS: We conducted a retrospective study on elderly patients with traumatic injuries at a Level 1 trauma center. We compared patients having only one traumatic event and those with one or more traumatic events with the presence of prescriptions for PIMs. RESULTS: Identified high risk categories of anticoagulant and antiplatelet agents (odds ratio [OR] 1.18, 95% confidence interval [CI] 1.08-1.28), psychiatric and neurologic agents (OR 1.32, 95% CI 1.22-1.43), as well as medication with anticholinergic properties (OR 1.14, 95% CI 1.03-1.27) were associated with an increased risk of recurrent trauma. CONCLUSIONS: We can quantify the risk of recurrent trauma with certain categories of PIM. Medication reconciliation and shared decision-making regarding the continued use of these medications may positively impact trauma recidivism.

Differences in Risks for Recurrent Injury and Death Among Survivors of Violence by Homeless Status.

A better understanding of the unique risks for survivors of violence experiencing homelessness could enable more effective intervention methods. The aim of this study was to quantify the risks of death and reinjury for unhoused compared to housed survivors of violent injuries. This retrospective study included a cohort of patients with known housing status presenting to the Boston Medical Center Emergency Department between 2009 and 2018 with a violent penetrating injury. Cox proportional hazards regression models were used to estimate hazard ratios (HR) and 95% confidence intervals (95% CI) for the risks of all-cause mortality and violent reinjury. Of the 2330 patients included for analysis, 415 (17.8%) were unhoused at the time of index injury. Within 3 years of the index injury, there were 319 (13.9%) violent reinjuries and 55 (2.4%) deaths. Unhoused patients were more likely than housed patients to be violently reinjured by all causes (HR = 1.39, 95% CI = 1.06-1.83, p = 0.02), by stab wound (HR = 2.34, 95% CI = 1.33-4.11, p = 0.0003), and by blunt assault (HR = 1.52, 95% CI = 1.05-2.21, p = 0.03). Housed and unhoused patients were equally likely to die within 3 years of their index injury; however, unhoused patients were at greater risk of dying by homicide (HR = 2.89, 95% CI = 1.34-6.25, p = 0.006) or by a drug/alcohol overdose (HR = 2.86, 95% CI = 1.17-6.94, p = 0.02). In addition to the already high risks that all survivors of violence have for recurrent injuries, unhoused survivors of violence are at even greater risk for violent reinjury and death and fatal drug/alcohol overdose. Securing stable housing for survivors of violence experiencing homelessness, and connecting them with addiction treatment, is essential for mitigating these risks.