Gang Migration to Rural and Suburban Areas
Written by Dr. Paul Thomas Clements   

Courtesy of the Academy of Forensic Nursing

This article appears in the November-December 2021 issue of Evidence Technology Magazine.
You can view that full issue here.

GANGS ARE CONTINUING TO PROLIFERATE, and healthcare personnel will encounter their members and associates in a variety of settings. This is of particular note since gang affiliates are now present in all 50 states and United States territories. Subsequently, it is critically important to raise awareness, enhance forensic assessment, and maintain facility safety.

Since 2005, gang-related crime has more than tripled among smaller towns and neighborhoods in the national trend towards gangs expanding beyond urban areas. This situation is compounded by an accompanying lack of awareness or, in many cases, denial (including on the part of healthcare personnel) that a gang problem exists. However, lesser populated regions often have small and sometimes underfunded police departments, which can make the communities vulnerable and attractive to criminals trying to avoid larger cities with more sophisticated gang units. Also, gangs find these non-urban areas to be full of eager new drug customers who may also have money, and there also may be a lack of significant competition from other gangs. The bottom line is that gangs go where business is good; where typically illegal drugs, illegal weapons and, most recently, where human trafficking can easily go unnoticed. For example, many people still perceive rural areas as being pastoral havens with rolling fields, grazing cattle, and flowing streams—when they may actually be places where a gang’s criminal activity is less detectable from law enforcement, and they aren't competing with a different illegal gang for business.

The threat of gang violence spilling over into healthcare settings has become a reality in communities of all sizes. The keys to a successful campaign against gang violence in a hospital setting are training and education of security and clinical staff, including coordination and cooperation with law enforcement, and proper reporting procedures and protocols. Specifically, what occurs when a gang member presents himself or herself to a healthcare environment? What can the security and nursing departments do to respond to the potential danger and prevent a possible incident? When and how are local law enforcement activated and involved? Healthcare institutions need to establish clear policy and procedures that can expand awareness and enhance early identification that can prevent violent gang activity and make both the healthcare environment and society safer places.

Healthcare professionals should be aware of the types of gang activity occurring in their communities, and the basic factors related to gang membership and behaviors.

For example, in one “middle-class suburb,” a gang member presented himself to the emergency department as the victim of a beating by rival gang members. The patient was accompanied by fellow gang members—all of whom were clearly dressed in “Blood” gang affiliated attire (red and white). Soon after they entered the ED lobby, registered, and were seated in the waiting area, a rival gang member—clearly dressed in opposing “Crip” gang affiliated attire (blue and white)—entered carrying a baseball bat and began striking the patient. Everyone was caught off guard, including security. As security impulsively attempted to respond, they, along with several gang members, were struck by the bat. The unit clerk dialed 911, but by the time the police responded, the assailant ran from the ED. The patient resultantly had severe head trauma, the security guard received a facial fracture, and several other patients and family members in the waiting area were injured with bruises and were emotionally traumatized. The other gang members were arrested; subsequently, several were noted to be in possession of firearms during their body searches by police.

In another case, a 29-year-old member of the MS-13 gang opened fire in the trauma unit of a rural hospital in an attempt to “finish off” the rival gang member who had survived an attack during a “gangbang” from the previous night. Knowing that the gang member was a “sitting duck” while basically trapped in a hospital bed, he would be an easy target for retaliation. However, during the attack, the intended target—the gang member—was actually surrounded by other MS-13 gang members and not struck by the gunfire. Rather, during the scuffle, a 37-year-old registered nurse received a non-life-threatening gunshot wound and a 42-year-old security guard received a head trauma from being struck with the gun as the assailant fled the unit. The unit had not been locked down in any manner and no early awareness or understanding of the reality of the risk for retaliation by the gang within the hospital had been undertaken.

Preparing and Educating a Facility for Gang Violence
To deal with the potential for gang violence in the hospital setting, there is a need to understand the basics of the gang culture, related behaviors, and the continuing gang threat. For example, the foundation of gang loyalty includes the Three Rs of gang life: Reputation, Respect, and Retaliation.

Reputation is crucial for the continued existence and achievement of any gang member. Additionally, gang reputation is critical in the endurance and promotion of the gang as a viable criminal enterprise. The fear of reprisal and violence is created through reputation. Gang-related behaviors, as well as the willingness of a gang member to do whatever it takes in furtherance of gang objectives, gain the member status and reputation. If a gang member feels that he or she will lose respect, they are motivated to prevent that from happening because they are protecting their own and the gang’s reputation and respect. For this reason, gangs will use violence almost anywhere.

Respect is a dominant desire for all gang members. Gang members seek respect and demand respect for themselves and their gang. They insist that rival gangs respect their territory, their gang colors, and their fellow members. They are often willing to risk serious injury or death to ensure this occurs. Maintaining respect is a fundamental goal for gang members and plays a role in gang behaviors. To lose face, to get challenged, or to be stared at too long and not respond are all ways that gang members think they lose respect. Gang members often have a sense that the gang they belong to and they themselves lose respect if any insult goes unanswered. This belief causes gangs to respond—often violently—to minor incidents, like those mentioned above.

If a gang member witnesses a fellow member failing to dis (i.e. disrespect) a rival gang through hand signs, graffiti (“tagging”), or a simple "mad dog" or stare-down, they can issue a "violation" to their fellow posse member and he/she can actually be "beaten down" by their own gang as punishment. After a dis has been issued, if it is witnessed, the third "R" will become evident.

Retaliation happens when gang members believe that they or the gang has been disrespected or their reputation has been violated. It must be understood that in gang culture, no challenge goes unanswered. Many times, drive-by shootings and other acts of violence follow an event perceived as a dis. A common occurrence is a confrontation between a gang set and single rival "gangbanger." Outnumbered, he departs the area and returns with others to complete the confrontation to keep his reputation intact. This may occur immediately or follow a delay for planning and obtaining the necessary weapons to complete the retaliatory strike.

Gang Levels / Membership
There are also various levels of memberships within gangs, and this can be important as far as understanding who healthcare providers might encounter in the emergency department and in what capacity.

Original Gangsters (OG)—These are the foundational members and are the highly protected leaders; they are in it forever. It is unusual to see these members in the ED unless they have been severely injured.


Emergency department workers will encounter hardcore members in trauma situations after gang shootouts. Photo: Shutterstock

Hardcore Members—These comprise approximately 5–15% of the gang. These are the die-hard gangsters, who thrive on the gang’s lifestyle and will always seek the gang's companionship. These hardcore gangsters will most always be the leaders and without them the gang may fall apart. The gang's level of violence will normally be determined by the most violent hardcore members. They are usually the shooters and therefore most prone to severe injury and death. Hardcore members used to be considered only males, but this is changing as more females become active gang members and weapon carriers. ED providers will see these members in trauma situations after gang shootouts.

Regular Members (Associates)—They usually range from 14 to 17 years old they are often oriented toward proving themselves to older gang members and running errands while making money. They usually join the gang for status and recognition, which is congruent with adolescent development. They may not participate in hardcore gang activities, but they may be involved in juvenile delinquent acts. They may doodle gang insignias, commit acts of graffiti vandalism (“tagging”), and speak in slang, use gang terminology, and display gang hand-signs. They also may carry concealed weapons for protection.

Wannabes—Usually 11 to 13 years old, their jobs are tagging and stealing. They are not yet initiated into the gang, but they hang around with them and usually will do most anything the gang members ask of them so that they may prove themselves worthy of belonging.

Could-Bes—They are usually under the age of ten. Children of this age are at more risk when they live in or close to an area where there are gangs or if they have a family member who is involved with gangs. It is important to find alternatives for these children in order that they may avoid gang affiliation completely.

The job of "tagging" (graffiti vandalism) is often the jobs of wannabes, usually 11 to 13 year olds. Photo: Shutterstock

Healthcare Facility Preparedness and Protocols
All healthcare facilities—not just those hospitals located in the inner cities—need to adopt a gang-awareness training program that incorporates area and regional gang identification, workplace violence, obvious warning signs, and established reporting procedures. This education should be available to all employees, especially ED, ICU, and security staffs. In 2017, the U.S. Department of Justice developed Gang Violence Protocols for Medical Facilities. This includes requesting gang identification training for ED personnel, including receptionists and security officers, from local law enforcement or gang officers on an annual basis. This training should include:

  • Visuals of local gang tattoos, clothing, and other identifiers, and should also describe existing rivalries.
  • Develop a relationship with local law enforcement or gang unit administrators.
  • Request dispatcher notification when victims of a gang conflict are transported to the ED. Emergency department personnel should also request further information, including the names/identifiers of the gangs involved and descriptions of suspects/vehicles. This information should be shared with security and reception personnel.
  • Limit the number of visitors who can accompany patients into waiting and treatment areas.
  • Notify security and/or request a law enforcement response in the ED when a gang-involved victim is treated.
  • Rival gang members may encounter one another inside hospital facilities and in parking areas, so both areas require attention and security.
  • Hospital administrators may wish to incorporate Crime Prevention Through Environmental Design (CPTED) strategies.
    • Many law enforcement and city planning agencies can provide CPTED reviews. Go here for information on CPTED courses:
  • Prepare for the possibility of treating members of rival gangs at the same time.
    • Do not allow rival gang members or their visitors to have contact, either inside or outside of the facility.
  • In the event of a serious gang incident in the community, hospitals may wish to develop escalated security protocols that include locking down the emergency department and waiting area.

Security and clinical staff in hospitals should be trained to recognize gang indicators, such as local gang tattoos. Photo: Shutterstock

In addition to these recommendations from the Department of Justice, it is very important that security and clinical staff be trained regarding potential warning indicators related to potential gang violence. These are some of the signs:

  • Obvious signs of agitation of patients and/or visitors arriving at the ED, or signs that they just came from a fight.
  • The staring down of other visitors or staff members may be an indicator of looming violence. Known as "mad dogging," this tactic is often used between rival gang members.
  • Gang indicators, whether it is the wearing of gang colors, identical clothing or sports attire, tattoos, or the use of hand-signs.
  • A patient suffering trauma arriving with a group or “posse,” or a shooting, stabbing, or assault victim being dropped off at the hospital entrance.
  • A patient refusing to give up clothing or packages. These may contain weapons or illegal drugs.

"There aren’t any ‘real’ gangs around here," and the common misconception that hospitals are considered “neutral territory” for gangs, are two mindsets regarding gangs and gang-related violence that need to be changed—particularly in suburban and rural areas. Gang violence is not only a societal issue but, now, a public health issue that doesn't stop at the hospital doors. Across the country, gang members enter hospital emergency departments on a daily basis as victims of shootings, stabbings, and beatings, as well as for medical needs that are not related to violence. Often accompanying these patients are fellow gang members—who they consider their “family”—even if they are not legally considered such. The conundrum for many healthcare providers is that, although gang activity may be illegal, treating gang members for health-related illness and injury is not. As a matter of fact, the opposite is true: it would not only be unethical, but also malpractice to not provide healthcare simply because they were in a gang. As such, when it is apparent that the patient being treated in the emergency department is a gang member, it does not necessarily mean that gang violence will inherently follow—but, it should mean that the healthcare provider should modify their assessment and environmental awareness throughout their therapeutic interaction.

In summary, a workplace violence policy should be in place and all hospital employees should be familiar with its content. This policy should be a part of any new-employee orientation program and should detail the procedures for incident reporting—not only incidents of violence but also the potential for violence. The clinical staff should receive education regarding the best methods to employ while interacting with suspected gang members. Should gang members feel disrespected by a nurse or physician, he or she may retaliate and lash out at the staff. Hospital staff should be straightforward and honest with the patient regarding his or her injuries and treatment. Treat the gang-member patient respectfully, as you would any other patient.

Like all patients, gang members cannot be turned away when seeking emergency medical treatment. Therefore, preparing for incidents of potential gang violence through training, education, and cooperation with law enforcement, as well as proper reporting procedures and protocols, are the keys to a successful campaign against gang violence in a hospital setting.

About the Author
Paul Thomas Clements, PhD, RN, DF-AFN, has been a psychiatric forensic nurse since 1993, working with victims and offenders of interpersonal violence and crime. He is a forensic psychiatric clinical specialist, a Certified Gang Specialist, and Certified in Danger Assessment. Clements has provided hospital consultation for EMTs, child protective agency personnel, trauma/emergency nurses, psychiatric providers, hospital systems, and corporate executives—each regarding vulnerability risk assessment, bullying, and decreasing the number of violent incidents in the workplace. He is a professor in residence at the University of Nevada, Las Vegas. He is also a Distinguished Fellow in the Academy of Forensic Nursing.


Office of Justice Programs – National Gang Center: Resources and training opportunities

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