Lethal means: The deadly combination of firearms and intimate partner violence

October is Domestic Violence Awareness Month, prompting the American College of Surgeons (ACS) to focus this issue of the Bulletin on this public health problem at the suggestion of this organization’s President, Barbara Lee Bass, MD, FACS. As the ACS explores ways to better address intimate partner violence (IPV) among our patients, colleagues, and communities, and we, as citizens, continue to discuss our constitutional relationship with firearms, surgeons would be remiss to overlook a discussion of the connection between IPV and firearm injury.

It is worthwhile to understand, as physicians, the complex ways in which firearms relate to the health care conditions we treat. As mandatory reporters of traumatic injuries and physicians who took a vow to “first, do no harm,” surgeons are compelled to consider firearm access and potential future injury in the care of their patients, particularly those individuals who are vulnerable to IPV. As professionals who understand that public health initiatives lead to improved individual outcomes and longer life spans for our patients, surgeons also are compelled to understand the data that help inform the public health approach to the mitigation of firearm injury and death. Moreover, as colleagues, teachers, and leaders in our institutions, it is vital to understand that IPV occurs across the spectrum of the population, including our surgical colleagues and trainees, and that our implicit bias regarding who may be at risk should not cloud our willingness to identify this problem among our own, intervene when we have concern, and report abuse when we are in a position to do so.

The correlation between IPV and firearms

While data-driven approaches inform much of our work in surgery, there is a paucity of high-quality epidemiologic data on firearm injury and its relationship to IPV. The sensitive nature of this issue and the generalized underreporting of IPV, coupled with the incomplete reporting of firearm injury data, make it difficult to understand the exact burden of this problem.1 We do know that the death of women by firearm at the hands of an intimate partner is a uniquely American problem. Women in the U.S. are 16 times more likely to be killed by firearms than women in other developed nations.2 Unfortunately, the presence of a firearm in the setting of IPV portends a fivefold (500 percent) increase in the risk of the victim being murdered.3

More general data on IPV—though incomplete and likely underreported—is alarming. IPV is the leading cause of injury to women in the U.S. More than half of all homicides among women in the U.S. are related to IPV, 72 percent of murder-suicides involve an intimate partner, and in 94 percent of these cases the victim is a woman.4 Homicide remains the single leading cause of maternal mortality in the U.S.5 Racial and sexual identity minority populations are both disproportionately affected, as are young women.6 Recently, increased attention has been given to the definition of IPV, specifically to include non-married relationships and adolescent dating relationships. The inclusion of these groups sharply increases the statistics for IPV, representing a disturbing trend for young women and adolescent girls, who are notably unprotected under present-day legislation that restricts firearm access to intimate partners who are convicted of violence, as most legislative bodies do not consider unmarried relationships to be “intimate.”7

Surgeon intervention

We know that physical abuse before a murder is predictive and that an abuser’s access to a firearm is strongly predictive (odds ratios 7.59; 95 percent confidence interval 3.85, 14.99) of homicide. Our approach to this public health problem can be organized into three interventional strategies: intervening when IPV is suspected, providing firearm safety information, and linking firearms to IPV to mitigate the greater risk  this combination brings.

Recognize the signs

The first, and perhaps the most obvious, step is to recognize the signs of IPV in our patients and our colleagues and to intervene before an abusive situation turns deadly. Developing an awareness of these signs, however, can be difficult, and it is critical to remember that this public health problem affects all ages, genders, ethnicities, and socioeconomic groups, making it virtually impossible to profile the “typical” survivor.

Despite the widespread prevalence of IPV, few women report that their physician has asked about potential abuse, and cultural practices and time constraints are often cited as barriers to screening.8 Even among women who are screened, 20 percent of individuals who have disclosed abuse to their physician report receiving no help or support.

Furthermore, although 91 percent of graduating U.S. medical students report receiving training in IPV recognition, fewer felt that their training was adequate and fewer still reported employing these screening techniques as a routine part of their practice.9 Even when students are trained to ask about these problems, the quality of the training is highly variable and testing for competency in IPV screening led to poor testing results.10

Routine screening of all women for IPV is supported in the medical literature, and increasing evidence demonstrates that select populations of males, specifically trauma patients, also should be screened.11,12 Women in general are receptive to screening, and most women are in favor of routine screening for abuse. The American Medical Association, the American College of Emergency Physicians, the American College of Obstetricians and Gynecologists, and other professional societies also support the College’s recommendation to screen for IPV.

Screening tools are widely available online for physicians looking to incorporate screening into their practice. These tools include the Hurt, Insult, Threaten, Scream (also known as HITS), the Woman Abuse Screening Tool (also known as WAST), the Partner Violence Screen (also known as PVS), and the Abuse Assessment Screen (also known as AAS).13 These tools are intended to screen the entire population, so deploying these assessments to all patients is critical to the successful identification of cases in need of intervention. Trauma surgeons, in particular, should be especially vigilant regarding the signs of IPV in both men and women and should consider screening all of their patients.14,15

Discuss firearm access

The second IPV intervention strategy involves the discussion of safe firearm storage or restricted firearm access in general. In cases in which a patient does not disclose IPV, a discussion of safe firearm storage independent of domestic abuse could be lifesaving. Counseling all of our patients on firearm safety and the importance of safe, responsible storage and lethal means restriction in dangerous circumstances may not only protect IPV survivors, but also extend to other critical issues, such as child access prevention and suicide.16

Explain risk factors

The third intervention is to explain the multiplicative risk to our patients. Helping IPV survivors understand the risks related to firearms in the home and encouraging individuals in high-risk situations to consider the compound hazards they are facing are all important topics that physicians should address within the confines of the surgeon-patient relationship. Discussing the extremely dangerous combination of IPV and lethal means and ensuring that survivors understand this heightened danger is critical to mitigating this problem. Legislation in some states, however, prohibits physicians from asking about firearms in the home specifically, and surgeons should check with their individual state departments of health to determine whether they are allowed to ask this question and document the response in the medical record.17

Advocating for our patients

Surgeons may also advocate for evidence-based legislative solutions to support our patients. Federal law requires a background check on all sales by federally licensed firearm dealers, but universal background checks are not required in all states, allowing loopholes that create opportunities for domestic abusers to obtain firearms by crossing state lines. Additionally, stalkers and dating partners are excluded from the federal law restricting firearm sales to abusers, despite the data cited in this article that suggests the incidence of IPV is rising in intimate, non-married relationships. Nonetheless, background checks have prevented nearly 300,000 gun sales to domestic abusers, and in states that require a background check for every handgun sale, 47 percent fewer women are shot to death by intimate partners.18,19 In states that require individuals experiencing an IPV situation to obtain a restraining order to compel abusers to relinquish their weapons, IPV homicides have been reduced by 9.7 percent and firearm-related intimate partner homicides have dropped by 14 percent.20 Most Americans, including 85 percent of gun owners who responded to a national survey in 2013, agree that background checks should be universal, and that advocating for the enforcement of these existing laws and reducing loopholes is a viable way to protect our patients.21

The ACS continues to strive to provide the best quality care to surgical patients, which includes a comprehensive exploration of the public health issues that surgeons encounter. Whether we care directly for trauma patients, manage the surgical problems of survivors of IPV, or have colleagues and trainees who may be affected by this public health issue, we should seek to identify and mitigate this crisis to keep our communities, families, and colleagues healthy and to prevent the tragedies that can arise from the deadly combination of firearms and violence.


References

  1. Gracia E. Unreported cases of domestic violence against women: Towards an epidemiology of social silence, tolerance, and inhibition. J Epidemiol Community Health. 2004;58(7):536-537.
  2. Grinshteyn E, Hemenway D. Violent death rates: The U.S. compared with other high-income OECD countries, 2010. Am J Med. 2016;129(3):266-273.
  3. Campbell JC, Webster D, Koziol-McLain J, et al. Risk factors for femicide in abusive relationships: Results from a multisite case control study. Am J Public Health. 2003;93(7):1089-1097.
  4. Petrosky E, Blair JM, Betz CJ, Fowler KA, Jack SPD, Lyons BH. Racial and ethnic differences in homicides of adult women and the role of intimate partner violence—United States, 2003–2014. MMWR Morb Mortal Wkly Rep. 2017;66(28):741-746.
  5. Chisholm CA, Bullock L, Ferguson JEJ II. Intimate partner violence and pregnancy: Epidemiology and impact. Am J Obstet Gynecol. 2017;217(2):141-144.
  6. Cho H. Racial differences in the prevalence of intimate partner violence against women and associated factors. J Interpers Violence. 2012;27(2):344-363.
  7. Sorenson SB, Spear D. New data on intimate partner violence and intimate relationships: Implications for gun laws and federal data collection. Prev Med. 2018;107:103-108.
  8. Beynon CE, Gutmanis IA, Tutty LM, Wathen CN, MacMillan HL. Why physicians and nurses ask (or don’t) about partner violence: A qualitative analysis. BMC Public Health. 2012;12:473.
  9. Frank E, Elon L, Saltzman LE, Houry D, McMahon P, Doyle J. Clinical and personal intimate partner violence training experiences of U.S. medical students. J Womens Health (Larchmt). 2006;15(9):1071-1079.
  10. Varjavand N, Cohen DG, Novack DH. An assessment of residents’ abilities to detect and manage domestic violence. J Gen Intern Med. 2002;17(6):465-468.
  11. O’Doherty LJ, Taft A, Hegarty K, Ramsay J, Davidson LL, Feder G. Screening women for intimate partner violence in healthcare settings: Abridged Cochrane systematic review and meta-analysis. BMJ. 2014;348:g2913.
  12. Zakrison TL, Rattan R, Milian Valdés D, et al. Universal screening for intimate partner and sexual violence in trauma patients—what about the men? An Eastern Association for the Surgery of Trauma Multicenter Trial. J Trauma Acute Care Surg. 2018;85(1):85-90.
  13. Rabin RF, Jennings JM, Campbell JC, Bair-Merritt MH. Intimate partner violence screening tools: A systematic review. Am J Prev Med. 2009;36(5):439-445.
  14. Zakrison TL, Ruiz X, Gelbard R, et al. Universal screening for intimate partner and sexual violence in trauma patients: An EAST multicenter trial. J Trauma Acute Care Surg. 2017;83(1):105-110.
  15. Davis JW, Parks SN, Kaups KL, Bennink LD, Bilello JF. Victims of violence on the trauma service: Unrecognized and underreported. J Trauma. 2003;54(2):352-255.
  16. Betz ME, Wintemute GJ. Physician counseling on firearm safety: A new kind of cultural competence. JAMA. 2015;314(5):449-450.
  17. Wintemute GJ, Betz ME, Ranney ML. Yes, you can: Physicians, patients, and firearms. Ann Intern Med. 2016;165(3):205-213.
  18. Hemenway D. Firearm legislation and mortality in the USA. Lancet. 2016;387(10030):1796-1797.
  19. Kalesan B, Mobily ME, Keiser O, Fagan JA, Galea S. Firearm legislation and firearm mortality in the USA: A cross-sectional, state-level study. Lancet. 2016;387(10030):1847-1855.
  20. Diez C, Kurland RP, Rothman EF, et al. State intimate partner violence-related firearm laws and intimate partner homicide rates in the United States, 1991 to 2015. Ann Intern Med. 2017;167(8):536-543.
  21. Barry CL, McGinty EE, Vernick JS, Webster DW. Two years after Newtown—public opinion on gun policy revisited. Prev Med. 2015;79:5558.

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