Domestic Violence and Safe Storage of Firearms in the COVID-19 Era.

Domestic violence (which includes violence against partners, children, parents, or the elderly), intimate partner violence (IPV) (which includes violence that occurs in a close relationship), and firearm availability go hand-in-hand. On average, 50 women in the United States (US) are shot and killed by intimate partners each month. Abused women are 5 times more likely to be killed by their abuser if the abuser owns a firearm.[1,2] The American College of Obstetrics and Gynecologists (ACOG) issued a statement noting that women disproportionately experience IPV, and abuser access to the presence of firearms within those relationships is a key risk factor for intimate partner homicide.[3,4] With presence of unsecured weapons in homes resulting from increased stress, economic instability, and restrictions resulting from stay-at-home orders during the COVID-19 pandemic, numbers of intimate partner homicides are very likely to rise without attempts at prevention. Higher prevalence of IPV among adult females (with males being mostly perpetrators) leads to increased incidence among pregnant women, particularly among pediatric pregnant females (≤18 years).[5,6] Furthermore, independent of shelter at home orders during a pandemic, both women and African American men are disproportionately at risk of intimate partner homicide and completion suicide, involving firearms and alcohol, but not mental illness.[7]

As the nation (and the world) grapples with the spread of COVID-19, citizens of many countries are required to follow stay-at-home orders to lessen virus transmission risk. Mounting data suggest that domestic abuse (DV) is acting like an opportunistic infection, flourishing in the conditions created by the pandemic, leading to "intimate terrorism."[8] Countries such as the US and China have seen an increase in DV calls, Spain has documented an 18% increase, whereas France has seen a 30% increase in such calls.[8] For victims and survivors of DV, including children exposed to it, being at home may not be a safe option; and the unprecedented stress of the pandemic could create an unsafe environment in homes where violence may not have previously been an issue.[9] Additional stressors including concern for the health and welfare of loved ones, and close quarters as parents work from home and try to homeschool their kids risk increasing DV. Elderly parents in the home may also experience DV through abuse and neglect, in addition to increased risk of mortality from COVID-19.[10]

Violence is a public health issue which crosses families, communities, and populations.[3,11,12] Some risk factors and social determinants of health for violence include but are not limited to poverty (although it affects all social classes), hopelessness, unemployment, access to firearms, lack of housing, lack of role models, mental illness, and substance abuse.[3] According to the Centers for Disease Control and Prevention (CDC), 1 in 4 women and 1 in 7 men in the US have experienced violence (sexual, physical) and/or stalking from an intimate partner in their lifetime; and the risks to victims are potentially severe. CDC data link IPV with an increased risk of injury and death.[1,9,13] Patients presenting to trauma centers after DV experienced a mortality rate of 6%,[5] with men experiencing the same rate of physical violence as women.[14] Structural racism and age play a role in a person's likelihood of experiencing abuse from an intimate partner, with African American communities[7] and older women at particular risk. Women with disabilities are more vulnerable to rape and sexual coercion, along with several forms of IPV. IPV rates are highest in the poorest neighborhoods, and increased stress levels among parents is often a major predictor of physical abuse and neglect of children.[9] An alarming study found a significantly higher mortality rate identified among children (8.6%), than among adults and elderly experiencing DV.[5] The stay-at-home orders, increased unemployment, and added stressors during the recent COVID-19 pandemic will likely act to increase exposure to risk factors for DV and IPV.

The impact of community violence exposure, in the form of a child being exposed to DV/IPV involving a parent, deserves mention because it has direct bearing on both the physical, mental, and emotional development of children. If the parent is unable to access services after DV/IPV, the exposed child will also not receive services. This may contribute to long-term behavioral problems for the child, such as perpetuating DV/IPV, and internalizing behaviors which lead to anxiety, withdrawal, and depression.[1,15] In addition, during this time, children are at risk of direct physical violence, as IPV can extend into DV, whereas they are forced to stay at home during a stressful period. Those that often raise the early alarm for child abuse, such as teachers, extended family members, and religious leaders no longer see the children regularly. Many child-protective organizations are experiencing strain with fewer workers available, so they may be unable to conduct home visits in areas with stay-at-home orders.[9]

As such, the effect on children will only be compounded without the ability to provide appropriate services to address important social determinants of health. Individuals (mostly women) experiencing DV may have limited places to go whereas shelter-at-home orders are in effect. Such victims may have no alternative but to continue living with their abusers, because they have nowhere else to turn. The Family Justice Center (FJC) model is a multi-faceted comprehensive site for victims of violence, to address issues that come along with being a victim, without re-traumatizing the individual. FJCs have the ability to navigate victims and their families through the complex process of interacting with the legal system, behavioral health, law enforcement, area agency on aging, sexual abuse counseling, temporary housing, etc, all under the same roof. This occurs without having to visit multiple separate organizations that may now be temporarily closed. Though these FJC services may be limited in the COVID-19 era based on geographic location, victims should be encouraged to reach out to such organizations, as many have alternate plans for directing at-risk individuals accordingly. Such streamlined access to multidisciplinary care should become the norm in our post-COVID-19 society, and be available for all sexes.

In these uncertain times, it is not surprising to have citizens express feelings of insecurity and loss of control, thus making people concerned for their safety. Several studies have reported that the presence of a firearm in the home increases the risk of homicide and suicide for all in the home.[16] There are currently no data supporting the notion that firearms reduce violence or the risk of death, rather the opposite is true.[16] Across the US, there were over 1 million more pre-sale background checks performed in March 2020, than in March 2019. The research firm, Small Arms Analytics & Forecasting (SAAF) estimated a 91% increase in handgun purchases between the same 2 months, a year apart.[17,18]

To practice appropriate firearm safety, gun owners (particularly first-time owners) should obtain firearm safety instruction about firearm use and safe storage. Access to shooting ranges for firearm safety training is complex, because the stay-at-home ruling in many states does not recognize shooting ranges as essential businesses. Without lessons in firearm safety or safe storage, it is likely that the availability of more unsecured weapons in households will likely make DV episodes more deadly. If firearms are not stored properly, they may be easily accessible to bored and curious children that are currently stuck at home, which increases opportunities for tragic, unintentional shootings. The Firearm Strategy Team of the American College of Surgeons Committee on Trauma (ACS-COT) endorses formal gun safety training for all new gun owners, and hunter safety and safe gun handling education. They also recommend direct adult supervision in the use of firearms for children younger than 12 years, and indirect supervision for children between the age of 12 and 18 years. As such, the Firearm Strategy Team recognizes and endorses the critical importance of safe and controlled firearm storage.[19]

Even though we are trained to heal traumatic injuries, some are not treatable. Every non survivable, preventable DV/IPV injury that health care professionals treat may contribute to emotional exhaustion, burnout, or moral distress. Making an intervention when we interact with such victims could break the chain of violence and lead to a completely different outlook for survivors and their families.

According to the American College of Surgeons, “The only thing more tragic than a death…is a death that could have been prevented.”

To curb the incidence of preventable firearm injuries, we are proposing the following:

Safe storage of firearms needs to be publicized and emphasized for firearm owners. See: American College of Surgeons/Committee on Trauma: Gun safety and your health brochure. Available at https://www.facs.org/-/media/files/quality%20programs/trauma/ipc/gumnsafety_brochure.ashx.[20]

Disseminate safe storage video: https://www.facs.org/quality-programs/trauma/advocacy/ipc.[21]

Recognizing that DV/IPV has no boundaries, we need to take care of each other. American College of Surgeons IPV Toolkit: https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=4&cad=rja&uact=8&ved=2ahUKEwjHk-6Q3uHoAhWGjp4KHfWtC4EQFjADegQIBRAB&url=https%3A%2F%2Fwww.facs.org%2F-%2Fmedia%2Ffiles%2Fmember-services%2Finitiatives%2Fintimate_partner_violence_toolkit.ashx&usg=AOvVaw39MyI4lr9LApwXcXV5naRu.[22]

Refer to, and disseminate the American College of Surgeons Trauma Quality Improvement Program (TQIP) Best practice guidelines for evidence-based recommendations on recognition of child abuse, elder abuse, and IPV.[23]

Victims experiencing domestic violence may have limited places to go whereas stay-at-home orders exist. Shelters will be dealing with increased volume and possible lower capacity given social distancing rules. Example of FJC: www.vcfjc.org.[24]

We need to continue supporting measures to ensure the governmental funding stream is maintained for conducting firearm research, and keeping shelters/FJCs afloat.

Other useful information:

National Domestic Hotline | (800) 799-7233

Crisis Text Line | Text HOME to 741741

IPV (fact sheet)

Psychological Wellness Guide for Survivors of Domestic Violence.