Guns and Violence

Gun use in America is associated with a number of medical problems for primary care physicians, including traumatic injury, homicide, suicide and domestic violence. All patients are susceptible to firearm violence: children playing with loaded weapons, teenagers walking unsafe streets, women in abusive relationships and adults defending their homes. Firearm-related injury and death occurs with surprising frequency. One child in America dies from a gunshot wound every 90 minutes, and 30 children and adolescents under age 19 - a school classroom - die every two days as a result of firearms.1 The number of violent events is growing; the incidence of firearm-related homicides has increased sharply over the past decade,2 peaking at 38,500 deaths in 1994.3 Very nearly the same as the number of people died in a motor vehicle accident in 1994,4 even though the use of motor vehicles is more widespread. Although physicians recognize the gravity of this epidemic of violence, very few promote gun safety in clinical encounters or publicly advocate control of gun violence. Medical students can educate themselves and faculty on firearms issues, and influence legislation to help reduce these unnecessary injuries and deaths.

• What are the statistics of guns and violence in the U.S.?
• What role does violence play in an adolescent's life?
• What can physicians do to promote firearm safety?
• How can I get involved in gun control advocacy efforts?

STUDENT ORGANIZERS GUIDE
Medical students can become involved in the prevention of firearm violence by raising awareness among fellow medical students and faculty about the medical consequences of unsafe firearm usage, educating patients on firearm dangers, promoting improved consciousness about conditions related to violent lifestyles, and advocating ways to improve gun safety.

Suggested Activities

• Educate yourself on violence and firearm safety. The medical literature contains much about homicide and suicide related to gun ownership. Speak with patients about why they own guns and what safety measures they take to prevent violence. Seek out ambulatory experiences in clinics for disadvantaged teenagers and speak with patients about violence in their lives. Visit a juvenile detention center to ask detainees about violence.
• Develop your own method of screening for firearm ownership and history of violence. Practice this routinely during primary care rotations.
• Educate other students and faculty on violence. Ask an experienced attending physician to interview a teenager who has experienced violence about his or her lifestyle, behavior, experiences with firearms and feelings about safety.
• Educate other students and faculty on firearm safety. Prepare a presentation during a primary care rotation about risks of firearm ownership and usage. Use practice cases to help make your discussion clinically relevant. Then, offer suggestions on screening for firearm safety. Use educational materials provided by the Center to Stop Handgun Violence and the National Rifle Association (NRA). Speak with the pediatric clerkship director about integrating firearm safety counseling into the teaching curriculum on pediatric rotations.
• Educate peers and faculty about medical conditions associated with firearms violence. Invite an experienced primary care attending to lecture on identifying symptoms and signs of depression, domestic violence and substance abuse. Have a skilled physician demonstrate interviewing a patient for these conditions. Provide a list of community resources for patients with these concerns.
• Invite speakers to address different facets of the gun control debate, moderating a discussion in which pro-gun and anti-gun speakers can find common ground on improving firearm safety. Medical students in your class may own firearms and be willing to speak about firearm safety and motivations for owning guns. Trauma doctors might speak on injuries and deaths related to violence that they have seen in the Emergency Department. Pediatricians could talk about screening for firearms violence and counseling patients and parents on firearms safety. Ask law enforcement officers about their experiences with homicide and domestic violence and their views about usage of firearms in the community.
• Organize a roundtable discussion between law enforcement officers and medical students on ways that these two groups can work together to reduce homicide and domestic violence in the community.

Who uses guns?
Exposure to guns and violent behavior begins in infancy. Children view a tremendous amount of violence on television; the average child witnesses 200,000 violent acts on television by age 18.5 Television widely ignores the consequences of using guns; only one out of every five times a gun is fired does something negative happen to the shooter.6 Children, males in particular, imitate what they see and adopt aggressive behaviors. In one study, 81% of children in one study played with guns;7 and in another study, children demonstrated more aggressive behavior when toy guns were introduced into play.8

Aggressive behavior carries over into adolescence and can foster an environment where teenagers feel unsafe. Teenagers are commonly involved in physical fights; a national study reported that 42.5% of high school students were in at least one physical fight in the year preceding the survey, and 26% of students carried a weapon, including a gun or a knife, at least once in the past 30 days.9 Fear of harm is a strong motivator for carrying a weapon. Students hearing gunfire in their neighborhoods more than twice a week were twice as likely as other students to own a handgun.10 Likewise, teens living in inner city neighborhoods cited self-protection as their main reason for owning a gun.11 A 15-year-old male who carried a gun when going out to clubs said, "You might just be in the wrong place at the wrong time. If they pull out their gun, you don't have a choice but to pull out yours."12 Among juvenile delinquents, 40% felt safer with a gun and 40% felt energized, excited or powerful when carrying guns, suggesting that guns are used not only in self-defense, but offensively as well. Guns were particularly easy to acquire and could be easily acquired "off the street" or stolen.12 Today, 37-50% of households in America contain guns.13,14,15 The number of people owning guns varies from region to region and is highest in rural areas. Guns are stored, unlocked and loaded in 10-24% of households.13,14 Women in particular acquire guns for self-protection and have been recently targeted by gun companies as potential first-time gun buyers. Gun enthusiasts claimed that the LadySmith .357 double-action revolver had "come to represent the very concept of strong, capable, self-sufficient modern women who own guns."16

Violence Can Be Pervasive in an Adolescent's Surroundings

Schools: Teens face a lot of violence at school. According to a Centers for Disease Control and Prevention (CDC) study, 26% of U.S. students carried a weapon in the past 30 days. In New York City, 30% had been threatened with physical harm, and 25% had been in a fight.32 Teens who had been in fights were not likely to feel that apologizing or walking away were effective means of avoiding fights; 78% believed their families would want them to fight back.

Solutions33: Metal detectors, while having no effect on the number of threats or physical fights, reduced weapon carrying and improved attendance at schools. Dress codes made it more difficult to carry concealed weapons.34

Streets: A 15-year-old female says, "I was always out on the streets. I was dating guys 20, 21, 22 and always have. I thought I needed some protection because I was around drug dealers and was point-blank fearful." A 15-year-old male who carries a gun says, "After I was being jumped by some boys trying to get me into a gang, I stole it from a house. I carried it everywhere I would go except school."35

Gangs: Gangs account for less than 1% of city youth and 60% of all homicides.36 After the Los Angeles riots in 1992, a gang truce officiated by the police resulted in a decline in shootings from two to three dozen per day to 4.5 per day.37

The Safety Paradox: Injuries and Deaths Related to Firearm Use
Although most people obtain handguns for home or personal protection, the actual use of a handgun for this purpose appears to be uncommon. In fact, wielding a gun in a home invasion crime can be more harmful than beneficial. In one study of 197 such crimes in Atlanta, a gun was successfully used to repel an intruder in only three cases (1.5%); whereas, in six cases (3.0%), the intruder actually reached the homeowner's gun first or seized it during a scuffle with the victim.17

Firearm-related death in the home is rarely related to strangers breaking in. One study of homicides revealed that 70% of murders were committed by a relative or intimate of the victim, with only 4% of murders traced to an intruder; in the remainder of cases, the victim-perpetrator relationship was unknown.18 The National Crime Victimization Survey reported 85,000 annual defensive uses of guns both inside and outside the home and one million instances of offensive uses of guns in injuries, deaths and criminal victimizations,19 suggesting that outcomes with guns are much more often negative than positive. Further research is necessary to determine how often guns are used for self-protection. For another perspective on firearm use for self-protection, see A Perspective on Carrying a Gun for Self-Protection on in this Box.

Handgun ownership concerns physicians because of subsequent medical problems when guns, particularly loaded weapons, are kept in the home. Violent acts are easier to commit when guns are already present. In one study, homicides were almost three times more likely to occur when there was a gun in the home.19 The risk of suicide also increased; adolescents were 13 times more likely to commit suicide with a handgun in the home and 32 times more likely if the gun was loaded. Adolescents with a diagnosis of depression or another psychiatric disorder had a reduced risk of suicide when a gun was not present at home.20

Unintentional injuries present additional problems. The National Electronic Surveillance System identified 34,485 unintentional injuries over a recent two-year period. Most unintentional injuries are self-inflicted, occur when cleaning or playing with guns, and involve handguns rather than rifles. Thirty-eight percent of unintentional injuries were serious enough to warrant hospitalization, and 1,500 people died in a two-year interval from reportedly unintentional gunshot wounds.21 A Government Accounting Office (GAO) report postulated that 30% of the injuries could be avoided or mitigated by changes in firearm design.23

Finally, the most unrecognized problem related to firearms is domestic violence. Thirty to forty percent of women murdered in the United States are killed in domestic disputes, and 50% of black women and 25% of white women who attempt suicide are trying to escape battering.22 Handguns indeed appear to facilitate injury and death associated with antisocial and aggressive behavior, substance abuse, abuse of women and simple human mistakes.

A Perspective on Carrying a Gun for Self-Protection: Are You Prepared to Kill?
Andre Dubus, a professor who carried a gun, writes, "...I was certain I would not have to shoot anyone ... maybe I would have to fire a shot straight up in the air, if this man who I did not believe would appear should appear anyway ... if a shot in the air did not change his dark direction - if, instead, he attacked - I would shoot his leg or shoulder."

He grew up in Louisiana, where guns were common in the home, and had training in firearms from his father and the Marine Corps. "I always assume that a gun is loaded. I also attribute to a gun the ability to load itself, even fire itself, without being touched by a human hand," he said.

"I love guns, especially well-made pistols and revolvers. Many of them are beautiful, and their shape and balanced weight are pleasing to hold. I love the relaxed concentration of aiming a gun and squeezing its trigger, the thrill of hitting a bull's eye or a can."

After a car accident left him wheelchair-bound, he carried a .22 Beretta semi-automatic for self-protection, and one day imagined his house broken into while he was home alone. "...I shoved the magazine into the pistol and worked its slide and aimed the gun, but he kept coming at me, and I shot his leg but he kept coming, and I shot his chest, again and again, till he stopped coming."

He gave up carrying his .22 when he decided that he would be unable to live with killing another human being.

Dubus, A. "Giving up the gun: why I did it." The New Yorker 1997; 73:84-87.

Physicians and Firearms: Acknowledged Risk Without Followup
Even though medical problems associated with firearm ownership and usage are widely documented and accepted as a public health threat, physicians generally do not integrate firearm screening and safety counseling into their daily practices.23 This may be due to lack of knowledge about firearm morbidity and mortality, lack of interest or lack of time to counsel patients. In one study of 420 family practice residencies, only 16% of programs offered formal safety counseling training. Perceived barriers to more widespread training include: no trained personnel, competing other important issues, a lack of educational resources and a lack of time.24 Furthermore, a survey of pediatricians revealed that fewer than 12% ever spoke with more than 5% of their patients about firearm safety.

Physician involvement in firearm safety and violence counseling may help reduce unnecessary injuries and deaths. Physicians can raise firearms and violence issues in multiple settings. First, all primary care providers can use well-child and adult preventive care visits to elicit risk factors for violence. A teen can be asked about aggressive behavior, violence in his or her environment, firearm ownership and usage, and history of injuries related to violence. Counseling on conflict resolution and gun safety may influence a teen's behavior in potentially dangerous situations.

A second critical way that physicians can address violence in patients' lives is through correct diagnosis of violence-related medical conditions. Astonishingly, only one in 20 battered women are correctly diagnosed by their doctors.25 Doctors miss the diagnosis of depression one half of the time, and two-thirds of people committing suicide visited the doctor within the month before dying.26 Clearly, physician screening and treatment for medical and psychosocial conditions underlying firearm usage can improve.

Doctors can also intervene when treating patients for injuries caused by violence. One method of assessing a patient's physical safety, recommended by the U.S. Preventive Health Task Force, is to ask: 1) Have you settled it? 2) Is there anyone who can settle this? Someone who you can to talk and explain your side? 3) Do you know where to go if this is not settled? 4) Are you safe?27 Then appropriate counseling and referral to community resources can occur.

Counseling on Violence and Firearms as Recommended by the U.S. Preventive Health Task Force, Department of Health and Human Services

Assess the risk of violence

1. Has your child or any family member ever been injured by a violent act?
2. Does anyone in the family, including children, use drugs or alcohol?
3. Are there guns or other weapons at home?
4. Is there violence in your neighborhood?

Speak about the dangers of guns in the home

1. Unintentional injury: 34,000 injuries per year
2. Homicide: three times as likely with a gun in the home. The victim usually knows the murderer.
3. Suicide: risk increases 14 times in adolescents without psychiatric diagnoses. For adolescents with a psychological diagnosis, the risk of suicide is 14 times greater when there is a gun in the home.
4. Gun can be used against you.

Give gun safety pointers

1. Remove guns from your home or keep your guns unloaded and locked. Lock ammunition separately.
2. Treat guns as if they were loaded and ready to fire.
3. Do not allow children access to guns.
4. Check that your antique and souvenir guns are not loaded.
5. Find out if there are guns in other homes where your children spend time.

Legislative Advocacy on Gun Safety
The main reasons that Americans own guns include fear of unsafe streets, fear of home intruders and fear of physical abuse from an intimately related individual. Legislative advocacy should address these fears. Two primary approaches to reducing gun crimes have been outlined: limiting the availability of guns and reducing demand through the increase in cost and the decrease in perceived benefits of gun ownership. Reduction in the availability of guns has been achieved through measures such as increased stringency in licensing gun dealers, a limit on gun purchases to one per month, and the 1993 Brady Bill, which requires a five-day waiting period after purchasing a gun to allow for background checks.

However, restricting gun sales will have a limited effect on crime, as only one-sixth of guns used in crimes are obtained legally.28 Instead, guns are obtained from acquaintances, family members or from the illegal gun market. A study of gun use in juvenile offenders revealed that guns could be easily acquired on the street or stolen, borrowed or traded.12 One-half of a million guns are added to this pool annually through theft. The illegal gun market is supported by retailers who sell under the counter, straw-man purchasers who obtain guns for individuals unable to legally purchase weapons, and gun traffickers.29 Shutting down the illegal market is crucial to reducing crime and improving safety, as seizure of illegally carried guns has been shown to reduce the number of gun crimes.29 Therefore, legislative advocacy for reducing gun crimes should support adequate resources for law enforcement to stop illegal purchases of guns. Stiffer sentences for using guns in crimes and against police officers may deter criminal firearm use as well. Advocacy for measures to reduce legal gun sales to criminals with a record can also reduce gun crimes while promoting community safety and decreasing motivations to own guns for self protection. Finally, improved arrest and prosecution of domestic violence perpetrators may help to reduce injury and death of physical abuse victims.

Another stumbling block to gun safety is the suppression of research describing the risks of gun ownership. To strengthen gun ownership rights, the 104th Congress voted to end funding for the National Center for Injury Prevention and Control at the CDC. This funding was later reinstated, with a warning that, "None of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention (CDC) may be used to advocate or promote gun control."30 Epidemiological research also has been impeded by legislative action. The Washington state legislature has prohibited epidemiologists from accessing handgun registration files. This makes it difficult to accurately assess risk for gun-related injury.17 Increased funding for gun safety and injury prevention research, better access to crime databases for public health researchers and improved crime surveillance would help to reduce firearm injuries. By determining who is at risk for gun injury and gun-related crime, medical students could better understand how to intervene and prevent injuries before they happen.

Further Activities
In the last election, the National Rifle Association (NRA) donated $1.8 million to political races to support unrestricted and unregulated access to all firearms. This was nine times as much as the highest-spending gun control lobby, Handgun Control.31

Sources for medical students to learn more about pending gun legislation and form advocacy coalitions with gun safety advocates include the Center to Prevent Handgun Violence, the American Academy of Pediatrics, and Physicians for Social Responsibility. Medical students can also organize letter-writing campaigns on issues related to gun violence and crime. Students can also visit their legislators to discuss concerns about gun injuries and deaths. For an in-depth discussion of medical student advocacy, see the Project-in-a-Box titled, Legislative Skills for Future Generalists.

Conclusion
Generalist physicians can help to prevent firearm injury and death through better assessment of gun ownership and violence. This requires knowledge about violence, trauma, psychiatric and psychosocial conditions and resources, as well as the initiative to be active in screening and patient education. Despite beliefs that screening and education are useful, generalist physicians have a long-standing, poor track record of helping patients reduce risk factors for violent outcomes. Medical students can reverse this record by becoming informed on firearm use and safety. This will enable them to assess patients for risk of violence, to counsel patients on gun storage practices, to teach other medical students and faculty about gun dangers, and to advocate for stronger crime control and gun safety laws and expanded research and crime surveillance efforts.

Case Studies

1. Nicole is a 16-year-old female who presents to the emergency department with a single gunshot wound to her left flank. She states she got into a verbal and physical fight with her ex-boyfriend and he shot her as she was trying to escape. Her circulatory status is deemed stable and she is admitted overnight for observation. Before turning her over to the ward surgery team:

• You want to assess the conflict. What questions do you ask her about the argument with her ex-boyfriend?
• What medical problems related to violence do you suspect and rule in or out?
• After discussion, you feel that she is at risk for further harm. What advice do you give her?

2. Frank is a 35-year-old, unmarried male who presents to your ambulatory clinic with decreased energy and trouble concentrating. You diagnose him with a major depressive episode and initiate appropriate therapy. On questioning, he admits to keeping a loaded gun in the home because he is afraid of burglars.

• What are alternatives to keeping a gun for self protection?
• What do you tell him about the risk of a gun in the home?
• What do you advise this patient to do?
• What other medical problems do you screen for?

RESOURCES
The NRA's Eagle Eddie recommends teaching gun safety to children as soon as they show interest in guns, including toy guns. Parents should talk to children about the difference between "getting killed" on TV and in real life. When children see a real gun, they should STOP! Don't touch. Leave the area. Tell an adult.

To get more information for patients, parents and physicians, contact:

American Academy of Pediatrics

141 Northwest Point Blvd., PO Box 927

Elk Grove, IL 60009-0927

(800) 433-9016

HELP Network

2300 Children's Plaza #88, Chicago, IL 60614

(773) 880-3826

Information and fact sheets on handgun violence

Handgun Legislation and Advocacy Organizations

Handgun Control

1225 Eye Street NW, Suite 1100

Washington, DC 20005

(202) 898-0792

http://www.handguncontrol.org
Media alerts

Physicians for Social Responsibility

1104 14th Street NW, Washington, DC 20005

(202) 898-0150

http://www.psr.org

Legislative analysis; fact sheets

National Rifle Association

11250 Waples Mill RD, Fairfax, VA 22030

(800) 267-1430

http://www.nra.org

Legislative updates; state-by-state gun laws

NRA Safety and Education Division

(703) 267-1560

For gun users, the NRA offers gun safety information and instruction

Violence Policy Center

http://www.vpc.org

Latest news on the gun industry and on gun policy; press releases

REFERENCES

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