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The Effects of Violence on Communities: The Violence Matrix as a Tool for Advancing More Just Policies

Beth E. Richie is Head of the Department of Criminology, Law and Justice and Professor of African American Studies at the University of Illinois at Chicago. She is the author of Arrested Justice: Black Women, Violence, and America's Prison Nation (2012) and Compelled to Crime: The Gender Entrapment of Battered Black Women (1996) and editor of The Long Term: Resisting Life Sentences, Working toward Freedom (with Alice Kim, Erica Meiners, Jill Petty, et al., 2018).

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Beth E. Richie; The Effects of Violence on Communities: The Violence Matrix as a Tool for Advancing More Just Policies. Daedalus 2022; 151 (1): 84–96. doi: https://doi.org/10.1162/daed_a_01890

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In this essay, I illustrate how discussions of the effects of violence on communities are enhanced by the use of a critical framework that links various microvariables with macro-institutional processes. Drawing upon my work on the issue of violent victimization toward African American women and how conventional justice policies have failed to bring effective remedy in situations of extreme danger and degradation, I argue that a broader conceptual framework is required to fully understand the profound and persistent impact that violence has on individuals embedded in communities that are experiencing the most adverse social injustices. I use my work as a case in point to illustrate how complex community dynamics, ineffective institutional responses, and broader societal forces of systemic violence intersect to further the impact of individual victimization. In the end, I argue that understanding the impact of all forms of violence would be better served by a more intersectional and critical interdisciplinary framework.

Rigorous interdisciplinary scholarship, public policy analyses, and the most conscientious popular discourse on the impact of violence point to the deleterious effects that violence has on both individual health and safety and community well-being. Comprehensive justice policy research on topics ranging from gun violence to intimate abuse support the premise that the physical injury, psychological distress, and fear that are typically associated with individual victimization are directly linked to subsequent social isolation, economic instability, erosion of neighborhood networks, group alienation, and mistrust of justice and other institutions. This literature also points to the ways that structural inequality, persistent disadvantages, and structural abandonment are some of the root causes of microlevel violent interactions and at the same time influence how effective macro-level justice policies are at responding to or preventing violent victimization. 1

The most exciting of these analyses have emerged from the subfields of feminist criminology, critical race theory, critical criminology, sociolegal theory, and other social science research that take seriously questions of race and culture, gender and sexuality, ethnic identity and class position, exploring with great interest how these factors influence the prevailing questions upon which practitioners in our field base their practice; questions such as how to increase access to justice, the role of punishment in desistance, the factors that lead to a disproportionate impact of institutional practices, and the perceptions about, and possibilities for, violence prevention and abolitionist practices. 2 Discussions about the future of justice policy would be well served by attending to this growing literature and the critical frameworks that are advanced from within it.

In this essay, I will attempt to illustrate how discussions of the effects of violence on communities are enhanced by the use of a critical framework that links various microvariables with macro-institutional processes. Drawing upon my work on the issue of violent victimization toward African American women and how conventional justice policies have failed to bring effective remedy in situations of extreme danger and degradation, I argue that a broader conceptual framework is required to fully understand the profound and persistent impact that violence has on individuals embedded in communities that are experiencing the most adverse social injustices. I use my work as a case in point to illustrate how complex community dynamics, ineffective institutional responses, and broader societal forces of systemic violence intersect to further the impact of individual victimization. In the end, I argue that understanding the impact of all forms of violence would be better served by a more intersectional and critical interdisciplinary framework.

Following a review of the data on violent victimization against African American women, I describe the violence matrix , a conceptual framework that I developed from analyzing data from several research projects on the topic. 3 I do so as a way to make concrete my earlier claim: that the effect of violence on communities must be understood from a critical intersectional framework. That is, my central argument here is an epistemological one, suggesting that in the future, the most effective and indeed “just” policies in response to violence necessitate the development of critical far-reaching systemic analysis and social change at multiple levels.

Violent victimization has been established as a major problem in contemporary society, resulting in long-term physical, social, emotional, and economic consequences for people of different racial/ethnic, class, religious, regional, and age groups and identities. 4 However, like most social problems, the impact is not equally felt across all subgroups, and even though the rates may be similar, the consequences of violent victimization follow other patterns of social inequality and disproportionately affect racial/ethnic minority groups. 5 When impact and consequences are taken into account, it becomes clear that African American women fare among the worst, in part because of the ways that individual experiences are impacted by negative institutional processes. 6

While qualitative data suggest that there is a link between social position in a racial hierarchy and Black women's subsequent vulnerability to violence, the specific mechanism of that relationship has yet to be described or tested. 7 However, despite new research that examines the effects of race/ethnicity and gender in combination, there has been a lack of systematic analysis of the intersection of race and gender with a specific focus on the situational factors, cultural dynamics, and neighborhood variables that lead to higher rates and/or more problematic outcomes of violent victimization in the lives of African American women. 8

These unanswered questions led to the years of fieldwork that informed the development of the violence matrix. I was interested in broadening the understanding of violence by analyzing the contextual and situational factors that correlate with multiple forms of violent victimization for African American women, incorporating the racial and community dynamics that influence their experiences. I was also concerned about the ways that state-sanctioned violence and systemic oppression contributed to the experience and impact of intimate partner abuse and looked for a way to incorporate “ordinary violence” and “the injustices of everyday life” into an analytic model. I offer this conceptual approach as a potential epistemological model because it proposes to enhance the scientific understanding of violent victimization of African American women by looking at gender and race, micro and macro, individual, community, and societal issues in the same analysis, whereas in most other research, rates of victimization are described either by gender or race, and typically not from within the contexts of household, neighborhood, and society.

More specifically, domestic violence, sexual abuse, and other forms of violence typically understood to be associated with household or familiar relationships are usually studied as a separate phenomenon constituting a gender violence subfield distinct from other forms of victimization that are captured in more general crime statistics. 9 The more general research that documents crimes of assault, homicide, and so on does not typically isolate analyses of the nature of the relationship between the perpetrator and the victim, even if it is noted. As a result, gender violence and other forms of violent victimization against women are studied separately, and their causes and consequences, the intervention and prevention strategies, and the needs for policy change are not linked analytically to each other. This leaves unexamined the significant influence of situational factors (such as intimacy) or contextual factors (such as negative images of African American women) on victimization, and on violence more generally.

Prior to describing the violence matrix, readers may benefit from a brief overview of the problems that it was designed to account for. African American women experience disproportionate impacts of violent victimization. 10 As the following review of the literature shows, the rates are high and the consequences are severe, firmly establishing the need to focus on this vulnerable group. The goal is not to suggest it is the only population group at risk or that racial/ethnic identity has a causal influence on victimization, but rather to look specifically at how race/ethnicity and gender interact to create significant disproportionality in rates of, perceptions about, and consequences of violence, and to develop an instrument to collect data that can be analyzed conceptually and discussed in terms of contextual particularities.

Assault . According to the Bureau of Justice Statistics, in 2005, Black women reported experiencing violent victimization at a rate of 25 per 1,000 persons aged twelve years or older. 11 In an earlier report, Black women reported experiencing simple assaults at 28.8 per 1,000 persons and serious violent crimes at 22.5 per 1,000 persons, twelve years or older. Black women are also more likely (53 percent) to report violent victimization to the police than their White or male counterparts. 12 Situational factors such as income, urban versus suburban residence, perception of street gang membership, and presence of a weapon influence Black women's violent victimization. Other variables are known to complicate this disproportionality, most notably income, age, neighborhood density, and other crimes in the community like gang-related events. However, few studies note or analyze their covariance. Additionally, reports after 2007 detail statistics on violent victimization for race or gender, but not race and gender; therefore, numbers regarding Black women's experiences are largely unknown.

Intimate partner violence . Intimate partner violence is a significant and persistent social problem with serious consequences for individual women, their families, and society as a whole. 13 The 1996 National Violence Against Women Survey suggested that 1.5 million women in the United States were physically assaulted by an intimate partner each year, while other studies provide much higher estimates. 14 For example, the Department of Justice estimates that 5.3 million incidents of violence against a current or former spouse or girlfriend occur annually. Estimates of violence against women in same sex partnerships indicate a similar rate of victimization. 15

According to most national studies, African American women are disproportionately represented in the data on physical violence against intimate partners. 16 In the Violence Against Women Survey, 25 percent of Black women had experienced abuse from their intimate partner, including “physical violence, sexual violence, threats of violence, economic exploitation, confinement and isolation from social activities, stalking, property destruction, burglary, theft, and homicide.” Rates of severe battering help to spotlight the disproportionate impact of direct physical assaults on Black women by intimate partners: homicide by an intimate partner is the second-leading cause of death for Black women between the ages of fifteen and twenty-five. 17 Black women are killed by a spouse at a rate twice that of White women. However, when the intimate partner is a boyfriend or girlfriend, this statistic increases to four times the rate of their White counterparts. 18 While the numbers are convincing, they are typically not embedded in an understanding of how situational factors like relationship history, religiosity, or availability of services impact these rates. 19

Sexual victimization . When race is considered a variable in some community samples, 7 to 30 percent of all Black women report having been raped as adults, and 14 percent report sexual abuse during their childhood. 20 This unusually wide range results from differences in definitions and sampling methods. However, as is true in most research on sexual victimization, it is widely accepted that rape, when self-reported, is underreported, and that Black women tend to underutilize crisis intervention and other supportive services that collect data. 21 Even though Black women from all segments of the African American community experience sexual violence, the pattern of vulnerability to rape and sexual assault mirrors that of direct physical assault by intimate partners. The data show that Black women from low-income communities, those with substance abuse problems or mental health concerns, and those in otherwise compromised social positions are most vulnerable to sexual violence from their intimate partners. 22 Not only is the incidence of rape higher, but a review of the qualitative research on Black women's experiences of rape also suggests that Black women are assaulted in more brutal and degrading ways than other women. 23 Weapons or objects are more often used, so Black women's injuries are typically worse than those of other groups of women. Black women are more likely to be raped repeatedly and to experience assaults that involve multiple perpetrators. 24

Beyond the physical, and sometimes lethal, consequences, the psychological literature documents the very serious mental health impact of sexual assault by intimate partners. For instance, 31 percent of all rape victims develop rape-related post-traumatic stress disorder. 25 Rape victims are three times more likely than nonvictims to experience a major depressive episode in their lives, and they attempt suicide at a rate thirteen times higher than nonvictims. Women who have been raped by a member of their household are ten times more likely to abuse illegal substances or alcohol than women who have not been raped. Black women experience the trauma of sexual abuse and aggression from their intimate partners in particular ways, as studies conducted by psychologists Victoria Banyard, Sandra Graham-Bermann, Carolyn West, and others have discussed. 26 It is also important to note the extent to which Black women are exposed to or coerced into participating in sexually exploitative intimate relationships with older men and men who violate commitments of fidelity by having multiple sexual partners. 27 Far from infrequent or benign, it can be hypothesized that these experiences serve to socialize young women into relationships characterized by unequal power, and they normalize subservient gender roles for women, although very little empirical research has been done to make this analytical case.

Community harassment . In addition to direct physical and sexual assaults, Black women experience a disproportionate number of unwanted comments, uninvited physical advances, and undesired exposure to pornography in their communities. Almost 75 percent of Black women sampled report some form of sexual harassment in their lifetime, including being forced to live in, work in, attend school in, and even worship in degrading, dangerous, and hostile environments, where the threat of rape, public humiliation, and embarrassment is a defining aspect of their social environment. 28 They also experience trauma as a result of witnessing violence in their communities. 29

For some women, this sexual harassment escalates to rape. Even when it does not, community harassment creates an environment of fear, apprehension, shame, and anxiety that can be linked to women's vulnerability to violent victimization. It is important to understand this link because herein lie some of the most significant situational and contextual factors, like the diminished use of support services and reduced social capital on the part of African American women.

Social disenfranchisement . Less well-documented or quantified in the criminological data is the disproportionate harm caused to African American women because of the ways that violent victimization is linked to social disenfranchisement and the discrimination they face in the social sphere. Included here is what other researchers have called coercive control or structural violence. 30 The notion of social disenfranchisement goes beyond emotional abuse and psychological manipulation to include the regulation of emotional and social life in the private sphere in ways that are consistent with normative values about gender, race, and class. 31 These aspects of violence against African American women in particular are conceptualized in the violence matrix, and include being disrespected by microracial slurs from community members and agency officials, and having their experience of violent victimization denied by community leaders. 32 African American women are also disproportionately likely to be poor, rely on public services like welfare, and be under the control of state institutions like prisons, which means that they face discrimination and degradation in these settings at higher rates. 33 These situational and contextual factors that cause harm are indirectly related to violent victimization and must be considered part of the environment that disadvantages African American women. From this vantage point, it could be argued that when women experience disadvantages associated with racial and ethnic discrimination, dangerous and degrading situations, and social disenfranchisement, they are more at risk of victimization. 34

The violence matrix ( Table 1 ) is informed by the data reviewed above and by my interest in bringing a critical feminist criminological approach to the understanding of violent victimization of African American women. It asserts that intimate partner violence is worsened by some of the contextual variables and situational dynamics in their households, communities, and broader social sphere, and vice versa. The tool is not intended to infer causation, but rather to broaden the understanding of the factors that influence violence in order to create justice policy in the future.

The Violence Matrix

The violence matrix conceptualizes the forms of violent victimization that women experience as fitting into three overlapping categories, reflecting a sense that the forms are co-constituted and exist within a larger context and in multiple arenas: 35 1) direct physical assault against women; 2) sexual aggressions that range from harassment to rape; and 3) the emotional and structural dimensions of social disenfranchisement that characterize the lives of some African American women and leave them vulnerable to abuse. Embedded in the discussion of social disenfranchisement are issues related to social inequality, systemic abuse, and state violence.

Consistent with ecological models of other social problems, the violence matrix shows that various forms of violent victimization happen in several contexts and are influenced by several variables. 36 First, violence occurs within households, including abuse from intimate partners as well as other family members and co-residents. Dynamics associated with household composition, relationship history, and patterns of household functioning can be isolated for consideration in this context. The second sphere is the community in which women live: the neighborhoods, schools, workplaces, and public spaces where women routinely interact with peers and other people. This context has both a geographic and a cultural meaning. Community, in this context, is where women share a sense of belonging and physical space. An analysis of the community context focuses attention on issues like neighborhood social class, degree of social cohesion, and presence or absence of social services. The third is the social sphere, where legal processes, institutional policies, ineffective justice policies, and the nature of social conditions (such as population density, neighborhood disorder, patterns of incarceration, and other macrovariables) create conditions that cause harm to women and other victims of violence. 37 The harm caused by victimization in this context happens either through passive victimization (as in the case of bystanders not responding to calls for help because of the low priority put on women's safety) or active aggression (as in police use of excessive force in certain neighborhoods) that create structural disadvantage. 38

The analytic advantage of using a tool like the violence matrix to explain violent victimization is that it offers a way to move beyond statistical analyses of disproportionality to focus on a more nuanced understanding of the relationship between contextual factors that disadvantage African American women and the situational variables leading to violent victimization. Two important features of this conceptual framework allow for this. First, the violence matrix theoretical model considers both the forms and the contexts as dialectical and reinforcing (as opposed to discrete) categories of experience. Boundaries overlap, relationships shift over time, and situations change. It helps to show how gender violence and other forms of violent victimization intersect and reinforce each other. For example, sexual abuse has a physical component, community members move in and become intimate partners, and sexual harassment is sometimes a part of how institutions respond to victims. This theoretical model examines the simultaneity of forms and contexts, a feature that most paradigms do not have. 39 The possibility that gender violence (like marital rape) could be correlated with violence at the community level (like assault by a neighbor) holds important potential for a deeper understanding of violent victimization of vulnerable groups and therefore informs the future of justice policy.

A second distinguishing feature of this conceptual model is that it broadens the discussion about violent victimization beyond direct assaults within the household (Table 1, cells 1 and 2) and sexual assaults by acquaintances and strangers (cells 5 and 8), which are the focus of the majority of the research on violence against women. It includes social disenfranchisement as a form of violence and social sphere as a context (cells 3, 6, 7, 8, and 9). In this way, the violence matrix focuses specific attention on contextual and situational vulnerabilities in addition to the physical ones. More generally, this advantages research and justice praxis. This approach responds to the entrenched problem of gender violence as it relates to issues of structural racism and other forms of systematic advantage. Models like this therefore hold the potential to inform justice policy that is more comprehensive, more effective, and, ultimately, more “just.”

My hope is that the violence matrix will deepen the understanding of the specific problem of violence in the lives of Black women and serve as a model for intersectional analyses of other groups and their experiences of violence. I hope it points to the utility of moving beyond quantitative studies and single-dimension qualitative analyses of the impact of violence and instead encourages designing conceptual models that consider root causes and the ways that systemic factors complicate its impact. This would offer an opportunity for a deeper discussion around violence policy, one that would include attention to individual harm, and how it is created by, reinforced by, or worsened by structural forms of violence. It would bring neighborhood dynamics into the analytical framework and engage issues of improving community efficacy and reversing structural abandonment in considerations of potential options. Questions about where strategies of community development and how the politics of prison abolition might appear would become relevant. And in the end, it would advance critical justice frameworks that answer questions about what 1) we might invest in to keep individuals safe; 2) how we might help neighborhoods thrive; and 3) how we might create structural changes that shift power in our society such that violence and victimization are minimized. More than rhetorical questions and naively optimistic strategies, these are real issues that must inform any discussion of the future of justice policy. A model like the violence matrix, modified and improved upon by discussions at convenings like those hosted by the Square One Project, offer some insights into both the what and the how of future justice policy. I hope that this essay is helpful in moving that discussion forward.

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Article Contents

Introduction, the burden of firearm violence, understanding and reducing firearm violence is complex and multi-factorial, interventions and recommendations, conclusions, research ethics.

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Firearm Violence in the United States: An Issue of the Highest Moral Order

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Chisom N Iwundu, Mary E Homan, Ami R Moore, Pierce Randall, Sajeevika S Daundasekara, Daphne C Hernandez, Firearm Violence in the United States: An Issue of the Highest Moral Order, Public Health Ethics , Volume 15, Issue 3, November 2022, Pages 301–315, https://doi.org/10.1093/phe/phac017

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Firearm violence in the United States produces over 36,000 deaths and 74,000 sustained firearm-related injuries yearly. The paper describes the burden of firearm violence with emphasis on the disproportionate burden on children, racial/ethnic minorities, women and the healthcare system. Second, this paper identifies factors that could mitigate the burden of firearm violence by applying a blend of key ethical theories to support population level interventions and recommendations that may restrict individual rights. Such recommendations can further support targeted research to inform and implement interventions, policies and laws related to firearm access and use, in order to significantly reduce the burden of firearm violence on individuals, health care systems, vulnerable populations and society-at-large. By incorporating a blended public health ethics to address firearm violence, we propose a balance between societal obligations and individual rights and privileges.

Firearm violence poses a pervasive public health burden in the United States. Firearm violence is the third leading cause of injury related deaths, and accounts for over 36,000 deaths and 74,000 firearm-related injuries each year ( Siegel et al. , 2013 ; Resnick et al. , 2017 ; Hargarten et al. , 2018 ). In the past decade, over 300,000 deaths have occurred from the use of firearms in the United States, surpassing rates reported in other industrialized nations ( Iroku-Malize and Grissom, 2019 ). For example, the United Kingdom with a population of 56 million reports about 50–60 deaths per year attributable to firearm violence, whereas the United States with a much larger population, reports more than 160 times as many firearm-related deaths ( Weller, 2018 ).

Given the pervasiveness of firearm violence, and subsequent long-term effects such as trauma, expensive treatment and other burdens to the community ( Lowe and Galea, 2017 ; Hammaker et al. , 2017 ; Jehan et al. , 2018 ), this paper seeks to examine how various evidence-based recommendations might be applied to curb firearm violence, and substantiate those recommendations using a blend of the three major ethics theories which include—rights based theories, consequentialism and common good. To be clear, ours is not a morally neutral paper wherein we weigh the merits of an ethical argument for or against a recommendation nor is it a meta-analysis of the pros and cons to each public health recommendation. We intend to promote evidence-based interventions that are ethically justifiable in the quest to ameliorate firearm violence.

It is estimated that private gun ownership in the United States is 30% and an additional 11% of Americans lived with someone who owed a gun in 2017 ( Gramlich and Schaeffer, 2019 ). Some of the reported motivations for carrying a firearm include protection against people (anticipating future victimization or past victimization experience) and hunting or sport shooting ( Schleimer et al. , 2019 ). A vast majority of firearm-related injuries and death occur from intentional harm (62% from suicides and 35% from homicides) versus 2% of firearm-related injuries and death occurring from unintentional harm or accidents (e.g. unsafe storage) ( Fowler et al. , 2015 ; Lewiecki and Miller, 2013 ; Monuteaux et al. , 2019 ; Swanson et al. , 2015 ).

Rural and urban differences have been noted regarding firearms and its related injuries and deaths. In one study, similar amount of firearm deaths were reported in urban and rural areas ( Herrin et al. , 2018 ). However, the difference was that firearm deaths from homicides were higher in urban areas, and deaths from suicide and unintentional deaths were higher in rural areas ( Herrin et al. , 2018 ). In another study, suicides accounted for about 70% of firearm deaths in both rural and urban areas ( Dresang, 2001 ). Hence, efforts to implement these recommendations have the potential to prevent most firearm deaths in both rural and urban areas.

The burden of firearm injuries on society consists of not only the human and economic costs, but also productivity loss, pain and suffering. Firearm-related injuries affect the health and welfare of all and lead to substantial burden to the healthcare industry and to individuals and families ( Corso et al. , 2006 ; Tasigiorgos et al. , 2015 ). Additionally, there are disparities in firearm injuries, whereby firearm injuries disproportionately affect young people, males and non-White Americans ( Peek-Asa et al. , 2017 ). The burden of firearm also affects the healthcare system, racial/ethnic minorities, women and children.

Burden on Healthcare System

Firearm-related fatalities and injuries are a serious public health problem. On average more than 38 lives were lost every day to gun related violence in 2018 ( The Education Fund to Stop Gun Violence (EFSGV), 2020 ). A significant proportion of Americans suffer from firearm non-fatal injuries that require hospitalization and lead to physical disabilities, mental health challenges such as post-traumatic stress disorder, in addition to substantial healthcare costs ( Rattan et al. , 2018 ). Firearm violence and related injuries cost the U.S. economy about $70 billion annually, exerting a major effect on the health care system ( Tasigiorgos et al. , 2015 ).

Victims of firearm violence are also likely to need medical attention requiring high cost of care and insurance payouts which in turn raises the cost of care for everyone else, and unavoidably becomes a financial liability and source of stress on the society ( Hammaker et al. , 2017 ). Firearm injuries also exert taxing burden on the emergency departments, especially those in big cities. Patients with firearm injuries who came to the emergency departments tend to be overwhelmingly male and younger (20–24 years old) and were injured in an assault or unintentionally ( Gani et al. , 2017 ). Also, Carter et al. , 2015 found that high-risk youth (14–24 years old) who present in urban emergency departments have higher odds of having firearm-related injuries. In fact, estimates for firearm-related hospital admission costs are exorbitant. In 2012, hospital admissions for firearm injuries varied from a low average cost of $16,975 for an unintentional firearm injury to a high average cost of $32,237 for an injury from an assault weapon ( Peek-Asa et al. , 2017 ) compared with an average cost of $10,400 for a general hospital admission ( Moore et al. , 2014 ).

Burden on Racial/Ethnic Minorities, Women and Children

Though firearm violence affects all individuals, racial disparities exist in death and injury and certain groups bear a disproportionate burden of its effects. While 77% of firearm-related deaths among whites are suicides, 82% of firearm-related deaths among blacks are homicides ( Reeves and Holmes, 2015 ). Among black men aged 15–34, firearm-related death was the leading cause of death in 2012 ( Cerdá, 2016 ). The racial disparity in the leading cause of firearm-related homicide among 20- to 29-year-old adults is observed among blacks, followed by Hispanics, then whites. Also, victims of firearms tend to be from lower socioeconomic status ( Reeves and Holmes, 2015 ). Understanding behaviors that underlie violence among young adults is important. Equally important is the fiduciary duty of public health officials in creating public health interventions and policies that would effectively decrease the burden of gun violence among all Americans regardless of social, economic and racial/ethnic backgrounds.

Another population group that bears a significant burden of firearm violence are women. The violence occurs in domestic conflicts ( Sorenson and Vittes, 2003 ; Tjaden et al. , 2000 ). Studies have shown that intimate partner violence is associated with an increased risk of homicide, with firearms as the most commonly used weapon ( Leuenberger et al. , 2021 ; Gollub and Gardner, 2019 ). However, firearm threats among women who experience domestic violence has been understudied ( Sullivan and Weiss, 2017 ; Sorenson, 2017 ). It is estimated that nearly two-thirds of women who experience intimate partner violence and live in households with firearms have been held at gunpoint by intimate partners ( Sorenson and Wiebe, 2004 ). Firearms are used to threaten, coerce and intimidate women. Also, the presence of firearms in a home increases the risk of women being murdered ( Campbell et al. , 2015 ; Bailey et al. , 1997 ). Further, having a firearm in the home is strongly associated with more severe abuse among pregnant women in a study by McFarlane et al. (1998) . About half of female intimate partner homicides are committed with firearms ( Fowler, 2018 ; Díez et al. , 2017 ). Some researchers reported that availability of firearms in areas with fewer firearms restrictions has led to higher intimate partner homicides ( Gollub and Gardner, 2019 ; Díez et al. , 2017 ).

In the United States, children are nine times more likely to die from a firearm than in most other industrialized nations ( Krueger and Mehta, 2015 ). Children here include all individuals under age 18. These statistics highlight the magnitude of firearm injuries as well as firearms as a serious pediatric concern, hence, calls for appropriate interventions to address this issue. Unfortunately, children and adolescents have a substantial level of access to firearms in their homes which contributes to firearm violence and its related injuries ( Johnson et al. , 2004 ; Kim, 2018 ). About half of all U.S. households are believed to have a firearm, making firearms one of the most pervasive products consumed in the United States ( Violano et al. , 2018 ). Consequently, most of the firearms used by children and youth to inflict harm including suicides are obtained in the home ( Johnson et al. , 2008 ). Beyond physical harm, children experience increased stress, fear and anxiety from direct or indirect exposure to firearms and its related injuries. These effects have also been reported as predictors of post-traumatic stress disorders in children and could have long-term consequences that persist from childhood to adulthood ( Holly et al. , 2019 ). Additionally, the American Psychological Association’s study on violence in the media showed that witnessing violence leads to fear and mistrust of others, less sensitivity to pain experienced by others, and increases the tendency of committing violent acts ( Branas et al. , 2009 ; Calvert et al. , 2017 ).

As evidenced from the previous sections, firearm violence is a complex issue. Some argue that poor mental health, violent video games, substance abuse, poverty, a history of violence and access to firearms are some of the reasons for firearm violence ( Iroku-Malize and Grissom, 2019 ). However, the prevalence and incidence of firearm violence supersedes discrete issues and demonstrates a complex interplay among a variety of factors. Therefore, a broader public health analysis to better understand, address and reduce firearm violence is warranted. Some important factors as listed above should be taken into consideration to more fully understand firearm violence which can consequently facilitate processes for mitigation of the frequency and severity of firearm violence.

Lack of Research Prevents Better Understanding of Problem of Firearm Violence

A major stumbling block to understanding the prevalence and incidence of firearm related violence exists from a lack of rigorous scientific study of the problem. Firearm violence research constitutes less than 0.09% of the Centers for Disease Control and Prevention’s annual budget ( Rajan et al. , 2018 ). Further research on firearm violence is greatly limited by the Dickey Amendment, first passed in 1996 and annually thereafter in budget appropriations, which prohibits use of federal funds to advocate or promote firearm control ( Rostron, 2018 ). As such, the Dickey Amendment impedes future federally funded research, even as public health’s interest in firearm violence prevention increased ( Peetz and Haider, 2018 ; Rostron, 2018 ). In the absence of rigorous research, a deeper understanding and development of evidence-based prevention measures continue to be needed.

Lack of a Public Health Ethical Argument Against Firearm Use Impedes Violence Prevention

We make an argument that gun violence is a public health problem. While some might think that public health is primarily about reducing health-related externalities, it is embedded in key values such as harm reduction, social justice, prevention and protection of health and social justice and equity ( Institute of Medicine, 2003 ). Public health practice is also historically intertwined with politics, power and governance, especially with the influence of the states decision-making and policies on its citizens ( Lee and Zarowsky, 2015 ). According to the World Health Organization, health is a complete physical, mental and social well-being that is not just the absence of injury or disease ( Callahan, 1973 ). Health is fundamental for human flourishing and there is a need for public health systems to protect health and prevent injuries for individuals and communities. Public health ethics, then, is the practical decision making that supports public health’s mandate to promote health and prevent disease, disability and injury in the population. It is imperative for the public health community to ask what ought to be done/can be done to curtail firearm violence and its related burdens. Sound public health ethical reasoning must be employed to support recommendations that can be used to justify various public policy interventions.

The argument that firearm violence is a public health problem could suggest that public health methods (e.g. epidemiological methods) can be used to study gun violence. Epidemiological approaches to gun violence could be applied to study its frequency, pattern, distribution, determinants and measure the effects of interventions. Public health is also an interdisciplinary field often drawing on knowledge and input from social sciences, humanities, etc. Gun violence could be viewed as a crime-related problem rather than public health; however, there are, of course, a lot of ways to study crime, and in this case with public health relevance. One dominant paradigm in criminology is the economic model which often uses natural experiments to isolate causal mechanisms. For example, it might matter whether more stringent background checks reduce the availability of guns for crime, or whether, instead, communities that implement more stringent background checks also tend to have lower rates of gun ownership to begin with, and stronger norms against gun availability. Therefore, public health authorities and criminologists may tend to have overlapping areas of expertise aimed to lead to best practices advice for gun control.

Our paper draws on three major theories: (1) rights-based theories, (2) consequentialism and (3) the common good approach. These theories make a convergent case for firearm violence, and despite their significant divergence, strengthen our public health ethics approach to firearm. The key aspects of these three theories are briefly reviewed with respect to how one might use a theory to justify an intervention or recommendation to reduce firearm injuries.

Rights-Based Theories

The basic idea of the rights framework is that people have certain rights, and that therefore it is impermissible to treat people in certain ways even if doing so would promote the overall good. People have rights to safety, security and an environment generally free from risky pitfalls. Conversely, people also have a right to own a gun especially as emphasized in the U.S.’s second amendment. Another theory embedded within our discussion of rights-based theories is deontology. Deontological approaches to ethics hold that we have moral obligations or duties that are not reducible to the need to promote some end (such as happiness or lives saved). These duties are generally thought to specify what we owe to others as persons ( rights bearers ). There are specific considerations that define moral behaviors and specific ways in which people within different disciplines ought to behave to effectively achieve their goals.

Huemer (2003) argued that the right to own a firearm has both a fundamental (independent of other rights) and derivative justification, insofar as the right is derived from another right - the right to self-defense ( Huemer, 2003 ). Huemer gives two arguments for why we have a right to own a gun:

People place lots of importance on owning a gun. Generally, the state should not restrict things that people enjoy unless doing so imposes substantial risk of harm to others.

People have a right to defend themselves from violent attackers. This entails that they have a right to obtain the means necessary to defend themselves. In a modern society, a gun is a necessary means to defend oneself from a violent attacker. Therefore, people have a right to obtain a gun.

Huemer’s first argument could be explained that it would be permissible to violate someone’s right to own or use a firearm in order to promote some impersonal good (e.g. number of lives saved). Huemer’s second argument also justifies a fundamental right to gun ownership. According to Huemer, gun restrictions violate the right of individual gun owners to defend themselves. Gun control laws will result in coercively stopping people to defend themselves when attacked. To him, the right to self-defense does seem like it would be fundamental. It seems intuitive to argue that, at some level, if someone else attacks a person out of the blue, the person is morally required to defend themselves if they cannot escape. However, having a right to self-defense does not entail that your right to obtain the means necessary to that thing cannot be burdened at all.

While we have a right to own a gun, that right is weaker than other kinds of rights. For example, gun ownership seems in no way tied to citizenship in a democracy or being a member of the community. Also, since other nations/democracies get along fine without a gun illustrates that gun ownership is not important enough to be a fundamental right. Interestingly, the UK enshrines a basic right to self-defense, but explicitly denies any right to possess any particular means of self-defense. This leads to some interesting legal peculiarities where it can be illegal to possess a handgun, but not illegal to use a handgun against an assailant in self-defense.

In the United States, implementing gun control policies to minimize gun related violence triggers the argument that such policies are infringements on the Second Amendment, which states that the rights to bear arms shall not be infringed. The constitution might include a right to gun ownership for a variety of reasons. However, it is not clear from the text itself that the right to bear arms is supposed to be as fundamental as the right to freedom of expression. Further, one could argue, then, that any form of gun regulation is borne from the rationale to retain our autonomy. Protections from gun violence are required to treat others as autonomous agents or as bearers of dignity. We owe others certain protections and affordances at least in part because these are necessary to respect their autonomy (or dignity, etc.). We discuss potential recommendations to minimize gun violence while protecting the rights of individuals to purchase a firearm if they meet the necessary and reasonable regulatory requirements. Most of the gun control regulations discussed in this article could provide an opportunity to ensure the safety of communities without unduly infringing on the right to keep a firearm.

Consequentialism

Consequentialism is the view that we should promote the common good even if doing so infringes upon some people’s (apparent) rights. The case for gun regulation under this theory is made by showing how many lives it would save. Utilitarianism, a part of consequentialist approach proposes actions which maximize happiness and the well-being for the majority while minimizing harm. Utilitarianism is based on the idea that a consequence should be of maximum benefit ( Holland, 2014 ) and that actions are right in proportion as they tend to promote happiness as the ultimate moral norm. If one believes that the moral purpose of public health is to make decisions that will produce maximal benefits for most affected, remove or prevent harm and ensure equitable distribution of burdens and benefits ( Bernheim and Childress, 2013 ), they are engaging in a utilitarian theory. Rights, including the rights to bear arms, are protected so long as they preserve the greater good. However, such rights can be overridden or ignored when they conflict with the principle of utility; that is to say, if greater harm comes from personal possession of a firearm, utilitarianism is often the ethical theory of choice to restrict access to firearms, including interventions that slow down access to firearms such as requiring a gun locker at home. However, it is important to note that utilitarians might also argue that one has to weigh how frustrating a gun locker would be to people who like to go recreationally hunting. Or how much it would diminish the feeling of security for someone who knows that if a burglar breaks in, it might take several minutes to fumble while inputting the combination on their locker to access their gun.

Using a utilitarian approach, current social statistics show that firearm violence affects a great number of people, and firearm-related fatalities and injuries threaten the utility, or functioning of another. Therefore, certain restrictions or prohibitions on firearms can be ethically justifiable to prevent harm to others using a utilitarian approach. Similarly, the infringement of individual freedom could be warranted as it protects others from serious harm. However, one might argue that a major flaw in the utilitarian argument is that it fails to see the benefit of self-defense as a reasonable benefit. Utilitarianism as a moral theory would weigh the benefits of proposed restrictions against its costs, including its possible costs to a felt sense of security on the part of gun owners. A utilitarian argument that neglects some of the costs of regulations wouldn’t be a very good argument.

One might legitimately argue that if an individual is buying a firearm, whether for protection or recreation, they are morally responsible to abide by the laws and regulations regarding purchasing that firearm and ensuring the safety of others in the society. Additionally, vendors and licensing/enforcement authorities would have the responsibility to ensure the safety of the rest of the society by ensuring that the firearm purchase does not compromise the safety of the community. Most people who own firearms would not argue against this position. However, arguments in support of measures that will reduce the availability of firearms center around freedom and liberty and are not as well tolerated by those who argue from a libertarian starting point. Further, this would stipulate that measures against firearm purchase or use impinge upon the rights of individuals who have the freedom to pursue what they perceive as good ( Holland, 2014 ). However, it seems as though the state has a fundamental duty to help ensure an adequate degree of safety for its citizens, and it seems that the best way to do that is to limit gun ownership.

Promoting the Common Good

A well-organized society that promotes the common good of all is to everyone’s advantage ( Ruger, 2015 ). In addition, enabling people to flourish in a society includes their ability to be healthy. The view of common good consists of ensuring the welfare of individuals considered as a group or the public. This group of people are presumed to have a common interest in protection and preservation from harms to the group ( Beauchamp, 1985 ). Health and security are shared by members of a community, and guns are an attempt to privatize public security and safety, and so is antithetical to the common good. Can one really be healthy or safe in a society where one’s neighbors are subject to gun violence? Maybe not, and so then this violence is a threat to one’s life too. If guns really are an effective means of self-defense, they help one defend only oneself while accepting that others in one’s community might be at risk. One might also argue that the more guns there are, the more that society accepts the legitimacy of gun ownership and the more that guns have a significant place in culture etc., and consequently, the more that there is likely to be a problem.

Trivigno (2018) suggests that the willingness to carry a firearm indicates an intention to use it if the need arises and Branas et al (2009) argue that perpetually carrying a firearm might affect how individuals behave ( Trivigno, 2018 ; Branas et al. , 2009 ). When all things are equal, will prudence and a commitment to the flourishing of others prevail? Trivigno (2013) wonders if such behaviors as carrying or having continual access to a firearm generates mistrust or triggers fear of an unknown armed assailant, allowing for aggression or anger to build; the exact opposite of flourishing ( Trivigno, 2013 ). One could suggest, then, that the recreational use of firearms is also commonly vicious. Many people use firearms to engage in blood sport, killing animals for their own amusement. For example, someone who kicks puppies or uses a magnifying glass to fry ants with the sun seems paradigmatically vicious; why not think the same of someone who shoots deer or rabbits for their amusement?. Firearm proponents might suggest that the fidelity (living out one’s commitments) or justice, which Aristotle holds in high regard, could justify carrying a firearm to protect one’s life, livelihood, or loved ones insofar as it would be just of a person to defend and protect the life of another or even one’s own life when under threat by one who means to do harm. Despite an argument justifying the use of a firearm against another for self-defense after the fact, the action might not have been right when evaluated through the previous rationale, or applying the doctrine of double effect as described by Aquinas’ passage in the Summa II-II, which mentions that self-defense is quite different than taking it upon one’s self to mete out justice ( Schlabach, n.d. ). The magistrate is charged with seeing that justice is done for the common good. At best, if guns really are an effective means of self-defense, they help one defend only oneself while accepting that others in one’s community might be at risk. They take a common good, the health and safety of the community, and make it a private one. For Aquinas and many other modern era ethicists, intention plays a critical part in judgment of an action. Accordingly, many who oppose any ownership of firearms do so in both a paternalistic fashion (one cannot intend harm if they don’t have access to firearms) and virtuous fashion (enabling human flourishing).

Classical formulations of the double doctrine effect include necessity and proportionality conditions. So, it’s wrong to kill in self-defense if you could simply run away (without giving up something morally important in doing so), or to use deadly force in self-defense when someone is trying to slap you. One thing the state can do, in its role of promoting the common good, is to reduce when it is necessary to use self-defense. If there were no police at all, then anyone who robs you without consequence will probably be back, so there’s a stronger reason to use deadly force against them to feel secure. That’s bad, because it seems to allow violence that truly isn’t necessary because no one is providing the good of public security. So, one role of the state is to reduce the number of cases in which the use of deadly force is necessary for our safety. Since most homicides in the United State involve a firearm, one way to reduce the frequency of cases in which deadly force is necessary for self-defense is to reduce the instances of gun crime.

We have attempted to lay the empirical and ethical groundwork necessary to support various interventions, and the recommendations aimed at curbing firearm violence that will be discussed in this next section. Specifically, by discussing the burden of the problem in its various forms (healthcare costs, disproportionate violence towards racial/ethnic minority groups, women, children, vulnerable populations and the lack of research) and the ethics theories public health finds most accessible, we can now turn our attention to well-known, evidence-based recommendations that could be supported by the blended ethics approach: rights-based theories, consequentialism and the common-good approach discussed.

Comprehensive, Universal Background Checks for Firearm Sales

Of the 17 million persons who submitted to a background check to purchase or transfer possession of a firearm in 2010, less than 0.5% were denied approval of purchase ( Federal Bureau of Investigation, 2014 ). At present, a background check is required only when a transfer is made by a licensed retailer, and nearly 40% of firearm transfers in recent years were private party transfers ( Miller et al. , 2017 ). As such, close to one-fourth of individuals who acquired a firearm within the last two years obtained their firearm without a background check ( Miller et al. , 2017 ). Anestis et al. , (2017) and Siegel et al. , (2019) evaluated the relationship between the types of background information required by states prior to firearm purchases and firearm homicide and suicide deaths ( Anestis et al. , 2017 ; Siegel et al. , 2019 ). Firearm homicide deaths appear lower in states checking for restraining orders and fugitive status as opposed to only conducting criminal background checks ( Sen and Panjamapirom, 2012 ). Similarly, suicide involving firearm were lower in states checking for a history of mental illness, fugitive status and misdemeanors ( Sen and Panjamapirom, 2012 ).

Research supports the evidence that comprehensive universal background checks could limit crimes associated with firearms, and enforcement of such laws and policies could prevent firearm violence ( Wintemute, 2019 ; Lee et al. , 2017 ). Comprehensive, universal background check policies that are applicable to all firearm transactions, including private party transfers, sales by firearm dealers and sales at firearm shows are justifiable using a blend of the ethics theories we have previously discussed. With the rights-based approach, one could still honor the right to own a firearm by a competent person while also enforcing the obligation of the firearm vendor to ensure only a qualified individual purchased the firearm. To further reduce gun crime, rather than ensure only the right people own guns, we can just reduce the number of guns owned overall. Consequentialism could be employed to ensure the protection of the most vulnerable such as victims of domestic violence and allowing a firearm vendor to stop a sale to an unqualified individual if they had a history of suspected or proven domestic violence. Also, having universal background checks that go beyond the bare minimum of assessing if a person has a permit, the legally required training, etc., but delving more deeply into a person’s past, such as the inclusion of a red flag ( Honberg, 2020 ), would be promoting the common good approach by creating the conditions for persons to be good and do good while propelling community safety.

Renewable License Before Buying and After Purchase of Firearm and Training Firearm Owners

At present, federal law does not require licensing for firearm owners or purchasers. However, state licensing laws fall into four categories: (1) permits to purchase firearms, (2) licenses to own firearms, (3) firearm safety certificates and (4) registration laws that impose licensing requirements ( Anestis et al. , 2015 ; Giffords Licensing, n.d. ). A study conducted in urban U.S. counties with populations greater than 200,000 indicated that permit-to-purchase laws were associated with 14% reduction in firearm homicides ( Crifasi et al. , 2018 ). In Connecticut, enforcing a mandatory permit-to-purchase law making it illegal to sell a hand firearm to anyone who did not have an eligible certificate to purchase firearms was associated with a reduction in firearm associated homicides ( Rudolph et al. , 2015 ). This also resulted in a significant reduction in the rates of firearm suicide rates in Connecticut ( Crifasi et al. , 2015 ). Conversely, the permit-to-purchase law was repealed in Missouri in 2007, which resulted in an increase of homicides with firearms and firearm suicides ( Crifasi et al. , 2015 ; Webster et al. , 2014 ). Similarly, two large Florida counties indicated that 72% of firearm suicides involved people who were legally permitted to have a firearm ( Swanson et al. , 2016 ). According to the study findings, a majority of those who were eligible to have firearms died from firearm-related suicide, and also had records of previous short-term involuntary holds that were not reportable legal events.

In addition to comprehensive, universal background checks for firearm purchases, licensing with periodic review requires the purchaser to complete an in-person application at a law enforcement agency, which could (1) minimize fraud or inaccuracies and (2) prevent persons at risk of harming themselves or others to purchase firearms ( Crifasi et al. , 2019 ). Subsequent periodic renewal could further reduce crimes and violence associated with firearms by helping law enforcement to confirm that a firearm owner remains eligible to possess firearms. More frequent licensure checks through periodic renewals could also facilitate the removal of firearms from individuals who do not meet renewal rules.

Further, including training on gun safety and shooting with every firearm license request could also be beneficial in reducing gun violence. In Japan, if you are interested in acquiring a gun license, you need to attend a one-day gun training session in addition to mental health evaluation and background check ( Alleman, 2000 ). This training teaches future firearm owners the steps they would need to follow and the responsibilities of owning a gun. The training completes with passing a written test and achieving at least a 95% accuracy during a shooting-range test. Firearm owners need to retake the class and initial exam every three years to continue to have their guns. This training and testing have contributed to the reduction in gun related deaths in Japan. Implementing such requirements could reduce gun misuses. Even though, this is a lengthy process, it could manage and reduce the risks associated with firearm purchases and will support a well-regulated firearm market. While some may argue that other forms of weapons could be used to inflict harm, reduced access to firearms would lead to a significant decrease in the number of firearm-related injuries in the United States.

From an ethics perspective, again, all three theories could be applied to the recommendation for renewable licenses and gun training. From a rights-based perspective, renewable licensure and gun training would still allow for the right to bear arms but would ensure that the right belongs with qualified persons and again would allow the proper state agency to exercise its responsibility to its citizens. Additionally, a temporary removal of firearms or prohibiting firearm purchases by people involuntarily detained in short-term holds might be an opportunity to ensure people’s safety and does so without unduly infringing on the Second Amendment rights. Renewable licenses and gun training create opportunities for law enforcement to step in periodically to ascertain if a licensee remains competent, free from criminal behavior or mental illness, which reduces the harm to the individual and to the community—a tidy application of consequentialism. Again, by creating the conditions for people to be good, we see an exercise of the common good.

Licensing Firearm Dealers and Tracking Firearm Sales

In any firearm transfer or purchase, there are two parties involved: the firearm vendor and the individual purchaser. Federal law states that “it shall be unlawful for any person, except for a licensed importer, licensed manufacturer, or licensed dealer, to engage in the business of importing, manufacturing, or dealing in firearms, or in the course of such business to ship, transport, or receive any firearm in interstate or foreign commerce” (18 U.S.C. 1 922(a)(1)(A)(2007). All firearm sellers must obtain a federal firearm license issued by the Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF). However, ATF does not have the complete authority to inspect firearm dealers for license, revoke firearm license, or take legal actions against sellers providing firearms to criminals ( Vernick and Webster, 2007 ). Depending on individual state laws, typically the firearm purchaser maintains responsibility in obtaining the proper license for each firearm purchase whereas the justice system has the responsibility to enforce laws regulating firearm sales. Firearm manufacturers typically sell their products through licensed distributors and dealers, or a primary market (such as a retail store). Generally, firearms used to conduct a crime (including homicide) or to commit suicide are the product of secondary markets ( Institute of Medicine, 2003 ) such as retail secondhand sales or private citizen transfers/sales. Such secondary firearm transfers are largely unregulated and allow for illegal firearm purchases by persons traditionally prohibited from purchasing in the primary market ( Vernick and Webster, 2007 ; Chesnut et al. , 2017 ).

According to evidence from Irvin et al. (2014) in states that require licensing for firearm dealers and/or allow inspections, the reported rates of homicides were lower ( Irvin et al. , 2014 ). Specifically, after controlling for race, urbanicity, poverty level, sex, age, education level, drug arrest rate, burglary rates and firearm ownership proxy, the states that require licensing for firearm dealers reported ~25% less risk of homicides, and the states that allow inspection reported ~35% less risk of homicides ( Irvin et al. , 2014 ). This protective effect against homicides was stronger in states that require both licensing and inspections compared to states that require either alone. The record keeping of all firearm sales is important as it facilitates police or other authorized inspectors to compare a dealer’s inventory with their records to identify any secondary market transactions or other discrepancies ( Vernick et al. , 2006 ). According to Webster et al. (2006) , a change in firearm sales policy in the firearm store that sold more than half of the firearms recovered from criminals in Milwaukee, resulted in a 96% reduction in the use of recently sold firearms in crime and 44% decrease in the flow of new trafficked firearms in Milwaukee ( Webster et al. , 2006 ).

The licensing of firearm vendors and tracking of firearm sales sits squarely as a typical public health consequentialist argument; in order to protect the community, an individual’s right is only minimally infringed upon. An additional layer, justifiable by consequentialism, includes a national repository of all firearm sales which can be employed to minimize the sale of firearms on the secondary market and dealers could be held accountable for such ‘off-label’ use ( FindLaw Attorney Writers, 2016 ). Enforcing laws, mandating record keeping, retaining the records for a reasonable time and mandating the inspection of dealers could help to control secondary market firearm transfers and minimize firearm-related crimes and injuries.

One could argue from a rights perspective that routine inspections and record keeping are the responsibility of both firearms vendors and law enforcement, and in doing so, still ensure that competent firearm owners can maintain their rights to bear arms. In Hume’s discussion of property rights, he situates his argument in justice; and that actions must be virtuous and the motive virtuous ( Hume, 1978 ). Hume proposes that feelings of benevolence don’t form our motivation to be just. We tend (perhaps rightly) to feel stronger feelings of benevolence to those who deserve praise than to those who have wronged us or who deserve the enmity of humanity. However, justice requires treating the property rights or contracts of one’s enemies, or of a truly loathsome person, as equally binding as the property rights of honest, decent people. Gun violence disproportionately impacts underserved communities, which are same communities impacted by social and economic injustice.

Standardized Policies on Safer Storage for Firearms and Mandatory Education

Results from a cross-sectional study by Johnson and colleagues showed that about 14-30% of parents who have firearms in the home keep them loaded, while about 43% reported an unlocked firearm in the home ( Johnson et al. , 2006 ; Johnson et al. , 2008 ). The risk for unintentional fatalities from firearms can be prevented when all household firearms are locked ( Monuteaux et al. , 2019 ). Negligent storage of a firearm carries various penalties based on the individual state ( RAND, 2018 ). For example, negligent storage in Massachusetts is a felony. Mississippi and Tennessee prohibit reckless or knowingly providing firearms to minors through a misdemeanor charge, whereas Missouri and Kentucky enforce a felony charge. Also, Tennessee makes it a felony for parents to recklessly or knowingly provide firearms to their children ( RAND, 2018 ).

While a competent adult may have a right to bear arms, this right does not extend to minors, even in recreational use. Many states allow for children to participate in hunting. Wisconsin allows for children as young as 12 to purchase a hunting license, and in 2017 then Governor Scott Walker signed into law a no age minimum for a child to participate in a mentored hunt and to carry a firearm in a hunt when accompanied by an adult ( Wisconsin Department of Natural Resources, 2020 ). The minor’s ‘right’ to use a firearm is due in part to the adult taking responsibility for the minor’s safety. As such, some have argued that children need to know how to be safe around firearms as they continue to be one of the most pervasive consumer products in the United States ( Violano et al. , 2018 ).

In addition to locking firearms, parents are also encouraged to store firearms unloaded in a safe locked box or cabinet to prevent children’s access to firearms ( Johnson et al. , 2008 ). It follows then that reducing children and youth’s access to firearm injuries involves complying with safe firearm storage practices ( McGee et al. , 2003 ). In addition to eliminating sources of threat to the child, it is also important for children to be trained on how to safely respond in case they encounter a firearm in an unsupervised environment. Education is one of the best strategies for firearm control, storage and reduction of firearm-related injuries via development of firearm safety trainings and programs ( Jones, 1993 ; Holly et al. , 2019 ). Adults also need firearm safety education and trainings; as such, inclusion of firearm safety skills and trainings in the university-based curriculum and other avenues were adults who use guns are likely to be, could also mitigate firearm safety issues ( Puttagunta et al. , 2016 ; Damari et al. , 2018 ). Peer tutoring could also be utilized to provide training in non-academic and social settings.

Parents have a duty to protect their children and therefore mandating safe firearm storage, education and training for recreational use and periodic review of those who are within the purview of the law. Given that someone in the U. S. gets shot by a toddler a little more frequently than once a week ( Ingraham, 2017 ), others might use a utilitarian argument that limiting a child’s access to firearms minimizes the possibility of accidental discharge or intentional harm to a child or another. Again, the common good approach could be employed to justify mandatory safe storage and education to create the conditions for the flourishing of all.

Firearm and Ammunition Buy-Back Programs

Firearm and ammunition buy-back programs have been implemented in several cities in the United States to reduce the number of firearms in circulation with the ultimate goal of reducing gun violence. The first launch in Baltimore, Maryland was in 1974. The Los Angeles Police Department (LAPD) has conducted a gun buy-back program for nearly eight years to remove more guns off the streets and improve security in communities. Currently there is a plan for a federal gun buy-back program in the United States. The objective of such programs is to reduce gun violence through motivating marginal criminals to sell their firearms to local governments, encourage law-abiding individuals to sell their firearms available for theft by would-be criminals, and to reduce firearm related suicide resulting from easy access to a gun at a time of high emotion ( Barber and Miller, 2014 ).

According to Kuhn et al. (2002) and Callahan et al. (1994) , gun buy-back programs are ineffective in reducing gun violence due to two main facts: 1- the frequently surrendered types of firearms are typically not involved in gun-related violence and 2- the majority of participants in gun buyback programs are typically women and older adults who are not often involved in interpersonal violence ( Kuhn et al. , 2002 ; Callahan et al. , 1994 ). However, as a result of implementation of the ‘‘good for guns’’ program in Worcester, Massachusetts, there has been a decline in firearm related injuries and mortality in Worcester county compared to other counties in Massachusetts ( Tasigiorgos et al. , 2015 ). Even though, there is limited research indicating a direct link between gun buy-back programs and reduction in gun violence in the United States, a gun buy-back program implemented in Australia in combination with other legislations to reduce household ownership of firearms, firearm licenses and licensed shooters was associated with a rapid decline in firearm related deaths in Australia ( Bartos et al. , 2020 ; Ozanne-Smith et al. , 2004 ).

The frequency of disparities in firearm-related violence, injuries and death makes it a central concern for public health. Even though much has been said about firearms and its related injuries, there continues to be an interest towards its use. Some people continue to desire guns due to fear, feeling of protection and safety, recreation and social pressure.

Further progress on reforms can be made through understanding the diversity of firearm owners, and further research is needed on ways to minimize risks while maximizing safety for all. Although studies have provided data on correlation between firearm possession and violence ( Stroebe, 2013 ), further research is needed to evaluate the interventions and policies that could effectively decrease the public health burden of firearm violence. Evidence-based solutions to mitigating firearm violence can be justified using three major public health ethics theories: rights-based theories, consequentialism and common good. The ethical theories discussed in this paper can direct implementation of research, policies, laws and interventions on firearm violence to significantly reduce the burden of firearm violence on individuals, health care systems, vulnerable populations and the society-at-large. We support five major steps to achieve those goals: 1. Universal, comprehensive background checks; 2. Renewable license before and after purchase of firearm; 3. Licensing firearm dealers and tracking firearm sales; 4. Standardized policies on safer storage for firearms and mandatory education; and 5. Firearm buy-back programs. For some of the goals we propose, there might be a substantial risk of non-compliance. However, we hope that through education and sensibilization programs, overtime, these goals are not met with resistance. By acknowledging the proverbial struggle of individual rights and privileges paired against population health, we hope our ethical reasoning can assist policymakers, firearm advocates and public health professionals in coming to shared solutions to eliminate unnecessary, and preventable, injuries and deaths due to firearms.

The conducted research is not related to either human or animal use.

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Violano , P. , Bonne , S. , Duncan , T. , Pappas , P. , Christmas , A. B. , Dennis , A. , Goldberg , S. , Greene , W. , Hirsh , M. , Shillinglaw , W. , Robinson , B. and Crandall , M. ( 2018 ). Prevention of Firearm Injuries With Gun Safety Devices and Safe Storage: An Eastern Association for the Surgery of Trauma Systematic Review . The Journal of Trauma and Acute Care Surgery , 84 , 1003 – 1011 .

Webster , D. W. , Vernick , J. S. and Bulzacchelli , M. T. ( 2006 ). Effects of a Gun Dealer’s Change in Sales Practices on the Supply of Guns to Criminals . Journal of Urban Health , 83 , 778 – 787 .

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Crime and Violence

Neighborhood and Built Environment

About This Literature Summary

This summary of the literature on Crime and Violence as a social determinant of health is a narrowly defined examination that is not intended to be exhaustive and may not address all dimensions of the issue. Please note, the terminology used in each summary is consistent with the respective references. For additional information on cross-cutting topics, please see the Incarceration literature summary. 

Related Objectives (5)

Here's a snapshot of the objectives related to topics covered in this literature summary. Browse all objectives .

• Reduce the rate of minors and young adults committing violent crimes — AH‑10
• Reduce nonfatal physical assault injuries — IVP‑10
• Reduce firearm-related deaths — IVP‑13
• Reduce adolescent sexual violence by anyone — IVP‑17
• Reduce sexual or physical adolescent dating violence — IVP‑18

Related Evidence-Based Resources (4)

Here's a snapshot of the evidence-based resources related to topics covered in this literature summary. Browse all evidence-based resources .

• Intimate Partner Violence, Elder Abuse, and Abuse of Vulnerable Adults: Screening
• Suicide and Violence Prevention
• Resources for Action for Violence Prevention
• Violence Prevention: School-Based Programs

Literature Summary

Any person can be affected by crime and violence either by experiencing it directly or indirectly, such as witnessing violence or property crimes in their community or hearing about crime and violence from other residents. 1 While crime and violence can affect anyone, certain groups of people are more likely to be exposed. For example, the national homicide rate is consistently higher for Black adolescents and young adults than their White counterparts. 2 Low-income neighborhoods are more likely to be affected by crime and property crime than high-income neighborhoods. 3 Types of violence include, but are not limited to, child abuse and neglect, firearm violence, intimate partner violence, sexual violence, and elder abuse. 4 In addition to the potential for death, disability, and other injuries, people who survive violent crime endure physical pain and suffering and may also experience mental distress and reduced quality of life. 5 , 6 Specific examples of detrimental health effects from exposure to violence and crime include asthma, hypertension, cancer, stroke, and mental disorders. 7  

Individuals can experience different types of violence throughout the lifespan, and the negative health effects of violence can occur at any age. Decades of research has established a connection between adverse childhood experiences (ACEs) such as violence or abuse and lifelong health outcomes, including chronic disease and mental disorders. 8 Children can be exposed to violence such as bullying or cyberbullying, abuse, or witnessing violence in a variety of settings, including at home or school, online, or in their neighborhoods. 9 Children and adolescents exposed to violence are at risk for poor long-term behavioral and mental health outcomes, such as depression, anxiety, and post-traumatic stress disorder, regardless of whether they are victims, direct witnesses, or hear about the crime. 10 , 11 Research has also shown an association between exposure to violence in childhood and an increased likelihood of experiencing intimate partner violence as an adult. 12 , 13  

In adulthood, exposure to violence can also lead to poor health outcomes. For example, women exposed to intimate partner violence have an increased risk of physical health issues such as injuries and mental disorders such as disordered eating, depression, and suicidal ideation. 14 Older adults can also experience violence, including elder abuse or intimate partner violence. 15 Evidence shows that older adults who experience elder abuse are more likely to experience increased stress and depression or develop fear and anxiety than those who do not experience elder abuse. 16

There are serious short- and long-term health effects from exposure to crime and violence in one’s community. For example, one study found an association between gun-related violent crime in a neighborhood and a reduction in park use and park-based physical activity. 17 Higher rates of neighborhood safety fears may lead to poorer self-rated physical and mental health. 18 One study also found that higher rates of neighborhood crime were associated with increased odds for adverse pregnancy outcomes in Chicago. 19 Community gun violence, which generally occurs in public spaces between non-related individuals, is a specific kind of violence that disproportionately affects Black and Hispanic/Latino communities. 20 One study conducted in 4 U.S. cities found that people who were exposed to gun violence fatalities experienced higher levels of depression and suicidal ideation than those who were not exposed. 21

Addressing exposure to crime and violence as a public health issue may help prevent and reduce the harms to individual and community health and well-being. Public health strategies to address crime and violence focus on building resilience and reducing susceptibility, building healthy gender norms, developing healthy relationships, and creating protective environments. 7 The Community Preventive Services Task Force (CPSTF) recommends universal school-based programs that focus on skill-building related to emotional self-awareness and control, social problem-solving, and teamwork to reduce or prevent violent behavior among school-aged children. Besides schools, other places where violence interventions occur are hospitals. Hospital-based violence intervention programs that involve screening and intensive case management have been shown to be successful and cost-effective in reducing violent injury recidivism. 22 , 23 Much of the evidence on strategies to prevent and reduce crime and violence focus on children and adolescents. Additional research and interventions are needed to address crime and violence throughout the entire life course.

Hartinger-Saunders, R. M., Rine, C. M., Nochajski, T., & Wieczorek, W. (2012). Neighborhood crime and perception of safety as predictors of victimization and offending among youth: A call for macro-level prevention and intervention models. Children and Youth Services Review, 34 (9), 1966–1973.

Sheats, K. J., Irving, S. M., Mercy, J. A., Simon, T. R., Crosby, A. E., Ford, D. C., Merrick, M. T., Annor, F. B., & Morgan, R. E. (2018). Violence-related disparities experienced by black youth and young adults: Opportunities for prevention. American Journal of Preventive Medicine, 55 (4), 462–469. doi:  10.1016/j.amepre.2018.05.017

Kang, S. (2016). Inequality and crime revisited: Effects of local inequality and economic segregation on crime. Journal of Population Economics, 29 (2), 593–626. 

Centers for Disease Prevention and Control. (2021, September 28). Violence prevention . https://www.cdc.gov/violenceprevention/

Krug, E. G., Mercy, J. A., Dahlberg, L. L., & Zwi, A. B. (2002). The world report on violence and health. Lancet, 360 (9339), 1083–1088.

McCollister, K. E., French, M. T., & Fang, H. (2010). The cost of crime to society: New crime-specific estimates for policy and program evaluation. Drug and Alcohol Dependence, 108 (1–2), 98–109. doi: 10.1016/j.drugalcdep.2009.12.002

American Public Health Association. (2018, November 3). Violence is a public health issue: Public health is essential to understanding and treating violence in the U.S. https://apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2019/01/28/violence-is-a-public-health-issue

Metzler, M., Merrick, M. T., Klevens, J., Ports, K. A., & Ford, D. C. (2017). Adverse childhood experiences and life opportunities: Shifting the narrative. Children and Youth Services Review, 72 , 141–149.

Moffitt, T. E., & Klaus-Grawe 2012 Think Tank. (2013). Childhood exposure to violence and lifelong health: Clinical intervention science and stress-biology research join forces. Development and Psychopathology, 25 (4 Pt 2):1619–1634. doi:  10.1017/S0954579413000801

Jones-Webb, R., & Wall, M. (2008). Neighborhood racial/ethnic concentration, social disadvantage, and homicide risk: An ecological analysis of 10 U.S. cities. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 85( 5), 662–676. doi:  10.1007/s11524-008-9302-y

Fowler, P. J., Tompsett, C. J., Braciszewski, J. M., Jacques-Tiura, A. J., & Baltes, B. B. (2009). Community violence: A meta-analysis on the effect of exposure and mental health outcomes of children and adolescents. Development and Psychopathology, 21 (1), 227–259. doi:  10.1017/S0954579409000145

Beyer, K., Wallis, A. B., & Hamberger, L. K. (2015). Neighborhood environment and intimate partner violence: A systematic review. Trauma, Violence & Abuse, 16 (1), 16–47. doi:  10.1177/1524838013515758

Raghavan, C., Mennerich, A., Sexton, E., & James, S. E. (2006). Community violence and its direct, indirect, and mediating effects on intimate partner violence. Violence Against Women, 12 (12), 1132–1149. doi:  10.1177/1077801206294115

Stockman, J. K., Hayashi, H., & Campbell, J. C. (2015). Intimate partner violence and its health impact on ethnic minority women. Journal of Women’s Health, 24 (1), 62-79.

Rosen, T., Makaroun, L. K., Conwell, Y., & Betz, M. (2019). Violence In older adults: Scope, impact, challenges, and strategies for prevention. Health Affairs (Project Hope), 38 (10), 1630–1637. doi:  10.1377/hlthaff.2019.00577

Yunus, R. M., Hairi, N. N., & Choo, W. Y. (2019). Consequences of elder abuse and neglect: A systematic review of observational studies. Trauma, Violence & Abuse, 20 (2), 197–213. doi:  10.1177/1524838017692798

Han, B., Cohen, D. A., Derose, K. P., Li, J., & Williamson, S. (2018). Violent crime and park use in low-income urban neighborhoods. American Journal of Preventive Medicine, 54 (3), 352–358. doi:  10.1016/j.amepre.2017.10.025

Meyer, O. L., Castro-Schilo, L., & Aguilar-Gaxiola, S. (2014). Determinants of mental health and self-rated health: A model of socioeconomic status, neighborhood safety, and physical activity. American Journal of Public Health, 104 (9), 1734–1741. doi:  10.2105/AJPH.2014.302003

Mayne, S. L., Pool, L. R., Grobman, W. A., & Kershaw, K. N. (2018). Associations of neighbourhood crime with adverse pregnancy outcomes among women in Chicago: Analysis of electronic health records from 2009 to 2013. Journal of Epidemiology and Community Health, 72 (3), 230–236. doi:  10.1136/jech-2017-209801

Centers for Disease Prevention and Control. (2021, May 4). Firearm violence prevention . https://www.cdc.gov/violenceprevention/firearms/fastfact.html

Smith, M. E., Sharpe, T. L., Richardson, J., Pahwa, R., Smith, D., & DeVylder, J. (2020). The impact of exposure to gun violence fatality on mental health outcomes in four urban U.S. settings. Social Science & Medicine (1982), 246 , 112587. doi:  10.1016/j.socscimed.2019.112587

Juillard, C., Cooperman, L., Allen, I., Pirracchio, R., Henderson, T., Marquez, R., Orellana, J., Texada, M., & Dicker, R. A. (2016). A decade of hospital-based violence intervention: Benefits and shortcomings. Journal of Trauma and Acute Care Surgery, 81 (6), 1156–1161. doi:  10.1097/TA.0000000000001261

Juillard, C., Smith, R., Anaya, N., Garcia, A., Kahn, J. G., & Dicker, R. A. (2015). Saving lives and saving money: Hospital-based violence intervention is cost-effective. Journal of Trauma and Acute Care Surgery, 78 (2), 252–258. doi:  10.1097/TA.0000000000000527

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Violence, violence prevention, and safety: A research agenda for South Africa

Catherine L Ward, Lillian Artz, Julie Berg, Floretta Boonzaier, Sarah Crawford-Browne, Andrew Dawes, Donald Foster, Richard Matzopoulos, Andrew Nicol, Jeremy Seekings, Arjan B (Sebastian) van As, Elrena van der Spuy

Violence is a serious problem in South Africa with many effects on health services; it presents complex research problems and requires interdisciplinary collaboration. Two key meta-questions emerge: ( i ) violence must be understood better to develop effective interventions; and ( ii ) intervention research (evaluating interventions, assessing efficacy and effectiveness, how best to scale up interventions in resource-poor settings) is necessary. A research agenda to address violence is proposed.

S Afr Med J 2012;102:215-218.

All the authors are associated with the Safety and Violence Initiative at the University of Cape Town, and Catherine Ward, Floretta Boonzaier, Andrew Dawes and Donald Foster also with the Department of Psychology; Lillian Artz with the Gender, Health and Justice Research Unit; Julie Berg and Elrena van der Spuy with the Centre of Criminology; Sarah Crawford-Browne with the Primary Health Care Directorate; Richard Matzopoulos with the School of Public Health and Family Medicine, and the Medical Research Council’s Burden of Diseases Research Unit; Andrew Nicol and Sebastian van As with the Department of Surgery; and Jeremy Seekings with the Centre for Social Science Research.

Corresponding author: C L Ward ([email protected])

Interpersonal violence is the leading cause of injury in South Africa, and the homicide rate is over seven times the global average. 1 Studies have identified risk factors 2 and effective interventions to prevent violence. 4 We suggest a research agenda that can support and extend this work, by attending to South Africa’s unique situation.

The ecological model, a standard in public health and violence prevention (Fig. 1), views individuals as nested within interactive systems. Individual characteristics influence risk and protective factors that may increase or decrease the risk of aggression and exposure to violence. Microsystems are where daily interactions shape their behaviour most closely; exosystems comprise contexts that affect the lives of families, their neighbourhoods, extended family systems, and services; and the macrosystem comprises more distal influences such as government policies, norms and ideologies, and the economy.

Individuals and violence

Individuals are considered from two perspectives: factors that affect ( i ) the likelihood of aggressive behaviour, and ( ii ) the likelihood of victimisation. In relation to the first, Moffitt suggests a typology of offending: life-course-persistent offenders and adolescence-limited offenders. 5 The former start young and continue for life; evidence suggests that neuropsychological deficits (acquired in utero and/or in early childhood) that affect functions such as self-regulation set them on this path, compounded by unsupportive, conflictual parenting. 5 The conduct of adolescence-limited offenders is restricted to that developmental period and declines as they mature into adult roles of work and marriage. 5

South Africa has high proportions of children exposed to risks for neurological damage in early life: the prevalence of fetal alcohol spectrum disorders is the highest in the world; 6 ,7 22.5% of children aged 1 - 9 years were stunted or wasted; 8 and we have high rates of domestic violence and child maltreatment. 9 ,10 These can all alter neurochemistry and result in aggression. 11 , 12 Such children may have learning disabilities 13 that if not identified or adequately addressed may cause them to disconnect from school and increase the possibility of delinquent behaviours. 14 Low-cost screening and cost-effective interventions are urgently needed.

A mechanism for reducing harm to others may be the development of a pro-social orientation termed ‘empathy-based guilt’ associated with harmful transgressions. 15 Children who learn to attend to the harm caused by an action and have a moral rationale for avoiding such harm are likely to internalise orientations to victims that reduce the probability of aggression. We found no studies of South African children’s capacity for empathy, or of factors that influence its development or its role in aggression. Studies to understand and determine suitable interventions to enhance empathy are urgently needed.

Many young South Africans experience complex transitions to employment and the formation of an independent household, and transition to the social status of adulthood may be extended or never completed. 16 The impact of delayed attainment of adulthood on aggression and violent crime, and thereby the larger effect of economic forces (e.g. availability of employment) on individual aggression, should be studied.

Whether violence can be reduced by reducing the vulnerability of potential victims (rather than reducing the aggression of potential perpetrators) should also be explored. Risk for victimisation in South Africa is shaped by context, age and gender: men are more likely to be victims of non-sexual violent crime than women; living in urban environments increases risk; 17 youth are at greater risk than adults; 9 and young black men are at the greatest risk of homicide. 3 Vulnerability is also increased by relative authority or control that the perpetrator has over the victim; low self-esteem or inability to see that victimisation is not warranted; 18 lack of personal support structures; mental illness or mental disability; 18 , 19 learning disabilities; 20 dependence on the perpetrator (material or emotional); exposure to violence as children and violence over a lifetime; 21 , 22 , 23 and substance misuse. 24 How can people with these vulnerabilities be protected and strengthened?

Microsystem contexts

Families in which parents have warm relationships with their children, provide consistent discipline without being harsh, and supervise adequately are less likely to have aggressive children. 25 Where high rates of child maltreatment occur, 10 improving parenting must be a priority. Since only about half of South African children live with both biological parents, and even fewer do so consistently through childhood and adolescence, 26 this must include all caregivers. Research must develop effective, culturally appropriate parenting interventions that are low in cost and easily available to those who most need them. There are some promising interventions from other contexts, but none has been evaluated here, 27 nor have local interventions been evaluated.

Intimate partner violence is prevalent in South Africa. 3 We have insufficient knowledge about how to intervene effectively to reduce domestic violence. Locally and internationally there is no clear evidence that men’s violence has been reduced through participation in programmes for batterers. 28 , 29 There are some promising local alternatives, 30 , 31 but more research in this area is sorely needed.

Schools with clear missions and strong stances against violence have lower rates of bullying. 32 However, many South African schools are in disarray, 33 and over 50% of children report that corporal punishment is used for discipline, despite its being prohibited. 9 This is incongruous with promoting non-violence and pro-social behaviours, and school-based violence prevention programmes and policies must form part of the violence prevention agenda.

Much offending does not occur as a single incident with one offender and one victim; it is much more frequently the case that there is more than one offender (for instance, gang or group violence), or multiple acts of violence by one person, over a period of time, against another person (such as domestic violence or child sexual abuse). However, theories of victimisation and offending frequently fail to consider the cumulative effects of multiple victimisations or chronic offending over a lifetime. 34

Gangs, one form of a violent peer group, are a feature in South African violence. There are many international studies into effective policing and models for detaching young people from gangs, 35 but there is little local research into effective interventions.

Agendas to prevent young people from joining gangs and engaging in delinquency must include pro-social leisure opportunities after school. These can be effective in reducing many risk behaviours, but their mechanisms are little understood and this too needs investigation. 36

Exosystem contexts

Neighbourhood.

Children’s caregivers cannot do parenting in isolation, and their effective parenting is influenced by available social support. For poor parents in particular, this often means support in their neighbourhoods. 37 How neighbourhood quality can be improved to better support parenting and the influence of family and neighbourhood characteristics on the development of antisocial behaviour among South African children is also poorly understood. For instance, how do South African children draw on available support to negotiate safety in unsafe families or neighbourhoods? 38 Understanding these inter-relationships can assist in developing better interventions.

Strong neighbouring relationships may influence rates of crime, e.g. by not tolerating groups of young people ‘hanging out’ on corners. 39 However, how can neighbourhood crime prevention be strengthened without encouraging vigilantism? 40 This must include work on police-community relations, and how these affect crime and violence at the local level. 41 Neighbourhood-level data on violence are key to such research. The South African Police Service must recognise this and make their data available.

Patterns of violence within communities often differ, e.g. within low-income, high-violence neighbourhoods the victims frequently know the perpetrators, 4 2 unlike in affluent communities. What causes this, and what would be effective interventions for different forms of violence? Policing strategies, tailored to meet the challenges of specific communities, must be documented and evaluated. 43

Health services

Those affected by violence are at risk of related psychological and social costs and of secondary victimisation from the criminal justice and health systems and society. 4 4 This may lead to problems such as post-traumatic stress, substance abuse and aggressive responses. The latter make effective services for victims an important part of violence prevention. How can medical and psychological services best be provided? Evidence suggests that recovery from a traumatic experience requires physical or psychological safety. 45 As many South Africans live under continuous threat, it is important to investigate alternative pathways to recovery.

Health services are obvious places to screen for and provide services to reduce aggression, including interventions for substance misuse; promoting maternal health; improving parenting; reducing intimate partner violence; and early detection of child mental health problems associated with aggression. It is critical to investigate whether the state has the capacity to carry out this screening and intervention.

The health system can provide surveillance systems that assess the extent of violence, which are crucial to monitor interventions and to determine their efficacy. The National Injury Mortality Surveillance System (NIMSS) has an important role, 1 but many injuries do not result in death, and until a comprehensive injury surveillance system is established, part of the picture will be missing. Establishing a system that is simple to administer is an important area for research and for implementation.

Under Apartheid, public order policing was associated with use of force. 46 Since the setting up of constitutional democracy the right to participate in public demonstrations has been liberalised, the role of the police circumscribed and the principle of minimum force professed. 47 However, in the context of increased service delivery protests, police action has become less restrained, suggesting the need for vigilance to ensure application of their principles for strengthening rather than diluting the search for peaceful coexistence. 48

Clarification is required regarding the roles of the state (e.g. police) and of non-state entities (e.g. private security companies, street committees) in the governance of violence and crime. The non-state is actively involved in governing crime, sometimes duplicating the state and participating in activities beyond what are expected of the state. 41 , 49 More research must map the range of policing-type functions of non-state entities, and investigate the type of non-state/state collaborations and the effects on (un)safety. Normative questions also arise such as who the state (police) should be in relation to the increasing plurality of policing entities and how to regulate and hold to account new configurations of state/non-state governance while ensuring their effective contribution to decrease crime and unsafety. 52 , 53

Studies have implicated media violence 54 and values of sexism and materialism 55 , 56 portrayed in various media as playing a role in driving violence. Yet their mechanisms are poorly understood, and whether these relationships hold in the high-violence areas of South Africa requires investigation.

Macrosystem contexts

Social norms around violence.

Despite overviews according importance to a ‘culture of violence’, the role of norms has been neglected in violence studies in South Africa. 57 , 58 But there is little empirical basis for these claims, in contrast with the study of violence elsewhere. 4 Cultural and social norms may be divided into two categories: ( i ) violence is deemed legitimate by higher-status individuals (especially men) against lower-status individuals (such as children or women); 10 and ( ii ) the general attitude towards violence in society might consider violence legitimate to resolve disputes or conflicts. Norms may influence violence through shaping the behaviour of possible perpetrators or the behaviour of others present in situations that are conducive to violence, and whose complicity or opposition to the use of violence might serve as fuel or constraint. Investigating norms around violence in South Africa will help in understanding and intervening in relationships between the psychologies of masculinity and femininity, the sociology of opportunity, and the perpetration of violence.

Socio-economic factors

Evidence suggests that violence occurs at higher rates in societies with high levels of economic inequality. 59 Investigation is needed into whether this holds in South Africa, where violence seems to have increased alongside an increase in inequality, high unemployment and income poverty. 60 In high-income countries the relationship between inequality and violence appears to be driven by concerns about status and social exclusion, but there is no strong evidence for this here.

Government policies

There are a number of polices in place in South Africa that are intended to deal directly with violence, e.g. the Children’s Act No. 38 of 2005, the Domestic Violence Act No. 116 of 1998, the Sexual Offences Act No. 32 of 2007, and the Victim Empowerment Policy. The links between government, civil society and community-based organisations must be evaluated. This might encompass economic research investigating the human and financial resources to give effect to them, evaluations of existing programmes (do they reach those in need and provide effective services?), and implementation research on providing potentially large-scale programmes.

Some policies may indirectly affect violence. For instance, government policy is turning towards controlling the availability of alcohol to reduce violence and injuries. Research into understanding the relationship between alcohol and violence, which will drive an appropriate, integrated and comprehensive alcohol policy, is desperately needed. Similarly, careful thought must be given to the control and policing of illegal substances, as the illicit economy is a driver of violence. Evidence suggests that law enforcement interventions to disrupt drug markets are unlikely to reduce drug-related violence and instead result in higher gun violence and higher homicide rates. 61 Another government policy needing ongoing monitoring and evaluation is the Firearms Control Act (No. 60 of 2000). Since its implementation in 2004, firearm-related deaths have decreased, but whether this is clearly linked to the new policy needs further investigation.

This is a complex research agenda, within which are strands that might be considered ‘meta-questions’ that cannot rely solely on health professionals. Health professionals from several specialties all have a role to play in carrying out a comprehensive research agenda for violence prevention in South Africa. But the complex research problems that violence presents demand inter-disciplinary collaboration by the full range of social and human scientists: economists, educationalists, psychologists, sociologists, anthropologists, etc. Only in working together can these problems be sufficiently well understood and effective interventions developed.

Research to understand violence better might take several forms, e.g. understanding ‘norms’ of violence and how they link several drivers of violence, or understanding factors that influence child development for good or for ill. Intervention research may evaluate interventions and assess efficacy and effectiveness; and once effectiveness has been established, understanding how the intervention might be scaled up and retain that effectiveness. Related questions concern effective implementation of programmes in our poorly resourced settings, e.g. nurse home visitation programmes for the first 2 years of life in the USA reduce later youth violence, but rely on trained, expensive nurses. 62 Can such programmes retain their effectiveness if community health workers are employed instead of nurses?

This paper therefore lays out a comprehensive agenda for understanding violence and promoting safety in South Africa. There are many questions about violence that are as yet unanswered, and there are key roles for many different disciplines in answering them.

Author note. This paper grew out of discussions among the authors. C Ward led the discussions and writing of the paper; all others contributed equally, and authorship is given in alphabetical order to reflect the equality of contribution.

Financial support. The University of Cape Town’s Vice-Chancellor’s Strategic Fund.

Conflicts of interest. All authors confirm no potential conflicts of interest.

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Fig. 1. The ecological model.

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About The Public Health Approach to Violence Prevention

What to know.

• The focus of public health is on the health, safety, and well-being of entire populations.
• A public health approach strives to provide the maximum benefit for the largest number of people.
• The public health approach, rooted in the scientific method, can be applied to prevent violence as a four-step process.

Public health draws on a science base that is multi-disciplinary. It relies on knowledge from a broad range of disciplines including medicine, epidemiology, sociology, psychology, criminology, education, and economics. This broad knowledge base has allowed the field of public health to respond successfully to a range of health conditions across the globe.

The public health approach also emphasizes input from diverse sectors including health, education, social services, justice, policy, and the private sector. Collective action on the part of these key collaborators can help in addressing problems like violence.

Steps to take

The public health approach is a four-step process that is rooted in the scientific method. It can be applied to violence and other health problems that affect populations.

Step 1: Define and Monitor the Problem

The first step in preventing violence is to understand the “who,” “what,” “when,” “where,” and “how” associated with it. Grasping the magnitude of the problem involves analyzing data such as the number of violence-related behaviors, injuries, and deaths. Data can demonstrate how frequently violence occurs, where it occurs, trends, and who the victims and perpetrators are. These data can be obtained from police reports, medical examiner files, vital records, hospital charts, registries, population-based surveys, and other sources.

Step 2: Identify Risk and Protective Factors

It is not enough to know the magnitude of a public health problem. It is important to understand what factors protect people or put them at risk for experiencing or perpetrating violence. Risk factors are characteristics that increases the likelihood of a person becoming a victim or perpetrator of violence. Protective factors are characteristics that decreases the likelihood of a person becoming a victim or perpetrator of violence.

Risk and protective factors help identify where prevention efforts need to be focused. Risk factors do not cause violence. The presence of a risk factor does not mean that a person will always experience violence. Victims are never responsible for the harm inflicted upon them.

Step 3: Develop and Test Prevention Strategies

Findings from the research literature and data from needs assessments, community surveys, key collaborator interviews, and focus groups are useful for designing prevention strategies. Using these data and findings is known as an evidence-based approach to program planning. Once prevention strategies are developed or existing strategies are identified, they are then evaluated rigorously to determine their effectiveness.

Step 4: Assure Widespread Adoption

The strategies shown to be effective in step three are then implemented and adopted more broadly. Communities are encouraged to implement strategies based on the best available evidence and to continuously assess whether the strategy is a good fit with the community context and achieving its goal of preventing violence. Dissemination techniques to promote widespread adoption include training, networking, technical assistance, and evaluation.

• Dahlberg LL, Krug EG. Violence: a global public health problem. In: Krug E, Dahlberg LL, Mercy JA, Zwi AB, Lozano R, eds. World Report on Violence and Health. Geneva, Switzerland: World Health Organization; 2002:1-21.

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The Link Between Mental Illness and Firearm Violence: Implications for Social Policy and Clinical Practice

The United States has substantially higher levels of firearm violence than most other developed countries. Firearm violence is a significant and preventable public health crisis. Mental illness is a weak risk factor for violence despite popular misconceptions reflected in the media and policy. That said, mental health professionals play a critical role in assessing their patients for violence risk, counseling about firearm safety, and guiding the creation of rational and evidence-based public policy that can be effective in mitigating violence risk without unnecessarily stigmatizing people with mental illness. This article summarizes existing evidence about the interplay among mental illness, violence, and firearms, with particular attention paid to the role of active symptoms, addiction, victimization, and psychosocial risk factors. The social and legal context of firearm ownership is discussed as a preface to exploring practical, evidence-driven, and behaviorally informed policy recommendations for mitigating firearm violence risk.

1. INTRODUCTION

The United States is one of only three countries with a Constitutionally protected right to own firearms; of the three, it is the only one with minimal restrictions on that right ( Elkins 2013 ). With over 350 million privately owned firearms ( Ingraham 2015 ), the United States substantially exceeds all other countries in both per capita ownership of guns and absolute number of guns: Approximately 30% of all privately owned firearms in the world are in the hands of US residents ( Small Arms Surv. 2011 ).

The number of lives taken with guns also makes the United States exceptional. The US rate of suicide by firearm is 8 times higher and the rate of homicide by firearm is 25 times higher than the rates in other economically developed countries ( Grinshteyn & Hemenway 2016 ). Although mass shootings capture the news cycle on an all too frequent basis, the quotidian toll of gun-related violent crime, domestic violence (DV), and suicide shatters lives and erodes communities. Mass shootings generally account for 1% or less of all firearm violence, and suicides routinely take twice as many lives as homicides. The public health impact of firearms in the United States is staggering.

Popular media, meanwhile, does little to keep the problem in perspective. The common perceptions driven by news media are that gun violence and mass shootings are increasing and are at historically high levels. Firearm homicide rates have actually decreased despite widespread perceptions to the contrary ( Cohn et al. 2013 ). Estimates of increases in mass shootings, meanwhile, are tenuous at best. Although there has been some suggestion that the absolute number and frequency of these events may have seen a recent uptick ( Blair & Schweit 2014 , Schweit 2016 ), other studies suggest that mass shootings have maintained a relatively steady share of approximately 1% of US violence over the past century ( Duwe 2004 , Stone 2015 ).

A pernicious and false but increasingly common message promoted in the media is that people with mental illness are prone to violence in general and are responsible for mass shootings ( McGinty et al. 2014b , 2016b ). Studies consistently indicate that, even among mass murders and shootings, mental illness is a factor in a minority of these events ( Duwe 2004 , Fox & DeLateur 2014 , Stone 2015 , Taylor 2016 , Vossekuil et al. 2002 ). Nonetheless, the notion that mental illness drives these events is stoked regularly, and the impact of this trend in US media coverage of violence is so significant that it is now seen to be distorting perceptions even outside of the United States ( Jorm & Reavley 2014 ).

The notoriety given to mass shootings and the link made to mental illness have two effects. First, they promote stigma by conflating mental illness and violence—a bias that affects patients, providers, the public, and policy makers ( Clement et al. 2015 , Corrigan et al. 2005 , Price & Khubchandani 2016 ). Second, they distract the public and policy makers from dealing with the issues of violence and mental illness, and gun violence in particular, in an empirically grounded, frank way.

The simplistic model of mental illness driving mass shootings or violent crime leads to a simplistic, politically popular, but ineffectual policy solution: provide more mental health services ( Gold 2013 , Pinals et al. 2015 ). Who could reasonably be against that idea? Policy makers and politicians are attracted to this solution because it helps them avoid more complicated and politically treacherous debates about effective limits on gun ownership, tracking, or registration. Given the overloaded state of current mental health services, mental health professionals are certainly tempted to endorse this solution and to take such funds, even knowing that access to mental health services will have little impact on gun violence, mass shootings, or violence in general. Such Faustian bargains have foreseeable consequences, though, including increased stigma for mentally ill individuals and the diversion of necessary resources from better interventions ( Rozel 2016 ). Policies intending to mitigate gun violence risk by narrowly focusing on the narrow intersection between mental illness and mass shootings will be intrinsically limited in scope and utility and may potentially disrupt effective elements of the mental health system ( Appelbaum 2013 , Metzl & MacLeish 2015 ).

There are additional issues for mental health practitioners beyond the ethics and utility of endorsing funding for mental health services as a solution to gun violence. Firearm access and storage is a bona fide and legitimate focus of clinical concern in a number of cases on many practitioners’ caseloads. The mental health provider’s role in the direct management of firearm access and the overall burden of firearm violence should not be neglected. In addition, innovative policy proposals for regulating access to firearms often imply substantial involvement of mental health professionals in making judgments about the risk of an individual’s access to firearms or of the lifting of a provision prohibiting an individual’s access. As discussions about ways to limit the damage caused by gun violence expand, mental health professionals will likely be called upon more frequently to be part of proposed solutions regarding this issue.

At the outset, it must be recognized that the impact of firearms is highly varied: Injuries due to accidental discharge, suicide, homicide, and mass shootings have different risk factors and will entail different interventions to mitigate risk at individual and population levels. The topics of accidental shootings and suicides, though vitally important from a public health perspective and intriguing from an evidence-based medicine and policy perspective, is left for more in-depth analyses by other authors in other forums. This article addresses the intersection between mental illness and firearm violence and how the nature of that intersection frames clinical and policy interventions to mitigate the damage of gun violence. This review focuses on how scientific information can inform these efforts, but the ethical and legal aspects of working with a legally protected social determinant of a public health issue must also be considered in any policy analysis ( Childress et al. 2002 ).

2. MENTAL ILLNESS, VIOLENCE, AND GUN VIOLENCE

2.1. mental illness and violence.

A useful starting point for examining the relationship between mental illness and violence, particularly gun violence, is to look at this issue from a broad, population-based perspective. Epidemiological studies have shown an association between having a mental illness and being involved in crime or violence ( Elbogen & Johnson 2009 , Stuart 2003 , Tiihonen et al. 1997 , Walsh et al. 2002 ). Although the power of this link is greatly overestimated by the general public ( Pescosolido 2013 ), it has been documented repeatedly that people who report diagnosable levels of psychiatric symptoms also report more involvement in acts of violence toward others than the general population reports. An even stronger association emerges, however, between being a victim of violence and having a mental illness ( Desmarais et al. 2014 , Teplin et al. 2005 ), with individuals with mental illness at least three times more likely to be targets than to be perpetrators of violence ( Choe et al. 2008 ). Several studies have also indicated that, among people with severe psychiatric illness, recent violent victimization is one of the best predictors of imminent violence risk ( Hiday et al. 2001 , Johnson et al. 2016 , ten Have et al. 2014 ).

The most basic lesson of this epidemiological literature is that the overwhelming majority of people with mental illness are not violent and the majority of people who are violent do not have identifiable mental illness ( Choe et al. 2008 ). Because an overwhelming percentage of people with mental illness are not violent, and because the occurrence of serious mental illness is relatively low, it is estimated that only about 4% of criminal violence can reasonably be attributed to mentally ill individuals ( Metzl & MacLeish 2015 , Swanson 1996 ). This means that even if all of the association between mental illness and violence could somehow be eliminated, we would still have to confront 96% of the violence in the United States ( Swanson 2008 , 2015 ).

Studies exploring gun violence by people with mental illness are limited, likely due to the rarity of this type of violence. One study has shown that gun violence by people with severe mental illness occurs in 2% or less of patients in the year after discharge from inpatient settings; rates may be lower among less acute patients ( Steadman et al. 2015 ). Clearly, there is a fairly small nexus at the intersection of people who are mentally ill, armed, and potentially violent. Again, even if all of these individuals could be identified and stopped from engaging in gun violence, the impact on the overall level of gun violence would not be substantial. At a population level, it seems that the designation of being “mentally ill” does little to identify a useful group for targeted violence prevention policy.

From the results of group comparison studies, it is apparent that the estimated relationship between involvement in violence and the presence of a mental illness varies considerably depending on the type of disorder examined and the methodology used. Serious mental illnesses, such as schizophrenia and depression, generally show associations that are several times weaker than those seen in more behaviorally based diagnoses, such as substance abuse or antisocial personality disorders ( Elbogen & Johnson 2009 , Oakley et al. 2009 , Steadman et al. 1998 ). There is some evidence that individuals experiencing first-episode psychosis could be at elevated risk for involvement in violence, with levels of involvement about 3–5 times what might be expected ( Large & Nielssen 2011 , Winsper et al. 2013 ). In addition, meta-analyses show considerable variation among estimates of association related to study design features and evaluation of moderating risk factors ( Fazel et al. 2009 , Fazel & Yu 2009 , Witt et al. 2013 ). Although a majority of studies show an association between serious mental illnesses and subsequent arrests for violence, some field studies using self-report methods ( Lidz et al. 1993 , Monahan et al. 2001 ) show that individuals with serious mental illness alone have no higher likelihood of violence than their neighbors.

2.2. Substance Use and Violence

A number of studies identify substance use and substance use disorders as particularly strong factors increasing the chance that an individual with a mental illness will get involved in violence ( Mulvey et al. 2006 , Swanson et al. 1990 ). The self-report studies cited in the previous section ( Lidz et al. 1993 , Monahan et al. 2001 , Steadman et al. 1998 ) indicate that individuals diagnosed with both a mental illness and a substance use disorder have a higher prevalence of involvement in violence than their neighbors. Other investigations also indicate that increased levels of substance use are associated with increased likelihood of violence in patients in the community ( Skeem et al. 2004 ), and comorbid mental illness is often considered a critical risk factor for violence among people with substance use disorders ( Chen & Wu 2016 ). Illicit substance use is associated with firearm violence in particular, especially when that substance use is also associated with involvement in illegal drug sales ( McGinty et al. 2016a ). Another review has identified a series of intersections between violence risk and alcohol use, including alcohol intoxication as a risk factor for being shot, firearm suicide, and accidental firearm injury ( Branas et al. 2016 ).

2.3. Psychosocial Risk Factors and Violence

The literature on psychosocial risk factors for violence also indicates that certain characteristics of an individual, e.g., age, socioeconomic status, and prior criminal involvement, are much more statistically predictive of involvement in violence than the presence of a mental illness ( Bonta et al. 1998 ). The power of mental illness as a predictor diminishes greatly when these characteristics are taken into account ( Elbogen & Johnson 2009 , Prins et al. 2015 , Skeem et al. 2014 ). This is most likely the case because mental illness and mental deterioration are rarely seen as the major forces behind involvement in violence ( Mulvey et al. 2006 ). Most violent incidents involving individuals with a mental illness involve either a family member or a close acquaintance ( Newhill et al. 1995 , Steadman et al. 1998 ) and are usually embedded in a history of tumultuous encounters. Moreover, examination of crimes involving individuals with mental illness indicate that less than 20% of them are directly preceded by exacerbated symptoms of the illness ( Peterson et al. 2014 ). It is rare that the presence of a mental illness is a dispositive explanation for an act of violence ( Monahan & Steadman 2012 , Skeem et al. 2016 ). Mental illness is one factor in a person’s life that is sometimes relevant to involvement in violence, but it is very rarely the only factor, or even a causal factor.

A particularly salient social and contextual factor to consider for its relation to violence in mentally ill individuals is exposure to and involvement in DV. Assessment and screening for current or prior DV has become a standard of care in most clinical disciplines, and mental health professionals are regularly called on to provide interventions for offenders despite the relatively small impact of most DV interventions ( Babcock et al. 2004 ). An estimated 30% of patients in treatment have been victims of DV, with women with depression or anxiety at the highest risk ( Oram et al. 2013 , Trevillion et al. 2012 ). This issue is clearly within the purview of mental health care and offers an opportunity for the prevention of violence.

It is clear that the social dynamics of DV situations are particularly relevant to assessing and preventing patient violence. Violence involving people with mental illness—both as targets and as perpetrators—is far more likely to involve family members or acquaintances ( Buila & Marley 2001 , Estroff et al. 1998 ). Similarly, 90% of women who are murdered are killed by a person they know, and half of these are victims of a current or former partner or spouse ( Catalano et al. 2009 ). In contrast, a recent meta-analysis places the risk of being killed by a stranger with severe psychotic illness at 1 in 14 million per year ( Nielssen et al. 2011 ).

This review of the literature about the correlates of violence in individuals with mental illness highlights the importance of recognizing the social context surrounding an individual and fluctuations in the state of an individual’s illness. Categorization of individuals by illness appears to introduce a large amount of interindividual heterogeneity on factors relevant to the occurrence of violence, and as a result, the use of psychiatric diagnosis or symptom level alone has very limited utility as a tool for the prediction of violence risk ( Rozel et al. 2017 ). Numerous factors can increase violence risk in people with mental illness, including prior criminal or violent behavior, prior victimization, substance use and intoxication, nonadherence with treatment, and the presence of other psychosocial stressors such as economic distress and housing instability ( Swanson et al. 2014 ).

This reality calls for approaches to identifying individuals at risk in terms of their social context and fluctuations in their life situation and behavior over time ( Mulvey & Lidz 1995 ). Mental illnesses progress, deteriorate, stabilize, or get better with time and circumstance; they are a condition, not an indicator of a person’s unique dangerousness ( Adam 2013 ). Like pulmonary disorders or heart conditions, mental illness must be managed to avoid decompensation and the harm that might occur during those periods of decompensation. Approaches that frame risk as an interaction of both static (or set) aspects of a person (such as history of prior violence or victimization) and dynamic (or shifting over time) factors (such as level of substance use or decreased emotion regulation) align with the greater body of the research on the factors related to violence in individuals with and without mental illness ( Douglas & Skeem 2005 ). This framework can lead to actionable interventions to limit violence risk and address gun violence more effectively. However, any of these approaches would also present new challenges for mental health professionals.

3. THE SOCIAL AND LEGAL CONTEXT OF GUN OWNERSHIP IN THE UNITED STATES

3.1. gun ownership and gun owners.

Any meaningful framing of the problem of gun violence—and any hope of enacting meaningful interventions—must be rooted in an understanding of the social and legal context of gun ownership in the United States. Not examining and appreciating these influences would be a major oversight for those interested in designing interventions to limit the tragedies of gun violence. As demonstrated in many other areas, the gap between efficacy and effectiveness is often determined by the ground truth: where clinical professionals work and their patients live. Clinical and public health interventions to mitigate gun violence are no different: They will only succeed if they accommodate or overcome intrinsic legal or sociocultural barriers. Unfortunately, few topics are currently as politicized and polarizing as the gun control/gun rights debate. The emotional nature of this debate almost inevitably engenders strong and often extreme beliefs in both policy makers and the public, which may not accurately reflect research evidence or the likely effectiveness of particular interventions.

The first clear fact is that gun ownership is common. Although gun ownership by household seems to have declined over the past 30 years, rates remain above 30% ( Morin 2014 , Smith & Son 2015 ), with well over 300 million guns in private hands ( Ingraham 2015 ). Firearms can be easily acquired from licensed gun dealers or through private transfers, the latter often bypassing any opportunity for a background check. Moreover, gun ownership can be concentrated: Half of gun owners have four or more firearms ( Hepburn et al. 2007 ). Ownership rates vary significantly by a number of factors: by demographic characteristics of a locale, by state (from a low of 5.2% in Delaware to 61.7% in Alaska), and by self-identified affiliation with gun culture ( Kalesan et al. 2016 ). Most (60%) of gun owners identify self-defense as a reason for gun ownership, with hunting, sport, and target shooting also commonly endorsed ( Swift 2013 ).

There are also some clear patterns regarding the possible consequences of gun ownership. The number and rates of incidents of gun violence, especially firearm homicides, have been decreasing steadily over the past few decades ( Fowler et al. 2015 , Wintemute 2015 ). When researchers have examined relative accessibility—by, for example, comparing gun-owning household with non-gun-owning households or comparing states with high versus low gun ownership rates—they have found that elevated rates of gun access in households are associated with increased risk of homicide and suicide over time by household and at a population level ( Fowler et al. 2015 ; Kellermann et al. 1992 , 1993 ; Miller et al. 2002 , 2006 ). This is particularly important because access to firearms by DV perpetrators is a critical risk factor in DV-related homicides ( Campbell et al. 2003 ). In addition, a law enforcement officer in a state with a high gun ownership rate is three times as likely to be shot and killed during their work ( Swedler et al. 2015 ).

It should also be noted that high gun ownership rates do not appear to convey any meaningful protection against violent victimization at a population level. The idea that increased firearm ownership leads to decreased crime ( Lott 2010 , Plassmann & Whitley 2003 ) does not appear to hold up to rigorous analysis ( Natl. Res. Counc. 2004 ; Donohue & Ayres 2003 , 2009 ), and international studies instead suggest that handgun ownership is associated with increased risk of violent victimization ( van Kesteren 2014 ). Although the issue remains controversial, the hypothesis can, at best, be described as unconfirmed, and self-defense alone is a weak argument for increased or easy gun access.

3.2. Legal Issues

The second significant point to recognize is that gun ownership is legal; this is unlikely to change in the foreseeable future. The United States is one of three countries to have a Constitutionally protected right to firearms ( Elkins 2013 ). The Second Amendment to the US Constitution, ratified into law in 1791, reads, “A well-regulated Militia, being necessary to the security of a free State, the right of the people to keep and bear Arms, shall not be infringed.” Although private citizens’ access to weapons has been a point of contention since the earliest participatory governments of Greece and Rome ( Halbrook 2013 ), the debate in the United States has become markedly pitched in the past 25 years. Increased media coverage of shootings; changes in the quantity, variety, and costs of firearms widely available for purchase; changes in the priorities of certain national advocacy groups; and a number of significant court rulings have all contributed to making this a currently volatile topic ( Wilson 2016 ).

One of the central points of contention has been whether the Second Amendment protected the right of individuals to own firearms in general or only in the context of their role in a militia or other state-related function. Removing any doubt on this matter, the US Supreme Court affirmed that the right to bear arms is an individual right not to be unduly limited by federal or state law ( District of Columbia v. Heller 2008 , McDonald v. City of Chicago 2010 ). These rulings are significant because they establish that the right is for the individual (i.e., attachment to a militia is not pertinent) and make clear that the protection expressly extends to firearms well-suited for self-defense—that is, the very revolvers and semiautomatic handguns used in more than 70% of criminal gun homicides ( https://ucr.fbi.gov/crime-in-the-u.s/2014/crime-in-the-u.s.-2014/tables/expanded-homicide-data/expanded_homicide_data_table_8_murder_victims_by_weapon_2010-2014.xls ).

Both Heller and McDonald acknowledge that some limitations on firearm access may be reasonable for persons with clearly identified risks. Specifically, the Court stated that their decision was not meant to eliminate “the longstanding prohibitions on the possession of firearms by … the mentally ill” ( District of Columbia v. Heller 2008 ). The case, however, did not present the necessity for the court to address exactly how these restrictions on the mentally ill would be constructed or the appropriate limits of the restrictions that might be imposed. Current state and federal standards limit access to firearms for people in a number of categories other than the mentally ill, including prior violent felons and people with addiction issues. The standard method for enforcing the restrictions on sales to individuals with mental illness is to have states transmit records of involuntary commitments for potential harm to self or others to a centralized federal data base, the National Instant Criminal Background Check System (NICS). This database must be consulted by federally licensed gun dealers to determine if an individual should be disqualified from purchasing a weapon.

There have been several problems with using this system for limiting purchases by mentally ill individuals. First, of course, is the fact that many purchases do not occur in situations where a background check is required. In most states, private purchases between individuals, transactions at gun shows, or sales of certain types of weapons (e.g., long guns) do not require checks. Second, the enduring wording of the criteria for restricting sale because of mental illness, i.e., the Gun Control Act of 1968’s exclusion of people who have been “adjudicated as a mental defective” [18 USC. § 922(d)(4)], has been quite complex in execution. This phrase has been generally translated as barring the purchase of firearms from a federally or state-licensed dealer by individuals who have been involuntarily committed (either at any point in life or within a stated prior time period). Standards and procedures for involuntary commitment vary considerably from state to state, however, making the standard far from uniform. Third, many states have been very slow to provide data to the registry. Estimates indicate that, before 2007, states had sent only a negligible number of their mental health commitment reports to the federal government ( Liu et al. 2013 ). Reporting is still far from complete ( Swanson et al. 2014 ).

Although broad revocation of the personal right to bear arms could occur either through subsequent court review or by constitutional amendment, neither seems likely or imminent. Continued acceptance of screening for appropriate denials at the point of purchase is the accepted compromise position on this issue. Thus, one may reasonably discard the notion of broad bans on firearms, seizures of existing firearms, or similar interventions as practical measures to reduce gun violence.

Despite the common and nearly clichéd calls for major overhaul of gun laws in the wake of highly publicized tragedies, substantial revisions rarely, if ever, occur. This trend is often the direct result of the fact that most gun laws are state statutes and, as such, affected by political party control of state legislatures. Moreover, many newly enacted gun laws seem to broaden rights rather than restrict them, possibly in reaction to fear of the loss of gun rights ( Luca et al. 2016 ). Highly publicized shootings drive sharp increases in gun sales, as do new gun laws or court rulings, regardless of whether the law or ruling is restrictive or expansive ( Aisch & Keller 2016 ). Given the array of political, social, and legal barriers, it is likely that any call for a broad ban on firearms would have negligible likelihood for success and may, thus, be an unwise application of political capital.

3.3. Gun Culture

Part of the reason that broad statutory changes regarding gun ownership are often met with deep resistance is that they are seen as more than just an attempt to revise a set of regulations; they are often seen as a threat to a way of life or culture. Many individuals who own guns are part of a gun culture that can be difficult for outsiders to understand. Fully grasping or appreciating this aspect of gun ownership may be particularly hard for mental health professionals. No reliable study examining relative ownership rates by profession—i.e., whether psychologists and other mental health professionals own guns at similar rates as the general population—seems to exist. It seems fair to assume, however, that firearm ownership by mental health professionals may be lower than that of the general population, based simply on demographics and related attitudes. This creates a situation that tests mental health professionals’ capacities to integrate respect for these differing cultural beliefs into their practice.

Defining and testing the impact of gun culture on gun ownership and attitudes toward firearm regulation is a difficult task. In general, it seems that there is a sense of identity among firearm owners and enthusiasts that is often anchored in a shared enjoyment of owning and using firearms, often tied to family traditions, personal beliefs, and social relationships. The values of the community of gun enthusiasts have shifted over time, and the current trend appears to be increased identification as a persecuted group ( Somerset 2015 ).

Most relevant to the discussion here, a sizable number of gun owners perceive health and mental health professionals as hostile to their interests, values, and rights ( Wheeler 2015 ). Focused training for these professionals on firearm-related issues has been limited ( Price & Khubchandani 2016 , Traylor et al. 2010 ). The stage is set for professionals to enter discussions about firearms with limited comfort and competence, which seems an invitation for misunderstandings. Cultural blindness on the part of mental health professionals may lead to failures in engaging the patient, understanding their interests, and communicating useful health information to them or their family ( Radant & Johnson 2003 , Shaughnessy et al. 1999 ). Effective work by clinicians with gun owners is increasingly seen as a cross-cultural problem and will require careful integration of both a quantitative understanding of gun violence and a qualitative understanding of the interests of gun owners ( Betz & Wintemute 2015 ).

4. CURRENT POLICY INITIATIVES ADDRESSING GUN VIOLENCE AND MENTAL ILLNESS

4.1. screening firearm purchasers.

Most of the current legal and policy efforts relating to mental illness and firearm violence revolve around limiting access by screening at the time of purchase. As mentioned above, this approach requires background checks on individuals purchasing firearms at a federally registered dealer. If the person has a record of involuntary commitment in the NICS, the seller is required to deny the sale.

Of the more than one million denials of potential purchasers since the inception of the NICS program, mental health issues account for only 1.4% ( Crim. Justice Inf. Serv. Div. 2015 ). Only a small proportion of the people on the NICS have mental health exclusions, and these rarely produce a denial for purchase. The exclusions apply only to people who have been adjudicated incompetent—generally through a judicially ordered involuntary commitment or guardianship— or who have criminal dispositions such as not guilty by reason of insanity. The rate of reporting to NICS and the rate of denial of purchase for this criterion have increased considerably since 2007 ( Swanson 2015 ), but 13 states and territories do not use the federal NICS program at all and another seven only use it for certain types of firearms ( Crim. Justice Inf. Serv. Div. 2015 ). Until the NICS Improvement Amendment Act of 2008, significant operational barriers and conceptual ambiguity remained about what data could and could not be reported to the database because of confidentiality; there remain concerns that past records have not been thoroughly reported ( Liu et al. 2013 ).

In 2014, the federal NICS system provided 3,772,583 background checks, approving 98% of those sales. Of the denials, approximately 3,600 potential purchasers were stopped by NICS from purchasing firearms due to mental health issues; these individuals made up 3.9% of all denials through NICS that year ( Crim. Justice Inf. Serv. Div. 2015 ). Substantially less is known about the disposition of the remainder of the 8,500,000 new firearms manufactured and shipped to US dealers for sale that year ( Bur. Alcohol Tob. Firearms Explos. 2015 ).

Although these screening processes do not appear to have a substantial impact on overall gun violence rates, it appears that they can have an impact on the small sector of gun violence involving people with severe mental illness. A recent study ( Swanson et al. 2016 ) used public records over an 8-year period to examine gun disqualifications and arrests for violent gun crimes as well as firearm suicides for a sample of people receiving publicly funded treatment for severe mental illness. This study found that the implementation of an increased level of NICS reporting of involuntary commitment incidents (in 2007) led to a substantial reduction in the rate of arrest for violent crime for individuals who had, in fact, been involuntarily committed. The level of violent crime in gun-disqualified persons was below that of others with mental illness who were never disqualified. Being denied a gun purchase based on the history of involuntary commitment alone, however, only accounted for 13% of the disqualifications of those who had a prior involuntary commitment and were arrested for a violent crime; 52% of these individuals were disqualified by virtue of a prior criminal record issue. Thus, the narrow criteria of involuntary commitment as an excluding factor affected a relatively small proportion of the patients who went on to engage in significant violence; past history of criminality would have disqualified these individuals ( Swanson et al. 2016 ).

Federal law and most states permit private transfer of firearms between two people, bypassing licensed dealers and background checks. An estimated 40% of firearm transfers occur as private transactions, and an estimated 90% of guns used in crimes came from resold firearms ( Wintemute et al. 2010 ). Private sales at gun shows often take place even when a potential purchaser explicitly indicates that they would not pass a background check. Some states with enhanced regulation of gun show sales limit such transactions ( Wintemute 2013 ).

Some states criminalize the knowing transfer of a firearm to a person who is disqualified from possessing a firearm. Such laws are neither common nor commonly understood, limiting their utility in preventing disqualified people with mental illness from obtaining firearms ( Fowler 2001 ). Prosecution of people who violate such laws also seems to be rare ( Sterzer 2012 ; http://smartgunlaws.org/gun-laws/policy-areas/background-checks/categories-of-prohibited-people/ ).

Private sales and transfers of firearms are easily facilitated through online services. Popular platforms such as Facebook and Instagram have had varying numbers of private sales facilitated through their sites, but recently took steps to limit facilitation of private sales of firearms. Some sites are entirely focused on firearm sales and allow searching based on region, identifying private sales opportunities where background checks are less likely or not legally required ( Daniels 2013 ). Such activities continue despite some limitations instituted by certain sites, and an emerging concern is that these methods of purchase may be serving as a conduit for heavy armament to militias in international conflicts. Private sales of semiautomatic handguns and rifles are routine through some of these websites, with potentially tragic outcomes; it is chilling to think what could happen with transfers of military-grade ordinance ( Chivers 2016 ).

Overall, screening of new purchasers of firearms provides minimal incremental decreases in rates of gun violence by people with severe mental illness and a history of commitment. The coverage of screening practices and their impact are low. Further, such benefits may be comparatively small when one considers the relative ease with which a person can obtain firearms through private sales and Internet-facilitated sales without undergoing a background check.

4.2. Removal After a Prohibiting Event

Several states have statutory provisions that allow for removal of firearms from previously lawful gun owners after a disqualifying event, such as an involuntary hospitalization. Most states obligate a newly prohibited firearm owner to transfer any guns in their possession to a lawful owner within a certain time frame after an event, but there is usually no process to confirm that this transfer has occurred. Only four states—California, Connecticut, Texas, and Indiana— have provisions allowing law enforcement officers to proactively remove firearms at the time of or after a disqualifying event (e.g., an officer who takes a person into custody on an emergency commitment can confiscate firearms at that time) ( http://smartgunlaws.org/gun-laws/policy-areas/background-checks/categories-of-prohibited-people/ ).

Removal of firearms by law enforcement after such disqualifying events is challenging. It is often unclear which agency—if any—would have the authority or responsibility to remove the firearms. There is significant variability in how different jurisdictions enumerate and enforce such laws, and many departments lack clear policies or standards that address this issue ( Int. Assoc. Chiefs Police 2007 ).

Gun violence restraining orders (GVROs) are an alternate pathway to removal established recently in several states. This mechanism creates a specific court order for the removal of firearms from a person who may ( a ) be a prohibited possessor under state or federal standards who has not voluntarily released custody of their firearm or ( b ) have significant risk factors for harming themselves or others with a firearm but not be technically prohibited from having the firearm by other legal standards. Such orders serve as a complementary tool to other prohibitive laws and can be used for people who are identified as posing imminent risk but who do not meet involuntary commitment criteria ( Frattaroli et al. 2015 ). In most instances, one individual seeks an order from a judge for removal of the firearm based on the current state and situation confronting another individual (e.g., heavy drinking with a history of gun-related violence when intoxicated). Additionally, GVROs are not predicated on the presence of a mental illness, which substantially mitigates some of the intrinsic stigma attached to mental illness–specific measures ( Wiehl 2014 ). This innovative strategy for targeted removal requires adequate provisions for weighing the conditions needed to prompt removal and reasonable procedures for reinstating ownership rights ( McGinty et al. 2014a ). There are no current empirical studies on the effectiveness of this strategy.

A variant of screening and gun removal after a precipitating event is found in the New York Secure Ammunition and Firearms Enforcement Act of 2013 (the NY SAFE Act). This act amended the state mental health law, introducing a requirement for mental health professionals to report individuals to a state registry if, in treating that individual, they “conclude, using reasonable professional judgment, that the individual is likely to engage in conduct that would result in serious harm to self or others” [Ment. Health Proced. Act at §9.46(b)]. The report is reviewed by a county official. If approved by the county official, the database for gun permits is then searched to see if that individual has a current permit. If so, the permit is revoked and the gun is seized. The individual is then barred from obtaining a permit until it is reinstated in a revocation hearing.

Systematic research on the effectiveness of the provisions in the NY SAFE Act regarding mental health professionals’ reporting of dangerous individuals has not been conducted. As emphasized above, the likelihood of such provisions having a significant impact on the overall level of gun violence is extremely low. Whether such a statute can have an impact on gun violence or suicide involving individuals with mental illness is the most logical, but methodologically thorny, question that must be addressed. There are also concerns about possible unintended effects, including an undermining of therapeutic relationships, reductions in high-risk individuals seeking treatment, restrictions on clinical discretion in handling potentially violent or suicidal situations, and increased stigma of mentally ill individuals. Sound information about the overall effects of clinical reporting requirements, as exemplified in this law, would be a valuable addition to the current debate on the topic of mental illness and gun violence.

4.3. Prohibitions on Asking About Access to Firearms

Other statutory efforts related to clinical practice and gun violence have been instituted, but primarily with the intent of limiting the intrusion of mental health professionals on this issue rather than encouraging their involvement. The Florida Firearm Owner’s Privacy Act of 2011— colloquially known as the “Docs and Glocks” law—creates disciplinary sanctions for licensed health care professionals who ask about or document ownership of firearms by their patients. Part of the rationale for this law is the suggestion that firearm safety counseling by professionals may increase the risk of people being attacked by limiting an individual’s access to a self-defense weapon ( Paola 2001 ). The notion of widespread use of firearms in self-defense, however, has been widely and repeatedly debunked (e.g., Hemenway & Solnick 2015 ).

The main purported merit of such legislation is that it protects patient privacy around the Constitutionally protected and potentially stigmatized act of owning a firearm. It is unclear, however, why this specific line of inquiry would be prohibited while other inquiries about stigmatized acts, Constitutionally protected or otherwise, are routine. For example, inquiries about sexual orientation, gender identity, and drug and alcohol use are often routinely expected in clinical assessments.

The impact of legal curbs on health professionals asking and counseling about firearm safety remains unclear, but it seems unlikely that this policy will decrease firearm violence and other injuries in people with mental illness. The impact for mental health professionals seems obvious and substantial. Although it should generally be easy to justify such an inquiry, the potential threat of professional sanctions would seem to discourage it, even in the face of clear evidence that asking about guns and discussing safe gun practices can produce a significant reduction in suicides ( Brent et al. 2000 , 2013 ).

5. TOWARD SOUND POLICY

There are many well-considered policy recommendations in the clinical and legal literature about how to address the overlap of mental illness, firearms, and violence. This section examines some of the more common approaches in terms of their likely utility and justifications. There are still a number of unanswered questions to address in this area that could focus the next round of policy suggestions.

5.1. Characteristics of an Optimal Policy

Not all policies are created equal, and relative merit is not always obvious or disconnected from basic values. Although the major aim of public health policies is to reduce disability and illness or to promote positive outcomes within a specific population, these policies are often enacted in a way that curtails the liberties of members of that same population. Policies aimed at preventing gun violence are particularly complicated because they often promote broad public health benefit at the expense of some of the most basic liberties. As such, very specific criteria must be met a priori for a policy in this area to be both ethical and effective ( Childress et al. 2002 ).

One requirement of an ethical public health policy is broad impact. Funding interventions that only address the needs of a small segment of the population are an expensive and inefficient use of cognitive, political, and financial resources and should be avoided. One could reasonably suggest that an intervention that only targets firearm violence risk by people with severe mental illness but ignores or has no impact on the other health needs of people with mental illness or does not mitigate other types of violence would be narrowly targeted. That is not to say that such a narrow target is unreasonable, but limited resources may be better spent on interventions that would have broader impact. Ideally, policies directed at the intersection of mental illness and gun violence should have significant benefits along the fuller spectrum of needs of people with mental illness or reduce a broader swath of potential violence.

Interventions should ideally be evidence based or at least reflect the best understanding of existing evidence. When there are rapidly emerging threats to public health, there may be a clear and pressing need to provide interventions that are untested (e.g., in the response to rapidly emerging infectious diseases such as Zika). Firearm violence, however, is not a novel or rapidly emerging threat and would not seem to qualify for this exemption from the need to be grounded in—or at the very least not expressly contrary to—known empirical evidence.

Interventions should also recognize that implementation of some interventions proceed quite differently in the real world than in a lab. Interventions targeting mental health, firearms, and violence need to take into account the heterogeneity of violence, the importance of non-mental-health risk factors for violence in people with mental illness, and the political and practical challenges of any intervention attempting to shift the ownership or use of the 300 million privately owned firearms in the United States. The real-world constraints in fashioning effective policy on firearm violence and individuals with mental illness cannot be downplayed.

Finally, any intervention needs to be assessed in terms of the balance of potential clinical benefit against the abrogation of rights. Whether by utilitarian or deontological standards, a public policy to mitigate violence risk must have an acceptable cost in terms of the civil rights of individuals. The test is not whether the policy or intervention is cost free in terms of rights but, instead, how expensive and expansive it is in the limitations it might create.

5.2. Ineffective Approaches

Many commonly proposed interventions for firearm violence fail to meet the above criteria for sound policy investments. Some interventions have a focus that is too narrow. Bans on assault weapons and large-capacity magazines would have a small, though delayed, impact on some mass shootings but only a negligible impact on most firearm violence. Achieving these meager benefits would require significant political and fiscal outlay to enact legislation and craft restrictions that could not be easily bypassed by manufacturers.

Some proposed policies are largely shaped by stigma or inflame stigma to such a degree that the ethical costs would outweigh any nominal benefit. Proposals for blanket bans of access to firearms for people with mental illness or extended hospitalization fail to pass the aforementioned criteria at multiple levels. The interventions are overly broad given the rarity of violence by people with mental illness; the net effect would be broad denial of rights to most people with mental illness who are not dangerous while leaving most firearm violence unaddressed. Such policy proposals scapegoat people with mental illness and have the potential to expand rather than correct stigma and bias ( Corrigan et al. 2005 ).

Similarly, calls to broadly ban or abolish firearms are also grossly impractical for the United States. Although state-sponsored gun buyback programs have been successful in Australia ( Chapman et al. 2016 ), they seem unlikely to be even remotely successful in the United States. In addition to the constitutional protection of ownership and high numbers of firearms in civilian hands, which create practical obstacles, a buyback program would also be unlikely to have a substantial impact on violent crime. While studies are challenging to conduct, most firearms intercepted in criminal investigation appear to have been illegally acquired ( Fabio et al. 2016 ) and, thus, seem unlikely to be easily surrendered.

Some interventions, though, may be more promising. There are several policy changes that could affect the level of firearm violence by people with mental illness and have a potentially positive impact on other types of violence and other risks such as suicide.

5.3. Potentially Effective Interventions

Several interventions would appear to meet Childress et al.’s (2002) criteria for effectiveness and proportional impact. Outlined in the following sections are potential public policy initiatives based in evidence and specifically intended to target the intersection of mental illness, firearms, and violence.

5.3.1. Expanded funding streams for well-designed objective research on firearm violence and violence prevention

It is difficult to take informed action when there is so little information about gun violence in general and gun violence in individuals with mental illness in particular. The ban on federally funded research on firearm violence in the United States has left many critical questions unanswered. Careful evaluation of comparative efficacy of firearm legislation in different jurisdictions is promising ( Rostron 2016 , Swanson et al. 2016 ) but often underfunded. Prospective studies to evaluate violence and suicide risk factors among firearm owners could help clarify the processes of gun ownership and use and identify potential high-risk groups. Improved legal and funding structures to promote and simplify retrospective evaluation of how people engage in violence, looking for differences relating to mental illness and other factors, could provide guidance for more refined clinical practice.

5.3.2. Promotion of safer storage as a standard goal

Much as reproductive health education professionals have moved from the overly reassuring notion of safe sex in favor of that of safer sex, professionals should shift from the idea of safe storage and removal to that of safer storage. These discussions have already occurred regarding ways to reduce suicide risk ( Mann & Michel 2016 , Stanley et al. 2016 ), with many clinicians—and, for that matter, firearm owners, policy makers, and other stakeholders—presenting gun access in stark and realistic terms. Guns, if present in the home, are dangerous; absence of guns in the home is not dangerous. The reality is that, in a nation with 300 million firearms, guns are easily accessed through dealers, private sales, or sharing among friends. The absence of a gun in a patient’s home should provide little assurance that the patient would have any difficulty accessing firearms elsewhere. Improving tools and practices for safer storage (e.g., locks, safes, or even use of smart gun technology) may limit impulsive acts of aggression or suicide, but can still be breached by a determined actor.

The resistance to these initiatives is strong. Most firearm owners identify personal or family safety as a factor in gun ownership ( Swift 2013 ), and even a simple lock or safe can impede access to a firearm in an emergency. This resistance, however, does not make the discussion of such issues futile. Open and frank discussion of relative risks and benefits may be useful in clinical settings, introducing the issue of safe storage as a reasonable compromise to competing needs. This is the basic building block of a series of reasonable changes in clinical care that could promote reductions in firearm violence in individuals with mental illness.

5.3.3. Assessment of firearm access and effective counseling about risk as a standard of care

It has become increasingly accepted that firearm access, as an element of general health and mental health assessment, is an ethically and clinically appropriate domain of interest for health care professionals ( Betz & Wintemute 2015 , Butkus et al. 2014 , Laine et al. 2013 , Wintemute et al. 2016 ). Formal enumeration and acceptance of this principle in the form of practice guidelines from major mental, public, and physical health institutions would certainly promote this reform in practice.

5.3.4. Development and distribution of evidence-based education on effective firearm safety counseling practices for clinicians

Establishment of gun safety counseling as part of core or continuing educational requirements for licensed practitioners could promote such efforts. For example, requirements to have a minimal level of education time spent on firearm safety or violence management or minimum standards for new trainees relating to firearm safety and violence management would promote the acceptance of firearm safety counseling being a standard of care.

One of the common critiques of counseling on firearm safety by health professionals is that high-quality training on such activities is difficult to find ( Price et al. 2015 ), even though appropriate and effective educational strategies and resources have been developed ( Brown & Goldman 1998 , McGee et al. 2003 , Rozel et al. 2015 , Slovak & Brewer 2010 ). Getting these methods into the hands of clinicians and endorsing their use is an essential step toward reducing firearm violence in cases appearing in the mental health system.

5.3.5. Evidence-based education on effective firearm safety practices for gun owners and family members of persons with mental illness

Although the effectiveness of widely available firearm safety training for youth is questionable ( Gatheridge et al. 2004 , Himle et al. 2004 , Jackman et al. 2001 ), this does not eliminate the necessity to develop more sound approaches for enlisting and educating those closest to individuals at risk. All of these efforts would benefit from explicit statutory protection for health professionals’ freedom of speech when they communicate evidence-based information and their interpretation thereof to patients.

5.3.6. Development of evidence-based education on effective firearm safety practices and on recognizing mental illness and acute mental health emergencies for firearm dealers

We have limited systematic data on the link between recent firearm purchase and suicide risk ( Wintemute et al. 1999 ); we have even less on the link between recent firearm purchase and violence toward others. It is possible, however, that interventions aimed at processes other than just screening at the point of purchase might reduce dangerous sales. For example, the expansion of mental health training for firearm dealers—programs such as those implemented by the New Hampshire Firearms Safety Coalition ( Vriniotis et al. 2015 ) or Mental Health First Aid training— could promote screening and intervention by licensed dealers in situations where a sale might be related to a mental health crisis.

5.3.7. Establishment of gun safety counseling as part of core or continuing educational requirements for licensed practitioners

States have an array of continuing education requirements for licensed health professionals; common required topics may include child abuse, safety and quality, pain management, or other topics often stipulated by state legislatures. Enacting requirements to spend a minimal level of education time on firearm safety or violence management may be beneficial. Additionally, agencies responsible for the national accreditation of training programs might consider developing minimum standards for new trainees relating to firearm safety and violence management.

5.3.8. Establishment of national best practices guidelines on evaluation for expungement

Many states provide a legal pathway for a person prohibited from owning or acquiring a firearm to have those rights restored. Not all of these states, however, require any type of mental health evaluation as part of that process. Clarifying and routinizing these procedures can provide safeguards for appropriate gun access, promotion of safe storage, and conditions for continued ownership related to clinical concerns.

It may seem counterintuitive to think that promoting restoration of firearm rights to people previously excluded from firearm ownership for mental illness reasons could be seen as a prevention initiative. However, given the earlier observation that individuals with mental illness go through periods when risk of violence may be reduced or elevated, it is reasonable to see the restoration process as an opportunity to promote safe practices and monitoring for such periods. In addition, reasonable restoration procedures might enhance reporting. Clinicians—as well as law enforcement officers, hospital administrators, and judges—may be reticent to involuntarily hospitalize a person out of a concern that such a commitment may infringe on that individual’s right to firearms. Although this may be a concern about Second Amendment rights in the abstract, it may also be a more specific concern about the negative effect that a commitment might have on a gun enthusiast or a person who has or aspires to a career in law enforcement or the military. Such reticence may ensure that an untreated or undertreated person with mental illness still has largely unfettered access to firearms, an obviously counterproductive outcome. A consensus-based standard for restoration of rights to gun ownership, if reasonable and practical, could better protect the rights of people with mental illness and potentially decrease the stigma attached to involuntary hospitalization.

5.3.9. Improved legal tools for temporary removal and safe storage of firearms during periods of crisis

Clarifications in the procedures for reinstating rights to own a firearm would be most effective if they operated in conjunction with a clear set of rules about the removal and safe storage of firearms for individuals in times of emotional or psychiatric crisis. As mentioned above, some individuals in acute mental health crisis should not have access to firearms, and some individuals with a history of violence and repeated criminal acts should also be limited in their access ( McGinty et al. 2014a ). Prior violence in general, intimate partner violence in particular, and recurring substance use stand out as highly sensitive risk factors for people both with and without mental illness. Stricter processes to prohibit firearm access or trigger heightened review of potential mental illness in people with these risk factors may help curb access to firearms and mitigate future harm. For example, a misdemeanor domestic violence charge in a person with known substance use or mental illness issues may be considered adequate for prohibiting— temporarily or permanently—that person from owning firearms even if the individual risk factors would not reach the threshold for firearm prohibition on their own.

The current, broad-brush approach of limiting gun sales to individuals with a history of commitment, however, does little to accommodate either the definition of people likely to use firearms violently or the reality of the fluctuating risk states of people who might do so. Legislation that allows for the removal of firearms during times of crisis in validated high-risk groups should produce a more targeted and effective use of the state’s power. In addition, although individuals who have firearms removed can improvise arrangements with friends or family or place them in storage, they may still be relatively accessible, or the individual may not have such resources. Permitting law enforcement agencies or licensed gun dealers to temporarily store and secure firearms for such persons, in conjunction with well-delineated processes allowing input from mental health professionals on removal and return, could be significantly beneficial.

More focused efforts such as these would also require improved legal tools and incentives for active or confirmed removal of firearms after disqualifying events. Few law enforcement agencies are permitted or willing to enter a person’s home to search for or remove firearms after a disqualifying event, such as a domestic violence arrest or terroristic threat. Legal requirements and adequate resources for law enforcement to actively remove firearms in such situations need to be in place to allow for targeted removal of firearms. If a person does not voluntarily give up possession of firearms within a reasonable time after a disqualifying event, application of civil forfeiture principles to confiscated firearms may provide added incentive to encourage active law enforcement intervention.

5.3.10. Exclusion of firearms from bars and other areas where alcohol or substance use is common or expected

Numerous studies, presented above, have identified strong links among substance use, particularly alcohol use ( Mulvey et al. 2006 ), violence, and firearm violence. Oddly, some states have taken steps to expressly permit or encourage concealed or open carry of firearms in bars. The promotion of laws and policies with the exact opposite intent would seem to make sense in light of the weight of available evidence. Potentially, such efforts could take advantage of the integration of firearm and alcohol regulation through offices such as the Bureau of Alcohol, Tobacco, Firearms and Explosives.

5.3.11. Clear media reporting guidelines for major violent events

Although they were a long time in coming, ( Hunt 1845 , Sonneck et al. 1994 , Bohanna & Wang 2012 ), there are currently guidelines on reporting about suicides that minimize the risk of copycat suicides and contagion. Similar guidelines could be developed and adopted by major media outlets for ethical reporting of mass shootings and similar events. Links between sensational reporting of mass shootings and copycat events are becoming better established ( Cantor et al. 1999 , Towers et al. 2015 ), and early proposals for media guidelines are already being developed ( Perrin 2016 ).

General considerations might include avoiding glamorization of assailants or speculation about motivations or the role of mental illness, as well as avoiding detailed descriptions of injuries or tactical methods that may provide practical guidance to potential copycats. Journalists may, instead, wish to consider emphasizing coverage about the victims and the impact of their loss; the acts of victims, bystanders, and law enforcement officers who intervened; or law enforcement investigation and prosecution of offenders. Task forces integrating media, mental health, violence, and health and media ethics experts would be useful in developing such formal guidelines.

6. CONCLUSION

Guns are ubiquitous, easy to access, and intrinsically linked to both US culture and the risk of suicide, violence, and injury. However, they are not, by and large, a mental health problem. Any intervention focusing on the link between mental illness and violence will have limited impact on overall gun violence. The amount of violence in general, and gun violence in particular, involving mentally ill individuals is so small that focusing on this aspect of the problem is largely a distraction. It can even be argued that interventions for narrow problems like the link between mental illness and gun violence are so ethically and logistically unwieldy that they inevitably spawn inefficient and ineffective approaches to an important public policy and public health issue. It is likely that interventions targeting mental illness and firearm access could have substantial impact on suicide risk, and that benefit should not be minimized or discarded lightly. The focus on violence to others, however, seems misguided if the idea is to fashion broad policy reforms.

This does not mean that mental health professionals can simply ignore firearm policies. Mental health professionals are called upon to help in efforts to reduce the harms associated with firearms. As responsible professionals, we can introduce empirically sound evidence and evidence-based approaches as considerations in the ongoing and often heated dialogue on these issues. We can provide perspective on clinical issues, respond firmly to policies driven by stigma, and promote reasoned and reasonable statutes grounded in our understanding of mental illness and the limitations and potentials of mental health services.

This review makes it clear that this role is likely to expand. Existing and proposed approaches to gun policy call for more refined determinations of the eligibility to access and retain firearms, and many of these determinations will involve mental health professionals. It is becoming increasingly clear that blanket provisions based on factors such as having a prior involuntary commitment are both expensive and ineffective. There are other risk factors that are far more predictive of future violence. Moreover, an examination of current research makes it clear that the link between mental illness and violence resides in fluctuating patterns of risk, not in static categorizations such as diagnosis. This implies that judgments about the current status of individuals will become more relevant to determinations about the ability to buy or retain possession of a firearm. Mental health professionals cannot evade their evolving role in assisting in the determination of useful risk factors and methods for making reasoned judgments about gun ownership.

Mental health professionals will also in all likelihood be called upon to help fashion more useful regulations regarding the provision of clinical care related to gun access and use. Health care professionals will likely be pushed to adopt standards of care related to screening for gun access and counseling about gun safety. Evidence-driven clinical interventions for assessing risk related to firearm access and counseling patients and families will need to be prioritized and disseminated. Evidence-based clinical practices will have to be mirrored and supported by evidence-based public policy. Neither can exist without adequately funded and carefully directed research to strengthen that evidence base.

The current research seems to indicate that mental health professionals must become more actively involved in the formulation of policies and changes in practice that recognize the realities and risk of gun ownership and access. Failure to do so will leave a looming vacuum, which will be readily filled by ill-informed and politically inspired policy makers, leaving our patients and communities vulnerable to ongoing violence.

SUMMARY POINTS

• Firearms and firearm violence are ubiquitous in the United States.
• The intersection of mental illness and firearm violence is limited, but public health opportunities relating to this intersection should not be ignored.
• Media reporting on violence and mental illness drives stigma and misdirected policy efforts.
• Mental illness alone is a weak predictor of violence and firearm violence risk.
• Violence risk in mental illness is driven by active symptom states, comorbid addiction, prior victimization, and other psychosocial risk factors.
• An expanded evidence base is needed to drive improved clinical interventions and health policy recommendations.
• Mental health professionals need to take an assertive role in helping to shape public policy relating to violence, firearms, and mental illness.

FUTURE ISSUES

• Improved research is needed on the pathways from firearm purchase to adverse outcomes such as violence.
• The outcomes of varying firearm policies, as applied across different states and jurisdictions, need to be studied and disseminated.
• Assessing access to firearms and effectively counseling patients and families on firearm safety is a public health imperative and will need to be protected from political incursion.
• Improved health education research on effective strategies for educating clinicians, patients and families, and firearm dealers on safer storage and injury prevention needs to be developed.

DISCLOSURE STATEMENT

The authors are not aware of any affiliations, memberships, funding, or financial holdings that might be perceived as affecting the objectivity of this review.

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