key: cord-0958796-i5v5xcv1 authors: Duncan, Thomas K.; Weaver, Jessica L.; Zakrison, Tanya L.; Joseph, Bellal; Campbell, Brendan T.; Christmas, A. Britton; Stewart, Ronald M.; Kuhls, Deborah A.; Bulger, Eileen M. title: Domestic Violence and Safe Storage of Firearms in the COVID-19 Era date: 2020-05-20 journal: Ann Surg DOI: 10.1097/sla.0000000000004088 sha: 34de3c0176cb048adb76805207936cb7b07473e7 doc_id: 958796 cord_uid: i5v5xcv1 nan Domestic violence (which includes violence against partners, children, parents or the elderly), intimate partner violence (which includes violence that occurs in a close relationship), and firearm availability go hand-in-hand. On average, 50 women in the United States (U.S.) are shot and killed by intimate partners each month. Abused women are five times more likely to be killed by their abuser if the abuser owns a firearm. 1,2 The American College of Obstetrics and Gynecologists (ACOG) issued a statement noting that women disproportionately experience intimate partner violence (IPV), and abuser access to the presence of firearms within those relationships is a key risk factor for intimate partner homicide. 3, 4 With presence of unsecured weapons in homes resulting from increased stress, economic instability, and restrictions resulting from stay-at-home orders during the COVID-19 pandemic, numbers of intimate partner homicides are very likely to rise without attempts at prevention. Higher prevalence of IPV among adult females (with males being mostly perpetrators) leads to increased incidence among pregnant women, particularly among pediatric pregnant females (< 18 years). 5,6 Furthermore, independent of shelter at home orders during a pandemic, both women and African American men are disproportionately at risk of intimate partner homicide and completion suicide, involving firearms and alcohol, but not mental illness. 7 As the nation (and the world) grapples with the spread of COVID-19, citizens of many countries are required to follow stay-at-home orders to lessen virus transmission risk. Mounting data suggest that domestic abuse (DV) is acting like an opportunistic infection, flourishing in the conditions created by the pandemic, leading to ‗intimate terrorism.' 8 Countries such as the U.S. and Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. China have seen an increase in DV calls, Spain has documented an 18% increase, while France has seen a 30% increase in such calls. 8 For victims and survivors of DV, including children exposed to it, being at home may not be a safe option; and the unprecedented stress of the pandemic could create an unsafe environment in homes where violence may not have previously been an issue. 9 Additional stressors including concern for the health and welfare of loved ones, and close quarters as parents work from home and try to homeschool their kids risk increasing DV. Elderly parents in the home may also experience DV through abuse and neglect, in addition to increased risk of mortality from Violence is a public health issue which crosses families, communities, and populations. 3,11,12 Some risk factors and social determinants of health for violence include but are not limited to poverty (although it affects all social classes), hopelessness, unemployment, access to firearms, lack of housing, lack of role models, mental illness, and substance abuse. 3 According to the Centers for Disease Control and Prevention, 1 in 4 women and 1 in 7 men in the United States (U.S.) have experienced violence (sexual, physical) and/or stalking from an intimate partner in their lifetime; and the risks to victims are potentially severe. CDC data link IPV with an increased risk of injury and death. 1,9,13 Patients presenting to trauma centers after DV experienced a mortality rate of 6%, 5 with men experiencing the same rate of physical violence as women. 14 Structural racism and age play a role in a person's likelihood of experiencing abuse from an intimate partner, with African American communities 7 and older women at particular risk. Women with Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. disabilities are more vulnerable to rape and sexual coercion, along with several forms of IPV. IPV rates are highest in the poorest neighborhoods, and increased stress levels among parents is often a major predictor of physical abuse and neglect of children. 9 An alarming study found a significantly higher mortality rate identified among children (8.6%), than among adults and elderly experiencing DV. 5 The stay-at-home orders, increased unemployment, and added stressors during the recent COVID-19 pandemic will likely act to increase exposure to risk factors for DV and IPV. The impact of Community Violence Exposure (CVE), in the form of a child being exposed to DV/IPV involving a parent, deserves mention because it has direct bearing on both the physical, mental, and emotional development of children. If the parent is unable to access services following DV/IPV, the exposed child will also not receive services. This may contribute to long-term behavioral problems for the child, such as perpetuating DV/IPV, and internalizing behaviors which lead to anxiety, withdrawal and depression. 1,15 In addition, during this time, children are at risk of direct physical violence, as IPV can extend into DV, while they are forced to stay at home during a stressful period. Those that often raise the early alarm for child abuse, such as teachers, extended family members, and religious leaders no longer see the children regularly. Many child-protective organizations are experiencing strain with fewer workers available, so they may be unable to conduct home visits in areas with stay-at-home orders. 9 As such, the effect on children will only be compounded without the ability to provide appropriate services to address important social determinants of health. Individuals (mostly women) experiencing DV may have limited Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. In order to practice appropriate firearm safety, gun owners (particularly first-time owners) should obtain firearm safety instruction about firearm use and safe storage. Access to shooting ranges for firearm safety training is complex, because the stay-at-home ruling in many states does not recognize shooting ranges as essential businesses. Without lessons in firearm safety or safe storage, it is likely that the availability of more unsecured weapons in households will likely make DV episodes more deadly. If firearms are not stored properly, they may be easily accessible to bored and curious children that are currently stuck at home, which increases opportunities for tragic, Even though we are trained to heal traumatic injuries, some are not treatable. Every non-survivable, preventable DV/IPV injury that health care professionals treat may contribute to emotional exhaustion, burnout or moral distress. Making an intervention when we interact with such victims could break the chain of violence and lead to a completely different outlook for survivors and their families. According to the American College of Surgeons, -The only thing more tragic than a death…is a death that could have been prevented.‖ In order to curb the incidence of preventable firearm injuries, we are proposing the following: American Association for the Surgery of Trauma Prevention Committee Topical Update: Impact of Community Violence Exposure, Intimate Partner Violence, Hospital-Based Violence Intervention, Building Community Coalitions and Injury Prevention Program Evaluation Risk factors for femicide in abusive relationships: results from a multisite case control study Prevention of Firearm Injuries: It all Begins with a Conversation American College of Obstetricians and Gynecologists Gun violence and Safety Statement of Public Policy Prevalence of Domestic Violence Among Trauma Patients Unauthorized reproduction of this article is prohibited. of pediatric trauma from a level I trauma center Comparison of male and female victims of intimate partner homicide and bidirectionality-an analysis of the national violent death reporting system New York Times; A New Covid-19 Crisis: Domestic Abuse Rises Worldwide American Psychological Association; How COVID-19 may increase domestic violence and child abuse Youth Violence: A Report of the Surgeon General. Office of the Surgeon General (US); National Center for Injury Prevention and Control (US); National Institute of Mental Health (US); Center for Mental Health Services (US). Youth Violence Violence is a public health issue National Center for Injury Prevention and control. The National Intimate Partner and Sexual Violence Survey Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited Universal screening for intimate partner and sexual violence in trauma patients-What about the men? An Eastern Association for the Surgery of Trauma Multicenter Trial Behaviors of children who are exposed and not exposed to intimate partner violence: an analysis of 330 black, white, and Hispanic children L; Firearm violence in the USA: a frank discussion on an American public health crisis-The Kansas City Firearm Violence Symposium Accepted for Publication in Annals of Surgery. Trauma Does Not Quarantine: Violence During the Covid-19 Pandemic Gun Sales Skyrocket in March On Pandemic Fears. Guns & America FACS Recommendations from the American College of Surgeons Committee on Trauma's Firearm Strategy Team (FAST) Workgroup: Chicago Consensus I Gun safety and your health American College of Surgeon Intimate Partner Violence Toolkit TQIP Best Practices Guidelines for Trauma Center Recognition of Child Abuse, Elder Abuse, and Intimate Partner Violence Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited