RESEARCHREVIEW

CURRENT RESEARCH FOR FAMILY ADVOCACY PROGRAMS • VOL. 1, NO. 1 SPRING 2023

NONFATAL FIREARM VIOLENCE: THREATS AND INJURIES IN FAMILIES
Nonfatal firearm injuries, both intentional and unintentional, account for many more emergency department
cases than fatalities. During 2009-2017, there were approximately 2.5 times the number of emergency department visits for nonfatal firearm injury (85,694) comparedto fatalities (34,538; Kaufman et al., 2021).
There are many incidents of domestic violence (DV) in
which a firearm is used in a nonlethal manner that do notreach an emergency department. These nonfatal firearm
injuries or threats are common in DV (Sorenson, 2017).
Of 35,413 DV incidents reported to police in a large city,
1.6% involved a gun. In such circumstances, guns wereused most often (69.1%) to threaten or intimidate thevictims, the gun was brandished in 42.4% of the guninvolved incidents, and in 26.7% the offender threatened
to shoot the victim, but did not do so. Nonfatal firearm
injuries constitute an important public health problem
for DV victims. Providers need to be prepared to screen
clients for firearm-related risks and take steps to prevent
firearm-related accidents.

When a firearm is used in a nonlethal
manner in incidents of domestic violence,
this may be called a nonfatal firearm injury
or threat. In incidents of DV-related nonfatal
firearm injury or threat, the firearm is used
to threaten or strike the victim or it can bebrandished or displayed in front of a victim in
an attempt to coerce them.
REFERENCES
Kaufman, E. J., Wiebe, D. J., Xiong, R. A., Morrison, C. N.,
Seamon, M. J., & Delgado, M. K. (2021). Epidemiologic
trends in fatal and nonfatal firearm injuries in the US,
2009-2017. JAMA Internal Medicine, 181(2), 237-244.

Sorenson, S. B. (2017). Guns in intimate partner violence:
Comparing incidents by type of weapon. Journal of
Women’s Health (Larchmt), 26(3), 249-258.

CONTENTS
Nonfatal Firearm Violence: Threats and Injuries in Families...........1
Assessing Risks for Nonfatal Gun Violence..........................................2
Experiences of Nonfatal Firearm Violence by DV Victims.............3
Assessing Children’s Knowledge of Firearm Storage in Homes...4
Assessing When Threats with Firearms are Forms of Coercive
Control in Domestic Violence...............................................................5
Research to Action: Screening for Firearm Safety
to Prevent Injury and Death.................................................................6
Healthcare Utilization and Expenditures for Nonfatal Firearm
Injuries of Children...................................................................................6

IN THIS ISSUE
We present Research Review (RR), a publication of theCenter for the Study of Traumatic Stress (CSTS). This issueof RR consists of summaries of research on the risks ofmortality and morbidity due to nonfatal firearm violencein domestic violence (DV). We emphasize the importanceof a variety of screening procedures for risks due to the
behavior of DV perpetrators. Screening can increase theknowledge of unsafe firearm practices and unsafe firearm
storage and may prevent the escalation of violence andsave lives. It is important to assess children’s knowledge offirearm presence, storage location, and whether parents
have counseled them about safe firearm practices.

ASSESSING RISKS FOR NONFATAL GUN VIOLENCE
Nonfatal firearm use is common in domestic violence(DV) and can have severe consequences for victim safety
and well-being. It is a form of coercive control in whichperpetrators attempt to injure, scare, and intimidate
partners through threats of the use of firearms. Amongthe most common threats with a firearm are brandishing,threats to shoot the victim, striking the victim with thefirearm, and threats of suicide by the perpetrator.
Remember, beyond the victim, others can be affected
including children, other family members, friends, strangers, and pets.
Providers of services for DV victims can assess thevictim’s risk for firearm violence by inquiring about the
behavior of the abuser in terms of prior firearm violence(see Box 1) and the abuser’s behavior with regard to thelocation and physical security (or insecurity) of the firearm (see Box 2).
SUGGESTED READING
Adhia, A., Lyons, V. H., Moe, C. A., Rowhani-Rahbar, A., &Rivara, F. P. (2021). Nonfatal use of firearms in intimate
partner violence: Results of a national survey. Preventive
Medicine, 147, 106500. doi:10.1016/j.ypmed.2021.106500

Kafka, J. M., Moracco, K. E., Williams, D. S., & Hoffman,
C. G. (2021). What is the role of firearms in nonfatal
intimate partner violence? Findings from civil protective
order case data. Social Science & Medicine, 283, 114212.
doi:10.1016/j.socscimed.2021.114212

BOX 1: The following are questions thatproviders can ask to assess the DV victim’s
risk for experiencing firearm violence by anabuser:1. Does the abuser have easy access to a firearm?
2. Has the abuser ever threatened to use a firearm on
the victim?
3. Has the abuser ever struck the victim with afirearm?
4. Has the abuser ever fired the weapon when angry,
but not shot anyone?
5. Has the abuser ever shot at or in the vicinity of thevictim?
6. Has the abuser ever shot the victim?

RESEARCH REVIEW
EditorTasanee R. Walsh, PhD, MPH, MSW1, 2
Senior Scientist
Department of Psychiatry, USU
e-mail to tasanee.walsh.ctr@usuhs.edu
Research Review is a publication of the CSTS Family Violence
and Trauma Project and and the Army Deputy Chief of Staff,
G-9, Family Advocacy Program, Washington, DC
Editorial Consultants
Stephen J. Cozza, MD, COL, U.S. Army Retired1
Professor of Psychiatry and Pediatrics, USU
James E. McCarroll, PhD, MPH, COL, US. Army Retired1, 2Research Professor, Department of Psychiatry, USU

BOX 2: If the victim answers ‘yes’ to any ofthe questions in Box 1, the provider can ask“in further consideration of your safety, do
you know”:
1.
2.
3.
4.
5.

Where the firearm is located?
Has the abuser ever attempted to hide the firearm?
Has the abuser locked the trigger of the firearm?
Has the abuser stored ammunition with the firearm?
Do you have a safety plan for yourself and forothers?

1.

Center for the Study of Traumatic Stress, Department of
Psychiatry, Uniformed Services University of the Health
Sciences

2.

Henry M. Jackson Foundation for the Advancement ofMilitary Medicine, Inc.

The opinions and assertions expressed herein are those of theauthor(s) and do not reflect the official policy or position of the
Uniformed Services University of the Health Sciences or the
Department of Defense.
The contents of this publication are the sole responsibilityof the author(s) and do not necessarily reflect the views,
opinions or policies of The Henry M. Jackson Foundation for
the Advancement of Military Medicine, Inc. Mention of trade
names, commercial products, or organizations does not imply
endorsement by the U.S. Government.
https://www.cstsonline.org/resources/newsletters2 • JOINING FORCES/JOINING FAMILIES

Spring 2023

EXPERIENCES OF NONFATAL FIREARM VIOLENCE BY DV VICTIMS
Nonfatal firearm use in domestic violence (DV) is
common and can have severe consequences for victim
safety and well-being. A 2020 nationwide study of 958
adults who had experienced DV asked them to describe
their experiences with nonfatal abuse by a perpetrator(Adhia, Lyons, Moe, Rowhani-Rahbar, & Rivara, 2021).
Consequences for the victim of nonfatal firearm
violence included: feeling fearful, on guard/watchful/easily startled, splitting up with their partner, moving out of
their home, going to a shelter, physical injury, contacting
a crisis hotline, and missing days of work or school.
Another nationwide study in 2020 asked 171 victim
service providers to describe their experiences with victims in which nonfatal firearm violence occurred during
the COVID-19 pandemic (Lynch & Logan, 2021). The
responses included information based on their knowledgeof victim reports of perpetrator firearm access, firearm
violence, and safety planning during the pandemic.
Almost half the providers who were surveyed reported
that perpetrators threatened to shoot the victim or others,
such as strangers or mass shootings, and that this had

become more frequent since the start of the pandemic.
Firearm-related violence and its consequences areimportant topics for FAP personnel to be aware of. Even
when DV incidents do not involve firearms, it is still
important for FAP personnel to discuss nonfatal firearm
violence with victims, as they could be involved in future
incidents of escalating violence. FAP personnel can work
together to provide Army-specific risk factors for thesafety of potential or actual victims of nonfatal firearmrelated violence.
REFERENCES
Adhia, A., Lyons, V. H., Moe, C. A., Rowhani-Rahbar, A., &Rivara, F. P. (2021). Nonfatal use of firearms in intimate
partner violence: Results of a national survey. Preventive
Medicine, 147, 106500. doi:10.1016/j.ypmed.2021.106500

Lynch, K. R., & Logan, T. (2021). “Always know where
the gun is”: Service providers perceptions of firearmaccess, violence, and safety planning during the COVID-19 pandemic. Journal of Interpersonal Violence.
doi:10.1177/08862605211046270

Nonfatal firearm abuse of an intimate partner can include spoken
threats, displaying a gun, or holding a partner at gunpoint. It is a formof coercive control in which perpetrators use firearms to injure, scare,and intimidate partners.

Nonfatal firearm abuse was defined as
experiences in which the offender:
1. Displayed a firearm,
2. Hit the victim with the firearm,
3. Threatened to shoot the victim or a pet or
someone else,
4. Shot the gun, but did not hit anyone, and
5. Shot the victim or someone else.

http://www.CSTSonline.org

Service providers can take important action
steps to reduce the risk of firearm-related
accidents, injuries, and abuse, such asadvising the victim to:
1. Seek outside help (police or 911),
2. Assess the location of the firearm and take steps toremove or disable it,
3. Have an escape plan to respond to firearm threatsor violence,
4. Discuss the dangers of firearms and the risk ofserious injury or death, and
5. Conduct a risk assessment for the victim’s safety,
and advise about the risks of firearm ownership in
their families.

RESEARCH REVIEW • 3

ASSESSING CHILDREN’S KNOWLEDGE OF FIREARM STORAGE IN HOMES
Public health campaigns to reduce firearm deaths andinjuries have put forth messages encouraging screening
and counseling of high-risk persons and families. Amongthese campaigns to enhance preventive measures are safe
storage practices, gun locks, and storing ammunition
away from the weapon. Other efforts have occurred inlegislation including removing access to firearms frompeople deemed to be at high risk for harm to themselves
and others.
While these efforts may reduce firearm-related fatalities, there are other means to learn about children’s
actions in relation to firearms in the home. A 2017 studyof 297 parent-child dyads in Atlanta who presented topediatric emergency departments evaluated parent-reported presence (or absence) of firearms in the home andfirearm storage practices (Doh et al., 2021). The survey
also assessed the children’s perception of their access tofirearms and their ability to identify a toy firearm versus a real one. Parents and children completed surveys
independently. Children were between ages 7-17. Parents
were largely females (79%), were less than 40 years of age
and had some college education or beyond. Fifty-three
percent of gun owners reported storing guns insecurely.
Firearm owners were more likely than non-gun owners
to believe their child could access a firearm (11%-3%).
That is, 11% of gun-owning parents thought their childknew where to get their gun, and 53% of children of gunowning parents knew where their parent’s gun was stored.
Importantly, 59% of children could not identify a toy gun
versus a real gun in a picture. Also important, only 14% of
non-gun-owning parents asked if firearms were present inhomes that they visited, compared to 55% of gun-owningparents.
This study concluded that there were significant discrepancies between what parents believed their children
knew and what their children perceived about guns. The
authors also stated there is a disconnect between public
policy recommendations on gun safety and reported risk
behaviors by parents and children around firearm storage.
In other words, while there are campaigns to improve thehome safety with regard to the storage of guns and gun
storage practices, these campaigns may have underestimated children’s knowledge about firearms and firearm
safety in the home.
What should FAP providers do to assess parent andchild knowledge about firearms, firearm location, andfirearm storage?
4 • JOINING FORCES/JOINING FAMILIES

Screen families of child and adultmaltreatment for:1. Firearm ownership
2. Firearm location
3. Firearm storage
4. Ammunition storage
5. Whether they have discussed safe firearm handlingwith family members
Screen children for their knowledge of gun
location and gun safety practices.
1. Is there a firearm in your house?
2. What does the firearm look like?
3. Is it real or is it a toy?
4. Where is the firearm stored?
5. Do you know how to get at it?
6. Have your parents told you not to try to get it?
FAP providers should know:
1. State and federal laws bearing on child exposure to
firearms,
2. Military unit policies on gun possession and storage,
3. Family members’ knowledge of family ownershipand storage of firearms, and
4. Recommended educational programs for parents toteach children about firearm safety.

REFERENCE
Doh, K. F., Morris, C. R., Akbar, T., Chaudhary, S., Lazarus,
S. G., Figueroa, J.,… Simon, H. K. (2021). The relationship between parents’ reported storage of firearms andtheir children’s perceived access to firearms: A safety
disconnect. Clinical Pediatrics (Phila), 60(1), 42-49.
doi:10.1177/0009922820944398

Among these campaigns to enhance
preventive measures are safe storagepractices, gun locks, and storing ammunition
away from the weapon.

Spring 2023

ASSESSING WHEN THREATS WITH FIREARMS ARE FORMS
OF COERCIVE CONTROL IN DOMESTIC VIOLENCE
Threats of violence are, at a minimum, psychologicalabuse and a form of coercive control. Coercive control
is domestic violence (DV) when it is used by a partner
to intimidate, degrade, isolate, and control the victim’s
behavior. It can include low-level physical violence, sexual
coercion, stalking, and threats as well as severe violenceand homicide. Coercive control can create an ongoing
sense of fear and chronic stress. Threats can be explicit or
implicit. Explicit threats are easily recognizable while implicit threats may depend on the context and the historyof the relationship. An example of an implicit threat is “I
hope nothing bad happens to you.”
Coercive control can involve the use of a firearm
as a means of explicit or implicit threat. Threats with aweapon may include brandishing, loading with ammunition, pointing, firing, and verbally threatening to harm or
shoot. In addition to frightening a victim, a firearm canbe used to strike a victim, same as in the use of any physical object such as a club. The U.S. Department of Justicereported that from 1993–1998, about 27% of DV female
victims were threatened with a weapon. Threats of harm
to a victim as well as to a wide variety of others, including
pets and property, are serious issues for law enforcement,
medical, and social service providers and may be criminal
assault.
Both threats and coercive control are associated with
DV homicide. A study of criminal justice and victim
service professionals reported the perceived risk factors
based on their experiences for potentially fatal DV-related
firearm violence (Lynch, Jackson, & Logan, 2021). The
perceived risk for DV-related homicide in order fromhighest to lowest was:
1. Abuser threatened victim with a firearm
2. Victim separated from abuser
3. Abuser has access to a firearm
4. Abuser is stalking the victim
5. Abuser’s coercive controlling behavior

Risk assessment of DV victims should always include
nonviolent coercive control as it can escalate to severe
violence and homicide. Assessment may allow service
providers to identify patterns of abuse and control in addition to focusing on violent incidents. It is important toinquire exactly how firearms are explicitly and implicitly
used as a means of coercive control in DV and when andhow this becomes violent. This is an important point ofinquiry for service providers as this pattern could carrythrough to fatal violence. Sexual coercion should also be
considered as a risk factor for DV abuse and homicide.
Finally, whatever the methods of coercive control usedby an abuser, its frequency and, particularly, its severity
should also be assessed.
REFERENCE
Lynch, K. R., Jackson, D. B., & Logan, T. (2021). Coercive
control, stalking, and guns: Modeling service professionals’ perceived risk of potentially fatal intimate partner
gun violence. Journal of Interpersonal Violence, 36(15-16),
NP7997-NP8018. doi:10.1177/0886260519839419

Service providers should assess DV
victims for:1. The abuser’s threat to use a gun, or
2. Nonviolent coercive control that can lead to agreater perceived threat of harm.
3. Is the victim becoming increasingly frightened by
the abuser’s behavior and threats?

Providers should consider referring victims
for law enforcement and legal assistancewhen risk seems to be increasing.

Coercive control can involve the use of a
firearm as a means of explicit or implicit threat.

http://www.CSTSonline.org

RESEARCH REVIEW • 5

RESEARCH TO ACTION: SCREENING FOR FIREARM SAFETY
TO PREVENT INJURY AND DEATH
While not all firearm deaths and injuries can be prevented, providers can screen and counsel clients/patientsfor better firearm safety in the home. Such screening
could be presented as a Safety Checkup, part of routine
care that emphasizes a variety of injury prevention measures. For example, if the family has infants or toddlers
in the household, safe sleeping and drowning prevention
could also be included. The gun safety checkup can bedivided into two types of screening questions: (a) for individuals and families and (b) physical gun safety measures.
These two gun safety checkup tools encourage providers to screen and counsel clients who are at risk for gun
violence. This checkup promotes individual and family
gun safety practices and improved gun safety practices by
securing guns in the household. There are many risks that
Individual and Family Counseling Tools to
Prevent Firearm Injury and Death
1. Presence of guns in the household
2. Storage and handling practices — locked/unlocked;
loaded/unloaded; ammunition stored with/away from gun
3. Other risk factors — suicidal/homicidal ideation; historyof violence; current or past mental health problems ofoccupants of the home; substance abusemake a person and a family vulnerable to gun violence. We
have listed the most common ones here. If any of these arethought to be present, the provider should consider themas red flags for more extensive screening and counseling aswell as referral for clinical treatment and/or administrative
action such as informing authorities when the provider
believes the risk is high.
REFERENCE
Roberts, B., Masiakos, P. T., Vzcek, J., & Sathya, C. (2022).
Firearm injury and mortality prevention in pediatrichealth-care settings. Pediatrics in Review, 43(4), 212-221.

Improved Gun Safety
1. Cable locks — blocks loading the firearm. Can be used on
any gun.
2. Trigger locks — Locks around the trigger to prevent the gun
from being fired. Uses a key or combination lock.
3. Lock box — Small box in which a handgun is stored. Can be
opened with a key or combination lock.
4. Gun safe — Large safe to store multiple long and small guns.
5. Disassembling guns — Taking gun apart, requiring
reassembly for use.
6. Relinquishing guns — Remove access to guns on temporary
or permanent basis, voluntarily or involuntarily.

HEALTHCARE UTILIZATION AND EXPENDITURES FORNONFATAL FIREARM INJURIES OF CHILDREN
Nonfatal firearm injuries of children add a substantial
burden to the health care system in addition to sometimes
tragic outcomes for the families and the children. Nonfatal firearm injuries are largely preventable. Estimates ofthe social and economic costs associated with nonfatal
firearm injuries underestimate the total on individuals
and systems of care since these estimates do not accountfor time lost from school, from employment, trauma recidivism, or the potential impact on future opportunities
or life choices of the child or family.
A study of children treated in emergency departments
and inpatient facilities during 2010–2016 calculated thenumbers of encounters and costs one year prior and one
year after a nonfatal firearm-related injury (Pulcini et al.,2021). A total of 1,821 children had intentional (10%),
self-inflicted (1%), unintentional (55%), and undetermined (33%) firearm-related injuries. Costs of health expenditures increased by $16.5 million, $9,084 per patient.
For family advocacy programs and medical providers,
6 • JOINING FORCES/JOINING FAMILIES

it is noteworthy that 10% of firearm-related injuries wereintentional. However, the research did not report how
many injuries were inflicted by family members or froman assault outside the family.
10% of firearm injuries to children who
were seen in emergency departments wereintentionally inflicted. Providers should beaware of the need for safety measures toprevent nonfatal firearm injuries as well as
violent encounters.
REFERENCE
Pulcini, C. D., Goyal, M. K., Hall, M., Gruhler De Souza,
H., Chaudhary, S., Alpern, E. R… Fleegler, E. W. (2021).
Nonfatal firearm injuries: Utilization and expenditures forchildren pre- and postinjury. Academic Emergency Medicine, 28(8), 840-847.
Spring 2023