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After 19 children and two teachers were slaughtered by a gunman at Robb Elementary School in Uvalde, Texas, many Americans are asking, yet again, how to prevent future acts of senseless violence from occurring. What gun laws need to be changed? Why is it so difficult to pass regulations? How can Second Amendment rights be balanced with firearm safety? 

Stanford scholars have been studying these issues from a range of perspectives, including law, politics, economics, and medicine. Here are some of their findings.

Update: May 25, 2022: This story was originally published on Feb. 26, 2018, and has been updated to include new content.

Causes, impacts of gun violence

Uncovering the causes of gun violence has been a challenge, in part because research is limited by federal legislation that constrains research funding on the issue. Scholar Nigam Shah at the Stanford School of Medicine has written about how this has affected empirical study. But that has not deterred scholars from examining its impacts. David Studdert, also at the School of Medicine, has studied the devastating consequences of gun violence, particularly the risks it poses to public health.  

Maya Rossin-Slater, an associate professor of medicine and a senior fellow at the Stanford Institute for Economic Policy Research (SIEPR), has also looked at the long-term impact of gun violence, specifically among American children who experienced a shooting at their school. Rossin-Slater found that they have higher rates of absenteeism, lower high school and college graduation rates, and by their mid-twenties, earn lower incomes.

Below is some of that research. 

Californians living with handgun owners more than twice as likely to die by homicide, study finds

Residents who don’t own a handgun but live with someone who does are significantly more likely to die by homicide compared with those in gun-free homes, research shows.

New study of gun violence in schools identifies long-term harms

Research from SIEPR’s Maya Rossin-Slater finds that students exposed to school shootings face “lasting, persistent” adversity in their educational and long-term economic outcomes.

Shirin Sinnar on the Buffalo shooting, hate crimes, and domestic terrorism

In the wake of the Buffalo shooting, Stanford Law School’s Shirin Sinnar discusses the scale of white supremacist violence in the U.S. and the rise of hate crimes.

Disconnect: The gap between gun violence and research in numbers

Gun violence is much discussed but little studied, largely due to federal decisions governing research funding. A new analysis highlights just how big the gap between the violence and our knowledge of it is. The answer? It’s huge.

Supporting students exposed to school shootings

Maya Rossin-Slater talks about her research into the mental health impact of severe school violence.

Panel discusses how shootings affect those unscathed by bullets

A panel of faculty members at the School of Medicine said shootings can affect the mental health of people close to the violence.

California handgun sales spiked after two mass shootings

In the six weeks after the Newtown and San Bernardino mass shootings, handguns sales jumped in California, yet there is little research on why – or on the implications for public health, according to a Stanford researcher.

Mass shootings: Public face of a much larger epidemic

While mass shootings have become the public face of gun violence, they account for less than 1% of the 40,000 firearm deaths each year.  

Short-term hospital readmissions for gun injuries cost $86 million a year

A study from Stanford researchers has found that readmissions account for 9.5% of the $911 million spent annually on gun-injury hospitalizations.

Supporting children through loss

Rabbi Patricia Karlin-Neumann talks about how to help young people experiencing grief.

Firearm injuries in children, teens costly for U.S. health care system, Stanford study finds

The average cost of initial hospitalization to treat pediatric gun injuries is about $13,000 per patient and has risen in recent decades, a Stanford Medicine study found.

Investigating psychiatric illnesses of mass shooters

Ira Glick and his collaborators studied the psychiatric state of 35 mass shooters in the United States who survived the incidents, which took place between 1982 and 2019.

The silent cost of school shootings

SIEPR’s Maya Rossin-Slater finds the average rate of antidepressant use among youths under age 20 rose by 21 percent in the local communities where fatal school shootings occurred.

New study analyzes recent gun violence research

Consensus is growing in recent research evaluating the impact of right-to-carry concealed handgun laws, showing that they increase violent crime, despite what older research says.

Handgun ownership associated with much higher suicide risk

Men who own handguns are eight times more likely to die of gun suicides than men who don’t own handguns, and women who own handguns are 35 times more likely than women who don’t.

Advice on how to cope with the threat of school shootings

Victor Carrion offers advice on how families can cope with the stress of school safety.

Reducing gun violence

Many Americans are demanding practical steps to reduce gun crime. One way is to have more stringent gun safety policies, such as legislation requiring guns to be stored safely, more stringent background checks, or as President Biden announced Tuesday, a federal ban on assault weapons and high-capacity magazines. 

Research has shown that states with tighter policies save lives: One study by Stephanie Chao found that states with stricter gun laws have lower rates of gun deaths among children and teenagers, and states with child prevention access laws are linked with fewer gun suicides in this age group.

“If you put more regulations on firearms, it does make a difference,” said Chao, assistant professor of surgery and senior author of the study. “It does end up saving children’s lives.” Her analysis found that states with the strictest laws had a mortality rate of 2.6 per 100,000 and for states with the least strict laws, mortality rate was almost double at 5.0 per 100,000.  

John Donohue: One tragic week with two mass shootings and the uniquely American gun problem

In a Q&A, Stanford Law School gun law expert John J. Donohue III discusses mass shootings in the U.S., the challenges facing police when confronting powerful automatic weapons and the prospect of gun safety laws.

Lax state gun laws linked to more child gun deaths

States with strict gun laws have lower rates of gun deaths among children and teenagers, and laws to keep guns away from minors are linked with fewer gun suicides in this age group, a Stanford study found.

Improved gun buyer background checks would impede some mass shootings, Stanford expert says

Stanford Law Professor John Donohue says a background check system that was universal and effectively operated could impede gun acquisition by people who commit mass shootings.

How to solve more gun crimes without spending more money

Simple tweaks to how police process bullet casings could dramatically improve their forensic data.

Reducing civilian firepower would boost police and community safety, Stanford expert says

In addition to restricting the firepower a person can amass, Stanford law Professor John J. Donohue advocates efforts to build trust between communities and law enforcement agencies as a way to enhance both police and citizen safety.

Stricter gun laws reduce child and adolescent gun deaths, Stanford study finds

Laws that keep guns away from young people are especially strongly linked to lower rates of gun suicides in youth.

Gun legislation and policy

For nearly three decades, law Professor John Donohue III has studied what can be done to prevent gun violence in the United States. A lawyer and economist, Donohue explores how law and public policy are connected to gun violence, including how gun laws in the U.S. compare to other countries, as well as how legislation varies across the states, to better understand the effect that has on rates of violence. 

“The U.S. is by far the world leader in the number of guns in civilian hands,” Donohue explained . “The stricter gun laws of other ‘advanced countries’ have restrained homicidal violence, suicides and gun accidents – even when, in some cases, laws were introduced over massive protests from their armed citizens.” 

Here are some of his findings, and other research related to legislating gun safety in the U.S.

Stanford’s John Donohue on guns, mass shootings and the law in the U.S.

On Nov. 30, American students were once again the victims of a school shooting. Stanford law Professor John Donohue discusses the case and gun violence in the U.S.

How U.S. gun control compares to the rest of the world

While deaths from mass shootings are a relatively small part of the overall homicidal violence in America, they are particularly wrenching. The problem is worse in the U.S. than in most other industrialized nations. And it’s getting worse.

4 gun control steps U.S. needs now

John Donohue pens an opinion piece for CNN laying out four steps the United States should take to strengthen gun legislation.

Violent crime increases in right-to-carry states

Stanford Law School Professor John Donohue found that states that adopted right-to-carry concealed handgun laws have experienced a 13 to 15 percent increase in violent crime in the 10 years after enacting those laws.

Another mass shooting: An update on U.S. gun laws

In a Q&A, John Donohue discusses gun safety law and legislative developments.

Stanford GSE holds teach-in on research into gun violence in schools

Education scholars look at the evidence behind policy ideas to address school shootings.

Will Americans ever think differently about guns?

Stanford medicine and law professor David Studdert thinks more public health evidence is needed before cultural attitudes around gun safety and violence will change.

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From the bio-psycho-social model to the development of a clinical–forensic assessment tool for chronic pain in victims of violence: a research protocol.

1. Introduction

Study objectives, 2. materials and methods, 2.1. participants: inclusion and exclusion criteria, 2.2. study setting, 2.3. first step: analyzing the etiology, 2.3.1. measures, 2.3.2. statistical analysis, 2.4. second step: building an assessment battery of tools, 2.4.1. measures, psychological symptoms, pain and quality of life, 2.4.2. statistical analysis, 3. discussion, author contributions, institutional review board statement, informed consent statement, data availability statement, acknowledgments, conflicts of interest.

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Uvelli, A.; Pugliese, E.; Masti, A.; Salvo, G.; Duranti, C.; Gualtieri, G.; Ferretti, F. From the Bio-Psycho-Social Model to the Development of a Clinical–Forensic Assessment Tool for Chronic Pain in Victims of Violence: A Research Protocol. Brain Sci. 2024 , 14 , 953. https://doi.org/10.3390/brainsci14100953

Uvelli A, Pugliese E, Masti A, Salvo G, Duranti C, Gualtieri G, Ferretti F. From the Bio-Psycho-Social Model to the Development of a Clinical–Forensic Assessment Tool for Chronic Pain in Victims of Violence: A Research Protocol. Brain Sciences . 2024; 14(10):953. https://doi.org/10.3390/brainsci14100953

Uvelli, Allison, Erica Pugliese, Alessandra Masti, Giulia Salvo, Cristina Duranti, Giacomo Gualtieri, and Fabio Ferretti. 2024. "From the Bio-Psycho-Social Model to the Development of a Clinical–Forensic Assessment Tool for Chronic Pain in Victims of Violence: A Research Protocol" Brain Sciences 14, no. 10: 953. https://doi.org/10.3390/brainsci14100953

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Meet the public health researchers trying to rein in america's gun violence crisis.

Christine Spolar

A digital illustration of a circle of hands extending from the edge of the image, each holding a sheet of paper. The papers overlap in the center and, like a puzzle, come together to reveal a drawing of a handgun. Oona Tempest/KFF Health News hide caption

A digital illustration of a circle of hands extending from the edge of the image, each holding a sheet of paper. The papers overlap in the center and, like a puzzle, come together to reveal a drawing of a handgun.

Gun violence has exploded across the U.S. in recent years — from mass shootings at concerts and supermarkets to school fights settled with a bullet after the last bell.

Nearly every day of 2024 so far has brought more violence. On Feb. 14, gunfire at the Super Bowl parade in Kansas City, Missouri, killed one woman and wounded 22 other people. Most events draw little attention — while the injuries and toll pile up.

Gun violence is among America's most deadly and costly public health crises. But unlike other big killers — diseases like cancer and HIV or dangers like automobile crashes and cigarettes — sparse federal money goes to studying or preventing it.

That's because of a one-sentence amendment tucked into the 1996 Congressional budget bill: "None of the funds made available for injury prevention and control at the Centers for Disease Control and Prevention may be used to advocate or promote gun control."

Its author was Jay Dickey, an Arkansas Republican who called himself the "point man" for the National Rifle Association on Capitol Hill. And for nearly 25 years the amendment was perceived as a threat to, and all but paralyzed, the CDC's support and study of gun violence.

Goats and Soda

How the u.s. gun violence death rate compares with the rest of the world.

Even so, a small group of academics have toiled to document how gun violence courses through American communities with vast and tragic outcomes. Their research provides some light as officials and communities develop policies mostly in the dark.

It has also inspired a fresh generation of researchers to enter the field – people who grew up with mass shootings and are now determined to investigate harm from firearms. There is momentum now, in a time of rising gun injury and death, to know more.

The reality is stark:

Gun sales reached record levels in 2019 and 2020. Shootings soared. In 2021, for the second year , more people died from gun incidents — 48,830 — than in any year on record, according to a Johns Hopkins University analysis of CDC data. Guns became the leading cause of death for children and teens. Suicides accounted for more than half of those deaths, and homicides were linked to 4 in 10.

Gun deaths hit their highest level ever in 2021, with 1 person dead every 11 minutes

Black people are nearly 14 times as likely to die from firearm violence as white people — and guns were responsible for half of all deaths of Black teens ages 15 to 19 in 2021, the data showed.

Harvard research published in JAMA in 2022 estimated gun injuries translate into economic losses of $557 billion annually , or 2.6% of the U.S. gross domestic product.

With gun violence touching nearly every corner of the country, surveys show that Americans — whatever their political affiliation or whether they own guns or not — support policies that could reduce violence .

Quashing a quest for knowledge

It is no secret that many strategies for reducing harm from guns proposed today — from school metal detectors to enhanced policing, to the optimal timing and manner of safely storing guns, to restrictions on gun sales — have limited scientific ballast because of a lack of data.

It could have been otherwise.

U.S. firearm production surged in the late 1980s , flooding communities with more than 200 million weapons . In that era, Mark Rosenberg was the founding director of the CDC's National Center for Injury Prevention and Control and his agency, over time, was pivotal in helping to fund research on gun violence and public health.

Mark Rosenberg, one of the nation's top authorities on gun violence and public health, was the founding director of the National Center for Injury Prevention and Control at the CDC. Oona Tempest/KFF Health News hide caption

Rosenberg thought then that gun violence could go the way of car crashes. The federal government spent $200 million a year on research to redesign roadways and cars beginning in the 1970s, he said, and had seen death rates plummeted.

"We said, 'Why can't we do this with gun violence?'" Rosenberg said. "They figured out how to get rid of car crashes — but not cars. Why can't we do the same thing when it comes to guns?"

The Dickey Amendment sidelined that dream.

A study published in 1993 concluded that "guns kept in the home are associated with an increase in the risk of homicide," a finding on risk factors that prompted an uproar in conservative political circles. To newly elected representatives in the midterm "Republican Revolution" of 1994, the research was a swipe at gun rights. The NRA stepped up lobbying, and Congress passed what's known as the Dickey Amendment in 1996.

Some Democrats, such as the influential John Dingell of Michigan (a onetime NRA board member who received the group's " legislative achievement award "), would join the cause. Dingell proposed his own bills, detailed last summer by The New York Times .

Under heavy political pressure, the CDC ousted Rosenberg in 1999. Soon after, some CDC administrators began alerting the NRA to research before publication.

"It was clearly related to the work we were doing on gun violence prevention," Rosenberg, now 78, said of his job loss. "It was a shock."

Gun researchers who persevered

The quarter-century spending gap has left a paucity of data about the scope of gun violence's health effects: Who is shot and why? What motivates the violence? With what guns? What are the injuries? Can suicides, on the rise from gunfire, be reduced or prevented with safeguards? Does drug and alcohol use increase the chances of harm? Could gun safeguards reduce domestic violence? Ultimately, what works and what does not to prevent shootings?

If researchers say they "lost a generation" of knowledge about gun violence, then American families lost even more, with millions of lives cut short and a legacy of trauma passed down through generations.

Rebecca Cunningham, the vice president of research at the University of Michigan and an emergency medical doctor, organized a national conference last fall on the prevention of firearm harm that drew more than 750 academics and public health, law, and criminal justice experts. "You can feel momentum" for change, she says. Oona Tempest/KFF Health News hide caption

Imagine if cancer research had been halted in 1996 — many tumors that are now eminently treatable might still be lethal. "It's like cancer," said Rebecca Cunningham, vice president for research at the University of Michigan, an academic who has kept the thread of gun research going all these years. "There may be 50 kinds of cancer, and there are preventions for all of them. Firearm violence has many different routes, and it will require different kinds of science and approaches."

Cunningham is one of a small group of like-minded researchers from universities across the United States, who refused to let go of investigating a growing public health risk, and they pushed ahead without government funds.

Garen Wintemute has spent about $2.45 million of his money to support seminal research at the University of California-Davis. With state and private funding, he created a violence prevention program in California, a leader in firearm studies. He has documented an unprecedented increase in gun sales since 2020 — about 15 million transactions more than expected based on previous sales data.

Daniel Webster, a Johns Hopkins University researcher, has focused on teenagers and guns. Oona Tempest/KFF Health News hide caption

Daniel Webster at Johns Hopkins University focused on teenagers and guns — particularly access and suicides — and found that local police who coped with gun risks daily were willing to collaborate. He secured grants, even from the CDC, with carefully phrased proposals that avoided the word "guns," to study community violence.

At Duke University, Philip J. Cook explored the underground gun market, interviewing people incarcerated in Chicago jails and compiling pivotal social science research on how guns are bought, sold, and traded.

David Hemenway , an economist and public policy professor at Harvard, worked on the national pilot to document violent deaths — knowing most gun deaths would be recorded that way — because, he said, "if you don't have good data, you don't have nothin'."

Hemenway, writing in the journal Nature in 2017, found a 30% rise in gun suicides over the preceding decade and nearly a 20% rise in gun murders from 2014 to 2015. The data was alarming and so was the lack of preventive know-how, he wrote. "The US government, at the behest of the gun lobby, limits the collection of data, prevents researchers from obtaining much of the data that are collected and severely restricts the funds available for research on guns," he wrote. "Policymakers are essentially flying blind."

David Hemenway, a Harvard economist and public policy professor, anchored the work that led to the most ambitious database of U.S. gun deaths today. Oona Tempest/KFF Health News hide caption

His work helped create the most ambitious database of U.S. gun deaths today — the National Violent Death Reporting System . Funded in 1999 by private foundations, researchers were able to start understanding gun deaths by compiling data on all violent deaths from health department, police, and crime records in several states. The CDC took over the system and eventually rolled in data from all 50 states.

Still, no federal database of nonfatal gun injuries exists. So the government would record one death from the Super Bowl parade shooting, and the 22 people with gunshot injuries remain uncounted — along with many thousands of others over decades.

Philanthropy has supported research that Congress would not. The Joyce Foundation in Chicago funded the bulk of the grants, with more than $33 million since the 1990s. Arnold Ventures ' philanthropy and the Robert Wood Johnson Foundation have added millions more, as has Michael Bloomberg, the politician and media company owner. The Rand Corp. , which keeps a tab of ongoing research, finds states increasingly are stepping up.

Timothy Daly, a Joyce Foundation program director, said he remembers when the field of gun harm was described by some as a "desert." "There was no federal funding. There was slim private funding," he said. "Young people would ask themselves: 'Why would I go into that?'"

Research published in JAMA in 2017 found gun violence "was the least-researched" among leading causes of death. Looking at mortality rates over a decade, gun violence killed about as many people as sepsis, the data showed. If funded at the same rate, gun violence would have been expected to receive $1.4 billion in research funds. Instead, it received $22 million from across all U.S. government agencies.

There is no way to know what the firearm mortality or injury rate would be today had there been more federal support for strategies to contain it.

A reckoning and new push for research

As gun violence escalated to once unthinkable levels, Congressman Dickey came to regret his role in stanching research and became friends with Rosenberg. They wrote a pivotal Washington Post op-ed about the need for gun injury prevention studies. In 2016, they delivered a letter supporting the creation of the California Firearm Violence Research Center.

Both men, they emphasized, were NRA members and agreed on two principles: "One goal must be to protect the Second-Amendment rights of law-abiding gun owners; the other goal, to reduce gun violence."

Dickey died in 2017, and Rosenberg has only kind words for him. "I did not blame Jay at all for what happened," he said. The CDC was "under pressure from Congress to get rid of our gun research."

As alarm over gun fatality statistics from diverse sectors of the nation — scientists, politicians, and law enforcement — has grown, research in the field is finally gaining a foothold.

Even Congress, noting the Dickey Amendment was not an all-out ban, appropriated $25 million for gun research in late 2019, split between the CDC — whose imperative is to research public health issues — and the National Institutes of Health. It's a drop in the bucket compared with what was spent on car crashes, and it's not assured. House Republicans this winter have pushed an amendment to once again cut federal funding for CDC gun research.

Still it's a start. And with growing interest in the field, the torch has passed to the next generation of researchers.

In November, Cunningham helped organize a national conference on the prevention of firearm-related harm. More than 750 academics and professionals in public health, law, and criminal justice met in Chicago for hundreds of presentations. A similar event in 2019, the first in 20 years, drew just a few dozen presentations.

"You can feel momentum," Cunningham said at the conference, reflecting on the research underway. "There's a momentum to propel a whole series of evidence-based change — in the same way we have addressed other health problems."

During a congressional hearing weeks later , Yale University School of Public Health Dean Megan L. Ranney bluntly described the rising number of gun deaths — noting the overwhelming number of suicides — as a warning for lawmakers. "We are turning into a nation of traumatized survivors," she said, urging their support for better data and research on risk factors.

Cassandra Crifasi, co-director of the Johns Hopkins Center for Gun Violence Solutions, was in high school when the Columbine massacre shook the country. Oona Tempest/KFF Health News hide caption

Cassandra Crifasi, 41, was a high school sophomore when the Columbine massacre outside Littleton, Colorado, shook the country. She recently succeeded Webster, her mentor and research partner , as co-director of the Johns Hopkins Center for Gun Violence Solutions.

Crifasi has spent much of her career evaluating risk factors in gun use, including collaborative studies with Baltimore police and the city to reduce violence.

Raised in Washington state, Crifasi said she never considered required training in firearms an affront to the Second Amendment. She owns guns. In her family, which hunted, it was a matter of responsibility.

"We all learned to hunt. There are rules to follow. Maybe we should have everybody who wants to have a gun to do that," she said.

Crifasi pointed to the 2018 shooting at Marjory Stoneman Douglas High in Parkland, Florida — which left 17 dead and 17 injured — as a turning point. Students and their parents took "a page out of Mothers Against Drunk Driving — showing up, testifying, being in the gallery where laws are made," she said.

"People started to shift and started to think: This is not a third rail in politics. This is not a third rail in research," Crifasi said.

Shani Buggs, a lead investigator at the California Firearm Violence Research Center, has studied anxiety and depression among young people who live in neighborhoods with gun violence. Oona Tempest/KFF Health News hide caption

Shani Buggs worked in corporate management before she arrived at Johns Hopkins to pursue a master's in public health. It was summer 2012, and a gunman killed 12 moviegoers at a midnight showing of "The Dark Knight Rises" in Aurora, Colorado. The town's pain led the national news, and "rightfully so," Buggs said. "But I was in Baltimore, in East Baltimore, where there were shootings happening that weren't even consistently making the local news."

Now violence "that once was considered out of bounds, out of balance — it is more and more common," said Buggs who recently joined the California Firearm Violence Research Center as a lead investigator.

Buggs' research has examined anxiety and depression among youths who live in neighborhoods with gun violence — and notes that firearm suicide rates too have drastically increased among Black children and adolescents.

There is a trauma from hearing gunshots and seeing gun injuries, and daily life can be a thrum of risk in vulnerable communities, notably those largely populated by Black and Hispanic people, Buggs said. Last year, Buggs organized the Black and Brown Collective with a core group of about two dozen scientists committed to contextualizing studies on gun violence.

"The people most impacted by the gun violence we usually hear about in America look like our families," she said of the collective.

"They are not resilient. People are just surviving," Buggs said. "We need way more money to research and to understand and address the complexity of the problem."

KFF Health News , formerly known as Kaiser Health News (KHN), is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF — the independent source for health policy research, polling, and journalism.

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Expert Commentary

Domestic violence and abusive relationships: Research review

Research review of data and studies relating to intimate partner violence and abusive relationships.

Republish this article

This work is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License .

by John Wihbey, The Journalist's Resource August 17, 2015

This <a target="_blank" href="https://journalistsresource.org/criminal-justice/domestic-violence-abusive-relationships-research-review/">article</a> first appeared on <a target="_blank" href="https://journalistsresource.org">The Journalist's Resource</a> and is republished here under a Creative Commons license.<img src="https://journalistsresource.org/wp-content/uploads/2020/11/cropped-jr-favicon-150x150.png" style="width:1em;height:1em;margin-left:10px;">

The controversy over NFL star Ray Rice and the instance of domestic violence he perpetrated, which was caught on video camera, stirred wide discussion about sports culture, domestic violence and even the psychology of victims and their complex responses to abuse . In 2015, domestic violence drew a national spotlight again when the South Carolina newspaper, the Post and Courier , won a Pulitzer Prize for its investigation of women who were abused by men and had been dying at a rate of one every 12 days.

The research on domestic violence, referred to more precisely in academic literature as “intimate partner violence” (IPV), has grown substantially over the past few decades. Although knowledge of the problem and its scope have deepened, the issue remains a major health and social problem afflicting women. In November 2014 the World Health Organization estimated that 35% of all women have experienced either intimate partner violence or sexual violence by a non-partner during their lifetimes. This figure is supported by the findings of a 2013 peer-reviewed metastudy — the most rigorous form of research analysis — published in the leading academic journal Science . That metastudy found that “in 2010, 30.0% [95% confidence interval (CI) 27.8 to 32.2%] of women aged 15 and over have experienced, during their lifetime, physical and/or sexual intimate partner violence.” The prevalence found among high-income regions in North America was 21.3%. Of course, under-reporting remains a substantial problem in this research area.

In 2010, the National Intimate Partner and Sexual Violence Survey, conducted by the U.S. Centers for Disease Control and Prevention, found that “more than 1 in 3 women (35.6%) … in the United States have experienced rape, physical violence, and/or stalking by an intimate partner in their lifetime.” That survey was subsequently updated in September 2014. The findings, based on telephone surveys with more than 12,000 people in 2011, include:

The lifetime prevalence of physical violence by an intimate partner was an estimated 31.5% among women and in the 12 months before taking the survey, an estimated 4.0% of women experienced some form of physical violence by an intimate partner. An estimated 22.3% of women experienced at least one act of severe physical violence by an intimate partner during their lifetimes. With respect to individual severe physical violence behaviors, being slammed against something was experienced by an estimated 15.4% of women, and being hit with a fist or something hard was experienced by 13.2% of women. In the 12 months before taking the survey, an estimated 2.3% of women experienced at least one form of severe physical violence by an intimate partner.

Still, the overall rates of IPV in the United States have been generally falling over the past two decades, and in 2013 the federal government reauthorized an enhanced Violence Against Women Act , adding further legal protections and broadening the groups covered to include LGBT persons and Native American women. (For research on the relatively higher violence rates among gay men, see the 2012 study “Intimate Partner Violence and Social Pressure among Gay Men in Six Countries.” )

A 2013 study published in the Journal of Marriage and Family , “Women’s Education, Marital Violence, and Divorce: A Social Exchange Perspective,” analyzes a nationally representative sample of more than 900 young U.S. women to look at factors that make females more likely to leave abusive relationships. The researchers, Derek A. Kreager, Richard B. Felson, Cody Warner and Marin R. Wenger, are all at Pennsylvania State University. They note that traditional “social exchange theory” would suggest that as women have more resources, they become less dependent on men and have more opportunities outside relationships, and therefore have more ability to divorce. The study sets out to “determine whether the relationship between a woman’s education and divorce is different in violent marriages.” The researchers also hypothesize that women who have higher levels of education are less likely to get divorced in general — prior academic work they cite supports this — but they aim to see how the introduction of intimate partner violence changes this dynamic.

The study’s findings include:

• The data provide “support for our primary hypotheses that women’s education typically protects against divorce but that this association weakens in abusive marriages. In addition, we found a similar pattern for wives’ proportional income, net of education. Together, these patterns suggest that educational and financial resources benefit women by increasing marital stability in nonabusive marriages and promoting divorce in abusive marriages.”
• Further, the “greater tendency for educated women to leave abusive marriages was substantial. For example, in highly violent marriages, women with a college degree had over a 10% greater probability of divorce in the observed time period than women without a college degree.”
• The study also finds that “women with economic resources were likely to leave unhappy marriages, regardless of whether they involve abuse. Similarly, degree-earning women were more likely than less educated women to leave violent marriages, regardless of their feelings of dissatisfaction.”

The researchers note that, across the U.S. population, more women are attaining college degrees, and given the study’s findings, this suggests “increases in women’s education should reduce rates of domestic violence. In a population with many educated women, violent marriages are likely to break up.” They caution that it is also possible “that our observed patterns reflect husbands’ perceptions and decisions. Perhaps abusive men feel threatened by successful wives, which then increases divorce risk. Nonabusive men may not feel threatened and thus stay with successful women.” On this point, more research is required.

Related research: A 2015 study titled “When War Comes Home: The Effect of Combat Service on Domestic Violence” suggests that multiple deployments and longer deployment lengths may increase the chance of family violence. A June 2014 study published in the  Journal of Interpersonal Violence , “Intimate Partner Violence Before and During Pregnancy: Related Demographic and Psychosocial Factors and Postpartum Depressive Symptoms Among Mexican American Women,”  provides a snapshot of domestic violence in a community sample of low-income Hispanic women. A March 2013 report from the U.S. Department of Justice’s Bureau of Justice Statistics, “Female Victims of Sexual Violence, 1994-2010,” provides a broad picture of such crimes across American society, examining the demographics of both victims and offenders. Regarding the issue of IPV prevention, a 2003 metastudy published in the Journal of the American Medical Association (JAMA) , “Interventions for Violence Against Women: Scientific Review,” found that “information about evidence-based approaches in the primary care setting for preventing IPV is seriously lacking…. Specifically, the effectiveness of routine primary care screening remains unclear, since screening studies have not evaluated outcomes beyond the ability of the screening test to identify abused women. Similarly, specific treatment interventions for women exposed to violence, including women’s shelters, have not been adequately evaluated.” Subsequent research continues to find problems with current techniques for screening and detection.

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About The Author

John Wihbey

Gun Violence: Prediction, Prevention, and Policy

• Gun Violence and Crime
• Physical Abuse and Violence

Gun violence is an urgent, complex, and multifaceted problem. It requires evidence-based, multifaceted solutions. Psychology can make important contributions to policies that prevent gun violence. Toward this end, in February 2013 the American Psychological Association commissioned this report by a panel of experts to convey research-based conclusions and recommendations (and to identify gaps in such knowledge) on how to reduce the incidence of gun violence — whether by homicide, suicide, or mass shootings — nationwide.

Following are chapter-by-chapter highlights and short summaries of conclusions and recommendations of the report’s authors. More information and supporting citations can be found within the chapters themselves.

Antecedents to Gun Violence: Developmental Issues

A complex and variable constellation of risk and protective factors makes persons more or less likely to use a firearm against themselves or others. For this reason, there is no single profile that can reliably predict who will use a gun in a violent act. Instead, gun violence is associated with a confluence of individual, family, school, peer, community, and sociocultural risk factors that interact over time during childhood and adolescence. Although many youths desist in aggressive and antisocial behavior during late adolescence, others are disproportionately at risk for becoming involved in or otherwise affected by gun violence. The most consistent and powerful predictor of future violence is a history of violent behavior.  P revention efforts guided by research on developmental risk can reduce the likelihood that firearms will be introduced into community and family conflicts or criminal activity.  Prevention efforts can also reduce the relatively rare occasions when severe mental illness contributes to homicide or the more common circumstances when depression or other mental illness contributes to suicide. Reducing incidents of gun violence arising from criminal misconduct or suicide is an important goal of broader primary and secondary prevention and intervention strategies. Such strategies must also attend to redirecting developmental antecedents and larger sociocultural processes that contribute to gun violence and gun-related deaths.

Antecedents to Gun Violence: Gender and Culture

Any account of gun violence in the United States must be able to explain both why males are perpetrators of the vast majority of gun violence and why the vast majority of males never perpetrate gun violence. Preliminary evidence suggests that changing perceptions among males of social norms about behaviors and characteristics associated with masculinity may reduce the prevalence of intimate partner and sexual violence. Such interventions need to be further tested for their potential to reduce gun violence. The skills and knowledge of psychologists are needed to develop and evaluate programs and settings in schools, workplaces, prisons, neighborhoods, clinics, and other relevant contexts that aim to change gendered expectations for males that emphasize self-sufficiency, toughness, and violence, including gun violence.

What Works: Gun Violence Prediction and Prevention at the Individual Level

Although it is important to recognize that most people suffering from a mental illness are not dangerous, for those persons at risk for violence due to mental illness, suicidal thoughts, or feelings of desperation, mental health treatment can often prevent gun violence. Policies and programs that identify and provide treatment for all persons suffering from a mental illness should be a national priority. Urgent attention must be paid to the current level of access to mental health services in the United States; such access is woefully insufficient. Additionally, it should be noted that behavioral threat assessment is becoming a standard of care for preventing violence in schools, colleges, and the workplace and against government and other public officials. Threat assessment teams gather and analyze information to assess if a person poses a threat of violence or self-harm, and if so, take steps to intervene.

What Works: Gun Violence Prevention at the Community Level

Prevention of violence occurs along a continuum that begins in early childhood with programs to help parents raise emotionally healthy children and ends with efforts to identify and intervene with troubled individuals who are threatening violence. The mental health community must take the lead in advocating for community-based collaborative problem-solving models to address the prevention of gun violence. Such models should blend prevention strategies in an effort to overcome the tendency within many community service systems to operate in silos. There has been some success with community-based programs involving police training in crisis intervention and with community members trained in mental health first aid. These programs need further piloting and study so they can be expanded to additional communities as appropriate. In addition, public health messaging campaigns on safe gun storage are needed. The practice of keeping all firearms appropriately stored and locked must become the only socially acceptable norm.

What Works: Policies to Reduce Gun Violence

The use of a gun greatly increases the odds that violence will lead to a fatality: This problem calls for urgent action. Firearm prohibitions for high-risk groups — domestic violence offenders, persons convicted of violent misdemeanor crimes, and individuals with mental illness who have been adjudicated as being a threat to themselves or to others — have been shown to reduce violence. The licensing of handgun purchasers, background check requirements for all gun sales, and close oversight of retail gun sellers can reduce the diversion of guns to criminals. Reducing the incidence of gun violence will require interventions through multiple systems, including legal, public health, public safety, community, and health. Increasing the availability of data and funding will help inform and evaluate policies designed to reduce gun violence.

Dewey Cornell, PhD, and Nancy G. Guerra, EdD

Gun violence is an important national problem leading to more than 31,000 deaths and 78,000 nonfatal injuries every year. Although the rate of gun homicides in the United States has declined in recent years, U.S. rates remain substantially higher than those of almost every other nation in the world and are at least seven times higher than those of Australia, Canada, France, Germany, India, Italy, Japan, South Korea, Spain, Sweden, the United Kingdom, and many others (see Alpers & Wilson).

Guns are not a necessary or sufficient cause of violence and can be used legally for a variety of sanctioned activities. Still, they are especially lethal weapons that are used in approximately two thirds of the homicides and more than half of all suicides in the United States. Every day in the United States, approximately 30 persons die of homicides and 53 persons die of suicides committed by someone using a gun (Centers for Disease Control and Prevention [CDC], 2013a). Guns also provide individuals with the capacity to carry out multiple-fatality shootings that inflict great trauma and grief on our society, and the public rightly insists on action to make our communities safer.

Gun violence demands special attention. At the federal level, President Barack Obama announced a new “Now Is the Time” plan (White House, 2013) to address firearm violence to better protect children and communities and issued 23 related executive orders to federal agencies. The importance of continued research to address firearm violence is reflected in the 2013 report of the Institute of Medicine (IOM) and the National Research Council (NRC) "Priorities for Research to Reduce the Threat of Firearm-Related Violence. "  This report calls for a public health approach that emphasizes the importance of accurate information on the number and distribution of guns in the United States, including risk factors and motivations for acquisition and use, the association between exposure to media violence and any subsequent perpetration of gun violence, and how new technology can facilitate prevention. The report also outlines a research agenda to facilitate programs and policies that can reduce the occurrence and impact of firearm-related violence in the United States.

Psychology can make an important contribution to policies that prevent gun violence. Rather than debate whether “people” kill people or “guns” kill people, a reasonable approach to facilitate prevention is that “people with guns kill people.” The problem is more complex than simple slogans and requires careful study and analysis of the different psychological factors, behavioral pathways, social circumstances, and cultural factors that lead to gun violence. Whether prevention efforts should focus on guns because they are such a powerful tool for violence, on other factors that might have equal or greater impact, or on some combination of factors should be a scientific question settled by evidence.

Toward this end, the American Psychological Association (APA) commissioned this report, with three goals. First, this report is intended to focus on gun violence, recognizing that knowledge about gun violence must be related to a broader understanding of violence. Second, the report reviews what is known from the best current science on antecedents to gun violence and effective prevention strategies at the individual, community, and national levels. Finally, the report identifies policy directions, gaps in the literature, and suggestions for continued research that can help address unresolved questions about effective strategies to reduce gun violence. For over a decade, research on gun violence has been stifled by legal restrictions, political pressure applied to agencies not to fund research on certain gun-related topics, and a lack of funding. The authors of this report believe the cost of gun violence to our society is too great to allow these barriers to remain in place.

The Role of Mental Health and Mental Illness

An important focus of this report is the role that mental health and mental illness play in why individuals commit firearm-related violence and how this can inform preventive efforts. This focus undoubtedly brings to mind shootings such as those in Newtown, Conn., Aurora, Colo., and Tucson, Ariz. However, it is important to realize that mass fatality incidents of this type, although highly publicized, are extremely rare, accounting for one tenth of 1 percent of all firearm-related homicides in the United States (CDC, 2013a). Moreover, serious mental illness affects a significant percentage of the U.S. population, with prevalence estimates in the general population as high as 5 percent (Substance Abuse and Mental Health Services Administration [SAMHSA], 2012). This is quite significant, given that the term serious mental illness is typically reserved for the most debilitating kinds of mental disorder, such as schizophrenia, bipolar disorder, and the most severe forms of depression, but can include other mental disorders that result in acute functional impairment.

Although many highly publicized shootings have involved persons with serious mental illness, it must be recognized that persons with serious mental illness commit only a small proportion of firearm-related homicides; the problem of gun violence cannot be resolved simply through efforts focused on serious mental illness (Webster & Vernick, 2013a). Furthermore, the overwhelming majority of people with serious mental illness do not engage in violence toward others and should not be stereotyped as dangerous (Sirotich, 2008).

It also is important to recognize that for the small proportion of individuals whose serious mental illness does predispose them to violence, there are significant societal barriers to treatment. Psychiatric hospitalization can be helpful, but treatment can be expensive, and there may not be appropriate follow-up services in the community. Civil commitment laws, which serve to protect individuals from being unreasonably detained or forced into treatment against their will, can also prevent professionals from treating someone who does not recognize his or her need for treatment.

Other kinds of mental disorders that do not rise to the level of serious mental illness also are associated with gun violence and criminal behavior generally. For example, conduct disorder and antisocial personality disorder are associated with increased risk for violence. (This link is not surprising because violent behavior is counted as one of the symptoms that helps qualify someone for the diagnosis.) Nevertheless, there are well-established, scientifically validated mental health treatment programs for individuals with these disorders, such as multisystemic therapy, that can reduce violent recidivism (Henggeler, 2011). Substance abuse is another form of mental disorder that is a risk factor for violence in the general population and also increases the risk for violence among persons with serious mental illness (Van Dorn, Volavka, & Johnson, 2012).

These observations reflect the complexity of relationships among serious mental illness, mental disorders, and violence. In contrast to homicide, suicide accounts for approximately 61 percent of all firearm fatalities in the United States (CDC, 2013a), and more than 90 percent of persons who commit suicide have some combination of depression, symptoms of other mental disorders, and/or substance abuse (Moscicki, 2001). This suggests that mental health and mental illness are especially relevant to understanding and preventing suicide, the leading type of firearm-related death.

Prediction and Prevention

The prediction of an individual’s propensity for violence is a complex and challenging task for mental health professionals, who often are called upon by courts, correctional authorities, schools, and others to assess the risk of an individual’s violence. Mental health professionals are expected to take action to protect potential victims when they judge that their patient or client poses a danger to others. However, decades of research have established that there is only a moderate ability to identify individuals likely to commit serious acts of violence. Much depends on the kind of violence and the time frame for prediction. For example, there are specialized instruments for the assessment of violence risk among sex offenders, civilly committed psychiatric patients, and domestic violence offenders. However, the time frame and focus for these predictions often are broadly concerned with long-term predictions that someone will ever be violent with anyone rather than whether a person will commit a particular act of targeted violence.

Research has moved the field beyond the assessment of “dangerousness” as a simple individual characteristic applicable in all cases to recognize that predictive efforts must consider a range of personal, social, and situational factors that can lead to different forms of violent behavior in different circumstances. Moreover, risk assessment has expanded to include concepts of risk management and interventions aimed at reducing risk.

In making predictions about the risk for mass shootings, there is no consistent psychological profile or set of warning signs that can be used reliably to identify such individuals in the general population. A more promising approach is the strategy of behavioral threat assessment , which is concerned with identifying and intervening with individuals who have communicated threats of violence or engaged in behavior that clearly indicates planning or preparation to commit a violent act. A threat assessment approach recognizes that individuals who threaten targeted violence are usually troubled, depressed, and despondent over their circumstances in life. A threat assessment leads to interventions intended to reduce the risk of violence by taking steps to address the problem that underlies the threatening behavior. Such problems can range from workplace conflicts to schoolyard bullying to serious mental illness. One of the most influential threat assessment models was developed by the U.S. Secret Service (Fein et al., 2002; Vossekuil, Fein, Reddy, Borum, & Modzelski, 2002) and has been adapted for use in schools, colleges, business settings, and the U.S. military.

The limited ability to make accurate predictions of violence has led some to question whether prevention is possible. This is a common misconception, because prevention does not require prediction of a specific individual’s behavior . For example, public health campaigns have reduced problems ranging from lung cancer to motor vehicle accidents by identifying risk factors and promoting safer behaviors even though it is not possible to predict whether a specific individual will develop lung cancer or have a motor vehicle accident (Mozaffarian, Hemenway, & Ludwig, 2013). A substantial body of scientific evidence identifies important developmental, familial, and social risk factors for violence. In addition, an array of rigorously tested psychological and educational interventions facilitate healthy social development and reduce aggressive behavior by teaching social skills and problem-solving strategies. It is important that policymakers and stakeholders recognize the value of prevention.

Prevention measures also should be distinguished from security measures and crisis response plans. Prevention must begin long before a gunman comes into a school or shopping center. Prevention efforts are often conceptualized as taking place on primary, secondary, and tertiary levels:

• Primary prevention (also called universal prevention) consists of efforts to promote healthy development in the general population. An example would be a curriculum to teach all children social skills to resist negative peer influences and resolve conflicts peacefully.
• Secondary prevention (also called selective prevention) involves assistance for individuals who are at increased risk for violence. Mentoring programs and conflict-mediation services are examples of such assistance.
• Tertiary prevention (also called indicated prevention) consists of intensive services for individuals who have engaged in some degree of aggressive behavior and could benefit from efforts to prevent a recurrence or escalation of aggression. Programs to rehabilitate juvenile offenders are examples.

Throughout this report, we discuss evidence-based prevention programs relevant to the issue of firearm-related violence.

Research can help us understand and prevent gun violence. The psychological research summarized in this report can inform public policy and prevention efforts designed to promote public safety and reduce violence. Gun violence is not a simple, discrete category of crime; it shares characteristics with other forms of violence, and it can be a product of an array of cultural, social, psychological, and situational factors. Nevertheless, there is valuable psychological knowledge that can be used to make our communities safer.

Robert Kinscherff, PhD, JD; Nancy G. Guerra, EdD; and Ariel A. Williamson, MA

Youth gun violence is often sensationalized and misunderstood by the general public, in part because of increasingly public acts of violence and related media coverage (Snyder & Sickmund, 2006; Williams, Tuthill, & Lio, 2008). In truth, only a small number of juvenile offenders commit the majority of violent juvenile crimes in the United States (Williams et al., 2008). Most juvenile offenders commit “nonperson” offenses, usually in terms of property and technical (parole) violations (Sickmund, Sladky, Kang, & Puzzanchera, 2011). For example, in 2010, the majority of juvenile offenses were nonperson offenses such as property offenses (27.2 percent), drug offenses (8.4 percent), public order offenses (10.7 percent), technical violations (14.4 percent), and status offenses (4.6 percent) — that is, crimes defined by minor (under age 18) status, such as alcohol consumption, truancy, and running away from home (Sickmund et al., 2011). Additionally, young adults between the ages of 18 and 34 are the most likely to commit violent crimes like homicide and to do so using a gun, compared with individuals under 18 (Cooper & Smith, 2011).

A subgroup of youth is particularly vulnerable to violence and victimization. Minority males constitute a disproportionate number of youths arrested and adjudicated, with 60 percent of all arrested youths identifying as part of a racial/ethnic minority group (Sickmund et al., 2011). Males also outnumber females in arrest rates for every area except status offenses and technical violations. Urban African American males are at substantially greater risk for involvement in gun-related homicides as perpetrators and as victims (CDC, 2013a; Spano, Pridemore, & Bolland, 2012). However, the majority of the infrequent but highly publicized shootings with multiple fatalities, such as those at Sandy Hook Elementary School or the Aurora, Colo., movie theater, have been committed by young White males.

This presents a picture of a small number of youths and young adults who are at an increased risk for involvement in gun violence. In the United States, these youths are somewhat more likely to be males of color growing up in urban areas. But it also is important to understand that most young males of all races and ethnicities — and most people in general — are not involved in serious violence and do not carry or use guns inappropriately.

How did this small subset of youths and young adults come to be involved in serious gun violence? Is there a “cradle-to-prison” pipeline, particularly for youths of color living in poverty and in disadvantaged urban areas, that triggers a cascade of events that increase the likelihood of gun violence (Children’s Defense Fund, 2009)? A developmental perspective on antecedents to youth gun violence can help us design more effective prevention programs and strategies.

This chapter describes the biological and environmental risk factors that begin early in development and continue into adolescence and young adulthood. Developmental studies that link children’s aggressive behavior to more serious involvement in the criminal justice system suggest the accumulation and interaction of many risks in multiple contexts (Dodge, Greenberg, Malone, & Conduct Problems Prevention Research Group, 2008; Dodge & Pettit, 2003). There is no single biological predisposition, individual trait, or life experience that accounts for the development and continuity of violent behavior or the use of guns. Rather, violence is associated with a confluence of individual, family, school, peer, community, and sociocultural risk factors that interact over time during childhood and adolescence (Brennan, Hall, Bor, Najman, & Williams, 2003; Dodge & Pettit, 2003). Risk for gun violence involves similar risk processes, although the complexity and variability of individuals means there is no meaningful profile that allows reliable prediction of who will eventually engage in gun violence. Nevertheless, developmental factors beginning in utero may increase the risk of aggressive behavior and lead to gun violence — especially when guns are readily available and part of an aggressive or delinquent peer culture.

Early-Onset Aggression

Early onset of aggressive behavior significantly increases risk for later antisocial behavior problems. The most consistent and powerful predictor of future violence is a history of violent behavior, and risk increases with earlier and more frequent incidents. Longitudinal work has shown that having a first arrest between 7 and 11 years of age is associated with patterns of long-term adult offending (Loeber, 1982). Children who are highly aggressive throughout childhood and continue to have serious conduct problems during adolescence have been identified as “life-course persistent” (LCP) youths (Moffitt, 1993). Examining longitudinal data from a large birth cohort in New Zealand, Moffitt (1993) created a taxonomy of antisocial behavior that differentiates LCP youths from an “adolescence-limited” subgroup. The latter subgroup characterizes those who engage in antisocial behaviors during adolescence and usually desist by adulthood. By contrast, LCP youths display more severe early aggression in childhood and develop a pattern of chronic violence during adolescence and into adulthood.

Both biological and environmental risks during prenatal development, infancy, and early childhood contribute to the development of early-onset aggression and the LCP developmental trajectory (Brennan et al., 2003; Dodge & Pettit, 2003; Moffitt, 2005). Pre- and postnatal risks associated with early-onset aggression include maternal substance abuse during pregnancy, high levels of prenatal stress, low birth weight, birth complications and injuries (especially those involving anoxia), malnutrition, and exposure to environmental toxins like lead paint (Brennan et al., 2003; Dodge & Pettit, 2003). According to Moffitt (1993), these early developmental risks disrupt neural development and are associated with neuropsychological deficits, particularly in executive functioning and verbal abilities.

Along with neuropsychological deficits, poor behavioral control and a difficult temperament are associated with the development of early-onset aggression (Dodge & Pettit, 2003; Moffitt, 1993). Children with difficult temperaments are typically irritable, difficult to soothe, and highly reactive. These patterns of behavior often trigger negative and ineffective reactions from parents and caregivers that can escalate into early aggressive behavior (Dodge & Pettit, 2003; Wachs, 2006). Family influences, such as familial stress and negative parent–child interactions, can interact with a child’s individual characteristics, leading to increased aggressive behavior during childhood.

Family Influences

Highly aggressive children who engage in serious acts of violence during later childhood and adolescence also are exposed to continued environmental risks throughout development (Dodge et al., 2008). The family context has been found to be quite influential in the development and continuity of antisocial behavior. Particularly for early-onset aggressive youths raised in families that are under a high degree of environmental stress, aggressive child behavior and negative parenting practices interact to amplify early-onset aggression. Examples of family risk factors include low parent–child synchrony and warmth, poor or disrupted attachment, harsh or inconsistent discipline (overly strict or permissive), poor parental monitoring, the modeling of antisocial behavior, pro-violent attitudes and criminal justice involvement, and coercive parent–child interaction patterns (Dodge & Pettit, 2003; Farrington, Jolliffe, Loeber, Stouthamer-Loeber, & Kalb, 2001; Hill, Howel, Hawkins, & Battin-Pearson, 1999; Patterson, Forgatch, & DeGarmo, 2010).

Coercive parent–child interactions have been associated with the emergence of aggressive behavior problems in children (Patterson et al., 2010). In these interactions, children learn to use coercive behaviors such as temper tantrums to escape parental discipline. When parents acquiesce to these negative behaviors, they inadvertently reward children for coercive behaviors, reinforcing the idea that aggression or violence is adaptive and can be used instrumentally to achieve goals. These interaction patterns tend to escalate in their severity (e.g., from whining, to temper tantrums, to hitting, etc.) and frequency, leading to increased aggression and noncompliance (Patterson et al., 2010). Such behaviors also generalize across contexts to children’s interactions with others outside the home, including with teachers, other adults, and peers. Indeed, prevention research has shown that intervening with at-risk families to improve parenting skills can disrupt the pathway from early-onset aggressive behavior to delinquency in adolescence (Patterson et al., 2010).

Other family risk factors for youths with early predispositions to aggression may be especially relevant to increased risk for gun violence. For instance, research has shown that many families with children own firearms and do not keep them safely stored at home (Johnson, Miller, Vriniotis, Azrael, & Hemenway, 2006). Although keeping firearms at home is not a direct cause of youth gun violence, the rates of suicides, homicides, and unintentional firearm fatalities are higher for 5–14-year-olds who live in states or regions in which rates of gun ownership are more prevalent (Miller, Azrael, & Hemenway, 2002). Poor parental monitoring and supervision, which are more general risk factors for involvement in aggression and violent behaviors (Dodge et al., 2008), may be especially salient in risk for gun violence. For example, impulsive or aggressive children who are often unsupervised and live in a home with access to guns may be at risk.

The family also is an important context for socialization and the development of normative beliefs or perceptions about appropriate social behavior that become increasingly stable during early development and are predictive of later behavior over time (Huesmann & Guerra, 1997). These beliefs shape an individual’s social-cognitive understanding about whether and under what circumstances threatened or actual violence is justified. Children who develop beliefs that aggression is a desirable and effective way to interact with others are more likely to use coercion and violence instrumentally to achieve goals or solve problems (Huesmann & Guerra, 1997). Antisocial attitudes and social-cognitive distortions (e.g., problems in generating nonviolent solutions, misperceiving hostile/aggressive intent by others, justifying acts of violence that would be criminal) can also increase risk for violence (Borum & Verhaagen, 2006; Dodge & Pettit, 2003).

Families can play a role in establishing and maintaining normative beliefs about violence and gun usage. For example, pro-violence attitudes and the criminality of parents and siblings during childhood have been found to predict adolescent gang membership and delinquency (Farrington et al., 2001; Hill et al., 1999). Youths from families that encourage the use of guns for solving problems also may be exposed to such attitudes in other contexts (in communities, with peers, and in the media) and may perceive firearms to be an appropriate means to solve problems and protect themselves.

School and Peer Influences

The school setting is another important context for child socialization. Children who enter school with high levels of aggressive behavior, cognitive or neurobiological deficits, and poor emotional regulation may have difficulty adjusting to the school setting and getting along with peers (Dodge et al., 2008; Dodge & Pettit, 2003). Highly aggressive children who have learned to use aggression instrumentally at home will likely use such behavior with teachers, increasing the chances that they will have poor academic experiences and low school engagement (Patterson et al., 2010). Academic failure, low school interest, truancy, and school dropout are all correlated with increased risk for problem behavior and delinquency, including aggression and violence (Dodge & Pettit, 2003). This risk is strongest when poor academic achievement begins in elementary school and contributes to school underachievement and the onset of adolescent problem behaviors, such as substance use and drug trafficking, truancy, unsafe sexual activity, youth violence, and gang involvement (Dodge et al., 2008; Guerra & Bradshaw, 2008).

Involvement in these risk behaviors also is facilitated by affiliation with deviant peers, particularly during adolescence (Dodge et al., 2008). Research has shown that children who are aggressive, victimized, and academically marginalized from the school setting may suffer high levels of peer rejection that amplify preexisting aggressive behaviors (Dodge et al., 2008; Dodge & Pettit, 2003). Longitudinal work indicates that experiences of academic failure, school marginalization, and peer rejection interact to produce affiliations with similarly rejected, deviant, and/or gang-involved peers. Friendships between deviant peers provide youths with “training” in antisocial behaviors that reinforce and exacerbate preexisting aggressive tendencies (Dishion, Véronneau, & Meyers, 2010; Dodge et al., 2008). Peer deviancy training is a primary mechanism in the trajectory from overt, highly aggressive behaviors during childhood to more covert processes during adolescence, such as lying, stealing, substance use, and weapon carrying (Dishion et al., 2010; Patterson et al., 2010).

The larger school context also can interact with youths’ experiences of academic failure, peer rejection, and deviant peer affiliations to influence the continuity of antisocial behavior. Poorly funded schools located in low-income neighborhoods have fewer resources to address the behavioral, academic, mental health, and medical needs of their students. In addition, these schools tend to have stricter policies toward discipline, are less clinically informed about problem behaviors, and have stronger zero tolerance policies that result in more expulsions and suspensions (Edelman, 2007). This contextual factor is important, as youths who are attending and engaged in school are less likely to engage in delinquent or violent behavior, whereas marginalized and rejected youths, particularly in impoverished schools, are at increased risk for aggression and violence at school and in their communities. Schools that provide safe environments that protect students from bullying or criminal victimization support student engagement, reduce incidents of student conflict that could result in volatile or violent behavior, and diminish risks that students will bring weapons to school.

Although few homicides (< 2 percent) and suicides occur at school or during transportation to and from school (Roberts, Zhang, & Truman, 2012) and widely publicized mass school shootings are rare, research indicates that a small number of students do carry guns or other weapons. In 2011, 5.1 percent of high school students in Grades 9–12 reported carrying a gun in the 30 days prior to the survey, and 5.4 percent of students had carried a weapon (gun, knife, or club) on school grounds at least once in the 30 days prior to the survey (Eaton et al., 2012). Studies show that youths who carry guns are more likely to report involvement in multiple problem behaviors, to be affiliated with a gang, to overestimate how many of their peers carry guns, and to have a high need for interpersonal safety. For instance, student reports of involvement in and exposure to risk behaviors at school such as physical fighting, being threatened, using substances, or selling drugs on school grounds have been positively correlated with an increased likelihood of carrying weapons to school (Furlong, Bates, & Smith, 2001).

In another study of high school students, 5.5 percent of urban high school students reported that they carried a gun in the year prior to the study, but students estimated that 32.6 percent of peers in their neighborhoods carried guns, a substantial overestimation of the actual gun-carrying rates. Lawful, supervised gun carrying by juveniles is not the concern of this line of research; however, when unsupervised youths carry guns in high-violence neighborhoods, they may be more likely to use guns to protect themselves and resolve altercations. Gun-carrying youths in this study had higher rates of substance use, violence exposure, gang affiliation, and peer victimization (Hemenway, Vriniotis, Johnson, Miller, & Azrael, 2011). Additionally, many gun-carrying youths had lower levels of perceived interpersonal safety (Hemenway et al., 2011). Research has also revealed that deviant peer group affiliations during specific periods of adolescent development may increase the risk for gun violence. For example, research findings have shown that gang membership in early adolescence is significantly associated with increased gun carrying over time. This changes somewhat in late adolescence and young adulthood, when gun carrying is linked more to involvement in drug dealing and having peers who illegally own guns (Lizotte, Krohn, Howell, Tobin, & Howard, 2000).

Communities Matter

The community context is an additional source of risk for the development and continuity of antisocial behavior. Living in extremely disadvantaged, underresourced communities with high levels of crime and violence creates serious obstacles to healthy development. Recent estimates show that currently in the United States, 16.4 million children live in poverty and 7.4 million of those live in extreme poverty (i.e., an annual income of less than half of the federal poverty level; Children’s Defense Fund, 2012). One in four children under 5 years of age is poor during the formative years of brain development. In addition, 22 percent of children who have lived in poverty do not graduate from high school, compared with 6 percent of children who have never been poor (Children’s Defense Fund, 2012). For families and youths, living in poverty is associated with high levels of familial stress, poor child nutrition, elevated risks of injury, and limited access to adequate health care (Adler & Steward, 2010; Patterson et al., 2010). Ethnic minority youth in the United States are overrepresented in economically struggling communities. These environmental adversities can, in turn, compromise children’s health status and functioning in other environments and increase the risk for involvement in violent behaviors, contributing significantly to ethnic and cultural variations in the rates of violence (Borum & Verhaagen, 2006).

In a community context, the degree to which children have access to adequate positive resources (e.g., in terms of health, finances, nutrition, education, peers, and recreation), have prosocial and connected relationships with others, and feel safe in their environment can significantly affect their risk for involvement in violent behaviors. Aggressive children and adolescents who are living in neighborhoods with high levels of community violence, drug and firearm trafficking, gang presence, and inadequate housing may have increased exposure to violence and opportunities for involvement in deviant behavior. Compared with communities that have better resources, disenfranchised and impoverished communities may also lack social, recreational, and vocational opportunities that contribute to positive youth development. Youths with high levels of preexisting aggressive behavior and emerging involvement with deviant or gang-involved peers may be especially at risk for increased violent behavior and subsequent criminal justice involvement when exposed to impoverished and high-crime communities.

Exposure to violence in one’s community, a low sense of community safety, unsupervised access to guns, and involvement in risky community behaviors such as drug dealing all contribute to youths’ involvement in gun carrying and gun violence. Decreased community perceptions of neighborhood safety and higher levels of social (e.g., loitering, public substance use, street fighting, prostitution, etc.) and physical (e.g., graffiti, gang signs, and discarded needles, cigarettes, and beer bottles) neighborhood disorder have been associated with increased firearm carrying among youths (Molnar, Miller, Azrael, & Buka, 2004). A study of African American youths living in poverty found that those who had been exposed to violence prior to carrying a gun were 2.5 times more likely than nonexposed youths to begin carrying a gun at the next time point, even when controlling for gang involvement (Spano et al., 2012). This study also indicated that after exposure to violence, youths were more likely to start carrying guns in their communities (Spano et al., 2012).

Studies have shown that apart from characteristics like conduct problems and prior delinquency, youths who are involved in gang fighting and selling drugs are also more likely to use a gun to threaten or harm others (e.g., Butters, Sheptycki, Brochu, & Erikson, 2011). Involvement in drug dealing in one’s community appears to be particularly risky for gun carrying during later adolescence and early adulthood, possibly due to an increased need for self-protection (Lizotte et al., 2000). Taken together, these studies show that firearm possession may be due to interactions between the need for self-protection in violent communities and increased involvement in delinquent behaviors.

Sociocultural Context: Exposure to Violent Media

Child and adolescent exposure to violent media, a more distal, sociocultural influence on behavior, is also important when considering developmental risks for gun violence. Decades of experimental, cross-sectional, and longitudinal research have documented that exposure to violent media, in movies and television, is associated with increased aggressive behaviors, aggressive thoughts and feelings, increased physiological arousal, and decreased prosocial behaviors (e.g., Anderson et al., 2003; Anderson & Bushman, 2001; Huesmann, 2010; Huesmann, Moise-Titus, Podolski, & Eron, 2003). In light of ongoing advances in technology, research has been expanded to include violent content in video games, music, social media, and the Internet (Anderson et al., 2010; IOM & NRC, 2013).

Findings on associations between violent media exposure and aggressive behavior outcomes have held across differences in culture, gender, age, socioeconomic status, and intellect (e.g., Anderson et al., 2010; Huesmann et al., 2003). Social-cognitive theory on violent media exposure suggests that these images are part of children’s socialization experiences, similar to violence exposure in interpersonal and community contexts (Huesmann, 2010). The viewing of violent images can serve to desensitize children to violence and normalize violent behavior, particularly when children have previously developed beliefs that aggression and violence are an acceptable means of achieving goals or resolving conflicts.

It is important to note that the link between violent media exposure and subsequent violent behaviors does not demonstrate a direct causal effect but instead shows how some children may be more susceptible to this risk factor than others. For instance, Huesmann et al. (2003) found that identification with aggressive characters on television and the perception that television violence was real were robust predictors of later aggression over time. Additionally, there is no established link between violent media exposure and firearm usage in particular. However, given the substantial proportion of media that includes interactions around firearms (e.g., in video games, movies, and television shows), the IOM and NRC (2013) recently identified a crucial need to examine specific associations between exposure to violent media and use of firearms. Exposure to violent media, especially for youths with preexisting aggressive tendencies and poor parental monitoring, may be an important contextual factor that amplifies risk for violent behavior and gun use.

Summary and Conclusions

The relatively small number of youths most likely to persist in serious acts of aggression (including increased risk of gun violence) have often experienced the following:

• Early childhood onset of persistent rule-breaking and aggression
• Socialization into criminal attitudes and behaviors by parents and caretakers who themselves are involved in criminal activities
• Exposure in childhood to multiple adverse experiences in their families and communities
• Social dislocation and reduced opportunities due to school failure or underachievement
• Persisting affiliation with deviant peers or gangs engaged in delinquent/criminal misconduct and with attitudes and beliefs that support possession and use of guns
• Broad exposure to sociocultural influences such as mass media violence and depictions of gun violence as an effective means of achieving goals or status

Most youths — even those with chronic and violent delinquent misconduct — desist in aggressive and antisocial behavior during late adolescence, and no single risk factor is sufficient to generate persisting violent behavior. Still, many are disproportionately at risk for becoming perpetrators or victims of gun violence. Homicide remains the second leading cause of death for teens and young adults between the ages of 15 and 24. In 2010, there were 2,711 infant, child, and adolescent victims of firearm deaths. In that year, 84 percent of homicide victims between the ages of 10 and 19 were killed with a firearm, and 40 percent of youths who committed suicide between the ages 15 and 19 did so with a gun (CDC, 2013a). 1

There is no one developmental trajectory that specifically leads to gun violence. However, prevention efforts guided by research on developmental risk can reduce the likelihood that firearms will be introduced into community and family conflicts or criminal activity. Prevention efforts can also reduce the relatively rare occasions when severe mental illness contributes to homicide or the more common circumstances when depression or other mental illness contributes to suicide.

Reducing incidents of gun violence arising from criminal misconduct or suicide is an important goal of broader primary and secondary prevention and intervention strategies. Such strategies must also attend to redirecting developmental antecedents and larger sociocultural processes that contribute to gun violence and gun-related deaths.

1 The 2010 data shown here are available online .

Eric Mankowski, PhD

Any account of gun violence in the United States must consider both why males are the perpetrators of the vast majority of gun violence and why the vast majority of males never perpetrate gun violence. An account that explains both phenomena focuses, in part, on how boys and men learn to demonstrate and achieve manhood through violence, as well as the differences in opportunities to demonstrate manhood among diverse groups of males. Although evidence exists for human biological and social-environmental systems interacting and contributing to aggressive and violent behavior, this review focuses on the sociocultural evidence that explains males’ higher rates of gun violence.

Reducing the propensity for some males to engage in violence will involve both social and cultural change. Hence, this section reviews existing research on the relationships between sex, gender (i.e., masculinity), and the perpetration and victimization of gun violence in the United States. The intersection of gender, race/ethnicity, and economic disadvantage is also considered in explaining the rates of gun violence across diverse communities. Finally, the relationships between masculinity, gender socialization, and gun violence are analyzed to identify gender-related risk factors for gun violence that can be targeted for prevention strategies and social policy.

Sex Differences in Gun Violence

Prevalence and Risk Men represent more than 90 percent of the perpetrators of homicide in the United States and are also the victims of the large majority (78 percent) of that violence (Bureau of Justice Statistics, 2008; Federal Bureau of Investigation [FBI], 2007). Homicide by gun is the leading cause of death among Black youth, the second leading cause of death among all male youth, and the second or third leading cause of death among female youth (depending on the specific age group) (e.g., Miniño, 2010; Webster, Whitehill, Vernick, & Curriero, 2012). In addition, roughly four times as many youths visit hospitals for gun-induced wounds as are killed each year (CDC, 2013a).

Even more common than homicide, suicide is another leading cause of death in the United States, and most suicides are completed with a firearm. Males complete the large majority of suicides; depending on the age group, roughly four to six times as many males as females kill themselves with firearms (CDC, 2013a). Among youth, suicide ranks especially high as a cause of death. It is the third leading cause of death of 15–24-year-olds and the sixth leading cause of death for 5–14-year-olds. However, the rate of suicide and firearm suicide gradually increases over the lifespan. In addition to gender and age differences in prevalence, sizable differences also exist among ethnic groups. Firearm suicide generally is at least twice as high among Whites than among Blacks and other racial groups from 1980 to 2010 (CDC, 2013a), and White males over the age of 65 have rates that far exceed all other major groups.

Perpetrator–Victim Relationship and Location The prevalence of gun violence strongly depends not only on the sex of the offender but also on the offender’s relationship to the victim and the location of the violence (Sorenson, 2006). Both men and women are more likely to be killed with firearms by someone they know than by a stranger. Specifically, men are most likely to be killed in a public place by an acquaintance, whereas women are most likely to be killed in the home by a current or former spouse or dating partner (i.e., “intimate partner”). Women compared with men are especially likely to be killed by a firearm used by an intimate partner.

Women are killed by current or former intimate partners four to five times more often than men (Campbell, Glass, Sharps, Laughon, & Bloom, 2007), including by firearm. These sex differences in victimization do not appear to hold in the limited data available on same-sex intimate partner homicide; it is more common for men to kill their male partners than for women to kill their female partners (Campbell et al., 2007). Notably, these sex differences in gun violence, as a function of the type of perpetrator–victim relationships, are also found in nonfatal gun violence when emergency room visits are examined (Wiebe, 2003).

A disproportionate number of gun homicides occur in urban areas. Conversely, a disproportionate number of firearm suicides occur in rural (compared with urban) areas (Branas, Nance, Elliott, Richmond, & Schwab, 2004). Although they are highly publicized, less than 2 percent of the homicides of children occur in schools (Borum, Cornell, Modzeleski, & Jimerson, 2010; CDC, 2008, 2013b). There are even fewer “random” or “mass” school shootings in which multiple victims are killed at the same time.

Gun Access and Possession A person must own or obtain a gun to be able to commit gun violence. Research shows that there are sex differences in access to and carrying a gun. Males are roughly two to four times as likely as females to have access to a gun in the home or to possess a gun (Swahn, Hamming, & Ikeda, 2002; Vaughn et al., 2012). In turn, gun carrying is a key risk factor for gun violence perpetration and victimization. For example, gun carrying is associated with dating violence victimization among adolescents, with boys more likely to be victimized than girls (Yan, Howard, Beck, Shattuck, & Hallmark-Kerr, 2010).

Conclusions based on sex differences in access to guns should be drawn with some caution, given that there also appear to be sex differences in the reporting of guns in the home. Men report more guns in the home than do women from the same household (e.g., Ludwig, Cook, & Smith, 1998; Sorenson & Cook, 2008), a sex difference that appears to stem specifically from the substantially higher level of contact with and experience in handling and using guns among boys than girls in the same household (Cook & Sorenson, 2006). Nonetheless, the presence of guns in the home remains predictive of gun violence.

Gender and Gun Violence

Robust sex and race differences in firearm violence have been established. Examined next is how the socialization of men as well as differences in living conditions and opportunities among diverse groups of boys and men help explain why these differences occur.

Making Gender Visible in the Problem of Gun Violence Gender remains largely invisible in research and media accounts of gun violence. In particular, gender is not used to explain the problem of “school shootings,” despite the fact that almost every shooting is perpetrated by a young male. Newspaper headlines and articles describe “school shooters,” “violent adolescents,” and so forth, but rarely call attention to the fact that nearly all such incidents are perpetrated by boys and young men. Studies of risk factors for school shootings may refer accurately to the perpetrators generally as “boys” but largely fail to analyze gender (e.g., Verlinden, Hersen, & Thomas, 2000).

The large sex differences in gun violence should not be overlooked simply because the vast majority of boys and men do not perpetrate gun violence or excused as “boys will be boys.” The size of sex differences in the prevalence of gun violence differs substantially within regions of the United States (Kaplan & Geling, 1998) and across countries (e.g., Ahn, Park, Ha, Choi, & Hong, 2012), which further suggests that gender differences in sociocultural environments are needed to explain sex differences in gun violence.

Masculinity, Power, and Guns Status as a “man” is achieved by the display of stereotypically masculine characteristics, without which one’s manhood is contested. Although the particular characteristics defining manhood and the markers of them can vary across subcultural contexts (Connell, 1995), masculinity has, historically, generally been defined by aggressive and risk-taking behavior, emotional restrictiveness (particularly the vulnerable emotions of fear and sadness, and excepting anger), heterosexuality, and successful competition (Brannon, 1976; Kimmel, 1994; O’Neil, 1981). Such normative characteristics of traditional masculinity are in turn directly related to numerous factors that are associated with gun violence. For example, risk taking is associated with adolescent males’ possession of and access to guns (Vittes & Sorenson, 2006).

Social expectations and norms, supported by social and organizational systems and practices, privilege boys who reject or avoid in themselves anything stereotypically feminine, act tough and aggressive, suppress emotions (other than anger), distance themselves emotionally and physically from other men, and strive competitively for power. Men of color, poor men, gay men, and men from other marginalized groups differ substantially in their access to opportunities to fulfill these manhood ideals and expectations in socially accepted ways. For example, men with less formal educational and economic opportunity, who in the United States are disproportionately Black and Latino, cannot fulfill expectations to be successful breadwinners in socially acceptable ways (e.g., paid, legal employment) as easily as White men, and gay men have less ability to demonstrate normative heterosexual masculinity where they cannot legally marry or have children.

At the same time, higher levels of some forms of violence victimization and perpetration (including suicide) are found among these disadvantaged groups. For example, gay youth are more likely than heterosexual males to commit suicide, and African American male youth are disproportionately the victims of gun violence. Such structural discrimination can be seen reflected in implicit cognitive biases against these group members. Virtual simulations of high-threat incidents, such as those used to train police officers, reliably demonstrate a “shooter bias” in which actors are more likely to shoot Black male targets than those from other race-gender groups (i.e., Black women, White men, and White women) (Plant, Goplen, & Kunstman, 2011).

Even to the extent that it is achieved, manhood status is theorized as precarious, needing to be protected and defended through aggression and violence, including gun violence, in order to avoid victimization from (mostly) male peers (Connell, 1995). Paradoxically, as in all competition, the more convincingly manhood is achieved, the more vulnerable it becomes to challenges or threats and thus requires further defending, often with increasing levels and displays of toughness and violence. The dynamic of these expectations of manhood and their enforcement is like a tight box (Kivel, 1998). Boys and men are either trapped inside this box or, in violating the expectations by stepping out of the box, risk being targeted by threats, bullying, and other forms of violence.

Adherence to stereotypic masculinity, in turn, is commonly associated with stress and conflict, poor health, poor coping and relationship quality, and violence (Courtenay 2000; Hong, 2000). Men’s gender role stress and conflict are directly associated with various forms of interpersonal aggression and violence, including the perpetration of intimate partner violence and suicide (Feder, Levant, & Dean, 2010; Moore & Stuart, 2005; O’Neil, 2008). Men with more restricted emotionality and more restricted affection with other men are more likely to be aggressive, coercive, or violent (O’Neil, 2008). These dimensions of masculinity also are related to a number of other harmful behaviors that are, in turn, associated directly with gun violence and other forms of aggression (see O’Neil, 2008, for a review). For example, the effect of alcohol consumption on intimate partner violence is greater among men than women (Moore, Elkins, McNulty, Kivisto, & Handsel, 2011), and alcohol consumption may be associated with lethal male-to-male violence at least partly because it is associated with carrying a gun (Phillips, Matusko, & Tomasovic, 2007).

In addition, accumulating research evidence indicates a relationship between gender and many of the factors that are associated with suicide (e.g., substance abuse, unemployment; Payne, Swami, & Stanistreet, 2008). Beliefs in traditional masculinity are related to suicidal thoughts, although differently across age cohorts (Hunt, Sweeting, Keoghan, & Platt, 2006). Men’s historic role as economic providers in heterosexual families typically ends with their retirement from the workforce. Suicide rates, including firearm suicide, increase dramatically at precisely this point in the life course (i.e., age 65 and older), whereas they decrease among women this age. The increase in suicide rates among White men at age 65 and older does not occur among Black men, who as a group have much higher levels of unemployment throughout their lives and consequently may not experience the same sense of loss of meaning or entitlement. Male firearm suicide also increases dramatically in adolescence and early adulthood, precisely the years during which young men’s sense of manhood is developing.

Beliefs about gender and sexual orientation also help explain sex differences in fatal hate crimes involving guns. Key themes in male gender role expectations are anti-femininity (Brannon, 1976) and homophobia (Kimmel, 1994). Boys are expected to rid themselves of stereotypically feminine characteristics (e.g., “you throw like a girl,” “big boys don’t cry”). Gun violence against lesbian, gay, bisexual, and transgendered persons can be understood in this context. One explanation of these hate crimes is that they are perpetrated to demonstrate heterosexual masculinity to male peer group members. These homicides, compared with violent crimes in which the victim is (or is perceived to be) heterosexual, often are especially brutal and are more commonly perpetrated by groups of men rather than individual men or women. However, such homicides appear to be perpetrated less often using firearms, which suggests motives beyond a desire to kill — for example, expressing intense hatred or transferring negative affect directly onto the victim (Gruenwald, 2012).

Male role expectations for achievement of success and power, combined with restricted emotionality, may have dangerous consequences, particularly for boys who suffer major losses and need help. A majority of the males who have completed homicides at schools had trouble coping with a recent major loss. Many had also experienced bullying or other harassment (Vossekuil et al., 2002). Such characteristics cannot and should not be used to develop risk profiles of attackers because school shootings are such rare events, and so many men who share these same characteristics never will perpetrate gun violence. However, when male gender and characteristics associated with male gender are highly common among attackers, it is responsible to ask how male gender contributes to school shootings and other forms of gun violence.

In their case studies of male-perpetrated homicide-suicides at schools, Kalish and Kimmel (2010) speculated that a sense of “aggrieved entitlement” may be common among the shooters. In this view, the young men see suicide and revenge as appropriate, even expected, responses for men to perceived or actual victimization. Related findings emerged from a similar analysis of all “random” school shootings (those with multiple, nontargeted victims) from 1982 to 2001 (Kimmel & Mahler, 2003). With a small number of exceptions, the vast majority were committed by White boys (26 of 28) in suburban or rural (not urban) areas (27 of 28). Many of these boys also had experienced homophobic bullying.

Masculinity and Beliefs About Guns Sex differences in beliefs about guns may begin at an early age as a function of parental socialization and attitudes. Fathers, particularly White fathers, are more permissive than mothers of their children, particularly sons, playing with toy guns (Cheng et al., 2003). Through the socialization of gender, boys and men may come to believe that displaying a gun will enhance their masculine power. Carrying a weapon is, in fact, instrumental in fulfilling male gender role expectations. Estimates of a person’s physical size and muscularity are greater when they display a gun (or large knife) than other similarly sized and shaped objects (e.g., drill, saw), even when the person is only described and not visible. This perception persists despite no apparent correlation between actual gun ownership and size or muscularity (Fessler, Holbrook, & Snyder, 2012). Guns symbolically represent some key elements of hegemonic masculinity — power, hardness, force, aggressiveness, coldness (Connell, 1995; Stroud, 2012).

Implications for Prevention and Policy

Sex Differences in Attitudes Toward Gun Policies Policies and laws addressing the manufacture, purchase, and storage of guns have been advocated in response to the prevalence of gun violence. Perhaps reflecting their differential access to firearms and differential perpetration and victimization rates, men and women hold different attitudes about such gun control policies. Females are generally much more favorable toward gun restriction and control policies (e.g., Vittes, Sorenson, & Gilbert, 2003).

Prevention Programs Addressing Gender The foregoing analysis of the link between gender and gun violence suggests the potential value of addressing gender in efforts to define the problem of gun violence and develop preventive responses. Preliminary evidence suggests that correcting and changing perceptions among men of social norms regarding beliefs about behaviors and characteristics that are associated with stereotypic masculinity may reduce the prevalence of intimate partner and sexual violence (Fabiano, Perkins, Berkowitz, Linkenbach, & Stark, 2003; Neighbors et al., 2010). However, the effect of such interventions in specifically reducing gun violence remains to be tested. The skills and knowledge of psychologists are needed to develop and evaluate programs and settings in schools, workplaces, prisons, neighborhoods, clinics, and other relevant contexts that aim to change gendered expectations for males that emphasize self-sufficiency, toughness, and violence, including gun violence.

Robert Kinscherff, PhD, JD; Arthur C. Evans Jr., PhD; Marisa R. Randazzo, PhD; and Dewey Cornell, PhD

A natural starting point for the prevention of gun violence is to identify individuals who are at risk for violence and in need of assistance. Efforts focused on at-risk individuals are considered secondary prevention because they are distinguished from primary or universal prevention efforts that address the general population. Secondary prevention strategies for gun violence can include such actions as providing prompt mental health treatment for an acutely depressed and suicidal person or conducting a threat assessment of a person who has threatened gun violence against a spouse or work supervisor.

To be effective, strategies to prevent gun violence should be tailored to different kinds of violence. One example is the distinction between acts of impulsive violence (i.e., violence carried out in the heat of the moment, such as an argument that escalates into an assault) and acts of targeted or predatory violence (i.e., acts of violence that are planned in advance of the attack and directed toward an identified target). The incidents of mass casualty gun violence that have garnered worldwide media attention, such as the shootings at Sandy Hook Elementary School in Newtown, Conn., at a movie theater Aurora, Colo., at the Fort Hood military base, and at a political rally in a shopping center in Tucson, Ariz., are all examples of targeted or predatory violence. Distinguishing between impulsive violence, targeted/predatory violence, and other types of violence is important because they are associated with different risk factors and require different prevention strategies.

Predicting and Preventing Impulsive Gun Violence

Research on impulsive violence has enabled scientists to develop moderately accurate predictive models that can identify individuals who are more likely than other persons to engage in this form of violence. These models cannot determine with certainty whether a particular person will engage in violence — just whether a person is at greater likelihood of doing so. This approach is known as a violence risk assessment or clinical assessment of dangerousness . A violence risk assessment is conducted by a licensed mental health professional who has specific training in this area. The process generally involves comparing the person in question with known base rates for those of the same age/gender who have committed impulsive violence and then determining whether the person in question has individual risk factors that would increase that person’s likelihood of engaging in impulsive violence. In addition, the process involves examining individual protective factors that would decrease the person’s overall likelihood of engaging in impulsive violence. Research that has identified risk and protective factors for impulsive violence is limited in that more research has been conducted on men than women and on incarcerated or institutionalized individuals than on those in the general population. Nevertheless, this approach can be effective for determining someone’s relative likelihood of engaging in impulsive violence.

Some risk factors for impulsive violence are static — for example, race and age — and cannot be changed. But those factors that are dynamic — for example, unmet mental health needs for conditions linked with violence to self (such as depression) or others (such as paranoia), lack of mental health care, abuse of alcohol — are more amenable to intervention and treatment that can reduce the risk for gun violence. Secondary prevention strategies to prevent impulsive gun violence can include having a trained psychologist or other mental health professional treat the person’s acute mental health needs or substance abuse needs. There must be a vigorous and coordinated response to persons whose histories include acts of violence, threatened or actual use of weapons, and substance abuse, particularly if they have access to a gun. This response should include a violence risk assessment by well-trained professionals and referral for any indicated mental health treatment, counseling and mediation services, or other forms of intervention that can reduce the risk of violence.

Youths and young adults who are experiencing an emerging psychosis should be referred for prompt assessment by mental health professionals with sufficient clinical expertise with psychotic disorders to craft a clinical intervention plan that includes risk management. In some cases, secondary prevention measures may include a court-ordered emergency psychiatric hospitalization where a person can receive a psychiatric evaluation and begin treatment. Criteria for allowing such involuntary evaluations vary by state but typically can occur only when someone is experiencing symptoms of a serious mental illness and, as a result, potentially poses a significant danger to self or others. There is an urgent need to improve the effectiveness of emergency commitment procedures because of concerns that they do not provide sufficient services and follow-up care.

Predicting and Preventing Targeted or Predatory Gun Violence

Acts of targeted or predatory violence directed at multiple victims, including crimes sometimes referred to as rampage shootings and mass shootings, 2 occur far less often in the United States than do acts of impulsive violence (although targeted violence garners far more media attention). Acts of targeted violence have not been subject to study that has developed statistical models like those used for estimating a person’s likelihood of impulsive violence. Although it seems appealing to develop checklists of warning signs to construct a profile of individuals who commit these kinds of crimes, this effort, sometimes described as psychological profiling, has not been successful. Research has not identified an effective or useful psychological profile of those who would engage in multiple casualty gun violence. Moreover, efforts to use a checklist profile to identify these individuals fail in part because the characteristics used in these profiles are too general to be of practical value; such characteristics are also shared by many nonviolent individuals.

Because of the limitations of a profiling approach, practitioners have developed the behavioral threat assessment model as an alternative means of identifying individuals who are threatening, planning, or preparing to commit targeted violence. Behavioral threat assessment also emphasizes the need for interventions to prevent violence or harm when a threat has been identified, so it represents a more comprehensive approach to violence prevention. The behavioral threat assessment model is an empirically based approach that was developed largely by the U.S. Secret Service to evaluate threats to the president and other public figures and has since been adapted by the U.S. Secret Service and U.S. Department of Education (Fein et al., 2002; Vossekuil et al., 2002) and others (Cornell, Allen, & Fan, 2012) for use in schools, colleges and universities, workplaces, and the U.S. military. Threat assessment teams are typically multidisciplinary teams that are trained to identify potentially threatening persons and situations. They gather and analyze additional information, make an informed assessment of whether the person is on a pathway to violence — that is, determine whether the person poses a threat of interpersonal violence or self-harm — and if so, take steps to intervene, address any underlying problem or treatment need, and reduce the risk for violence.

Behavioral threat assessment is seen as the emerging standard of care for preventing targeted violence in schools, colleges, and workplaces, as well as against government officials and other public figures. The behavioral threat assessment approach is the model currently used by the U.S. Secret Service to prevent violence to the U.S. president and other public officials, by the U.S. Capitol Police to prevent violence to members of Congress, by the U.S. State Department to prevent violence to dignitaries visiting the United States, and by the U.S. Marshals Service to prevent violence to federal judges (see Fein & Vossekuil, 1998). The behavioral threat assessment model also is recommended in two American national standards: one for higher education institutions (which recommends that all colleges and universities operate behavioral threat assessment teams; see ASME-Innovative Technologies Institute, 2010) and one for workplaces (which recommend s similar teams to prevent workplace violence; see ASIS International and Society for Human Resource Management, 2011). In addition, a comprehensive review conducted by a U.S. Department of Defense (2010) task force following the Fort Hood shooting concluded that threat assessment teams or threat management units (i.e., teams trained in behavioral threat assessment and management procedures) are the most effective tool currently available to prevent workplace violence or insider threats like the attack at Fort Hood.

Empirical research on acts of targeted violence has shown that many of those attacks were carried out by individuals motivated by personal problems who were at a point of desperation. In their troubled state of mind, these individuals saw no viable solution to their problems and could envision no future. The behavioral threat assessment model is used not only to determine whether a person is planning a violent attack but also to identify personal or situational problems that could be addressed to alleviate desperation and restore hope. In many cases, this includes referring the person to mental health services and other sources of support. In some of these cases, psychiatric hospitalization may be needed to address despondence and suicidality. Nonpsychiatric resources also can help alleviate the individual’s problems or concerns. Resources such as conflict resolution, credit counseling, job placement assistance, academic accommodations, veterans’ services, pastoral counseling, and disability services all can help address personal problems and reduce desperation. When the underlying personal problems are alleviated, people who may have posed a threat of violence to others no longer see violence as their best or only option.

Predicting and Preventing Violence by Those With Acute Mental Illness

When treating a person with acute or severe mental illness, mental health professionals may encounter situations in which they need to determine whether their patient (or client) is at risk for violence. Typically, they would conduct a violence risk assessment if the clinician’s concern is about risk for impulsive violence, as discussed previously. Clinicians also can conduct — or work with a team to help conduct — a threat assessment if their concern involves targeted violence. The available research suggests that mental health professionals should be concerned when a person with acute mental illness makes an explicit threat to harm someone or is troubled by delusions or hallucinations that encourage violence, but even in these situations, violence is far from certain. Although neither a violence risk assessment nor a threat assessment can yield a precise prediction of someone’s likelihood of violence, it can identify high-risk situations and guide efforts to reduce risk. It is important to emphasize that prevention does not require prediction; interventions to reduce risk can be beneficial even if it is not possible to determine who would or would not have committed a violent act.

When their patients (or clients) pose a risk of violence to others, mental health professionals have a legal and ethical obligation to take appropriate action to protect potential victims of violence. This obligation is not easily carried out for several reasons. First, mental health professionals have only a modest ability to predict violence, even when assisted by research-validated instruments. Mental health professionals who are concerned that a patient is at high risk for violence may be unable to convince their patient to accept hospitalization or some other change in treatment. They can seek involuntary hospitalization or treatment, but civil commitment laws (that vary from state to state) generally require convincing evidence that a person is imminently dangerous to self or others. There is considerable debate about the need to reform civil commitment laws in a manner that both protects individual liberties and provides necessary protection for society.

There is no guarantee that voluntary or involuntary treatment of a potentially dangerous individual will be effective in reducing violence risk, especially when the risk for violence does not arise from a mental illness but instead from intense desperation resulting from highly emotionally distressing circumstances or from antisocial orientation and proclivities for criminal misconduct. When individuals with prior histories of violence are released from treatment facilities, they typically need continued treatment and monitoring for potential violence until they stabilize in community settings. Jurisdictions vary widely in the resources available to achieve stability in the community and in the legal ability to impose monitoring or clinical care on persons who decline voluntary services.

Furthermore, if unable to obtain civil commitment to a protective setting, mental health professionals must consider other protective actions permitted in their jurisdictions, which may include warning potential victims that they are in danger or alerting local law enforcement, family members, employers, or others. Whether their particular jurisdiction mandates a response to “warn or protect” potential victims or leaves this decision to the discretion of the clinician, mental health professionals are often reluctant to take such actions because they are concerned that doing so might damage the therapeutic relationship with their patient and drive patients from treatment or otherwise render effective treatment impossible.

Another post-hospitalization strategy is to prohibit persons with mental illness from acquiring a firearm. The Gun Control Act of 1968 prohibited persons from purchasing a firearm if they had been involuntarily committed to a psychiatric inpatient unit. The Brady Handgun Violence Act (1994), known as the Brady Law, began the process of background checks to identify individuals who might attempt to purchase a firearm despite prohibitions. There is some evidence that rates of gun violence are reduced when these procedures are adequately implemented, but research, consistent implementation, and refinement of these procedures are needed (Webster & Vernick, 2013a).

Predicting and Preventing Gun-Based Suicide

Suicide accounts for approximately 61 percent of all firearm fatalities in the United States — 19,393 of the 31,672 firearm deaths reported by the CDC for 2010 (Murphy, Xu, & Kochanek, 2013). When there is concern that a person may be suicidal, mental health professionals can conduct suicide screenings and should rely on structured assessment tools to assess that person’s risk to self. Behavioral threat assessment also may be indicated in such situations if the potentially suicidal individual may also pose a threat to others.

More than half of suicides are accomplished by firearms and most commonly with a firearm from the household (Miller, Azrael, Hepburn, Hemenway, & Lippmann, 2006). More than 90 percent of persons who commit suicide had some combination of symptoms of depression, symptoms of other mental disorders, and/or substance abuse (Moscicki, 2001). Ironically, although depression is the condition most closely associated with attempted or completed suicide, it is also less likely than schizophrenia or other disorders to prompt an involuntary civil commitment or other legal triggers that can prevent some persons with mental illness from possessing firearms. As in behavioral threat assessment, suicide risk may be reduced through identifying and providing support in solving the problems that are driving a person to consider suicide. In many cases the person may need a combination of psychological treatment and psychiatric medication.

Tragic shootings like the ones at Sandy Hook Elementary School and the movie theater in Aurora, Colo., spark intense debate as to whether specific gun control policies would significantly diminish the number of mass shooting incidents. This debate includes whether or how to restrict access to firearms, especially with regard to persons with some mental illnesses. Another line of debate concerns whether to limit access to certain types of firearms (e.g., reducing access to high-capacity magazines). Empirical evidence documents the efficacy of some firearms restrictions, but because the restrictions often are not well implemented and have serious limitations, it is difficult to conduct the kind of rigorous research needed to fairly evaluate their potential for reducing gun violence.

The often-debated Brady Law (1994) does not consistently prevent persons with mental illness from acquiring a firearm. The prohibition applies only to persons with involuntary commitments and omits both persons with voluntary admissions and those with no history of inpatient hospitalization. The law does not prevent a person with a history of involuntary commitment from obtaining a previously owned firearm or one possessed by a friend or relative. Additional problems with implementing the Brady Law include incomplete records of involuntary commitments, background checks limited to purchases from licensed gun dealers, and exceptions from background checks for firearms purchased during gun shows.

Despite these limitations and gaps, there is some scientific evidence that background checks reduce the rate of violent gun crimes by persons whose mental health records disqualify them from legally obtaining a firearm. A study of one state (Connecticut) found that the risk of violent criminal offending among persons with a history of involuntary psychiatric commitment declined significantly after the state began reporting these individuals to the National Instant Criminal Background Check System (Swanson et al., 2013). This study supports the value of additional research to investigate strategies for limiting access to firearms by persons with serious mental illness.

In contrast, access to appropriate mental health treatment can work to reduce violence at the individual level. For example, one major finding of the MacArthur Risk Assessment study (Monahan et al., 2001) was that getting continued mental health treatment in the community after release from a psychiatric hospitalization reduced the number of violent acts by those who had been hospitalized. In other studies, outpatient mental health services, including mandated services, have been effective in preventing or reducing violent and harmful behavior (e.g., New York State Office of Mental Health, 2005; N.Y. Mental Hygiene Law [Kendra’s Law], 1999; O’Keefe, Potenza, & Mueser, 1997; Swanson et al., 2000).

There is abundant scientific research demonstrating the effectiveness of treatment for persons with severe mental illness such as schizophrenia and bipolar disorder. However, there are social, economic, and legal barriers to treatment. First, there is a persistent social stigma associated with mental illness that deters individuals from seeking treatment for themselves or for family members. Public education to increase understanding of and support for persons with serious mental illness and to encourage access to treatment is needed.

Second, mental health treatment, especially inpatient hospitalization, is expensive, and persons with mental illness often cannot access this level of care or afford it. Commercial insurers often have limitations on hospital care or do not cover intensive services that are alternatives to inpatient admission. Public sector facilities such as community mental health centers and state-operated psychiatric hospitals have experienced many years of shrinking government support; demand for their services exceeds their capacity. Many mental health providers limit their services to the most acute cases and cannot extend services after the immediate crisis has resolved.

Third, there are complex legal barriers to the provision of mental health services when an individual does not desire treatment or does not believe he or she is in need of treatment. A severe mental illness can impair an individual’s understanding of his or her condition and need for treatment, but a person with mental illness may make a rational decision to refuse treatment that he or she understandably regards as ineffective, aversive, or undesirable for some reason (e.g., psychiatric medications can produce unpleasant side effects and hospitalization can be a stressful experience).

When an individual refuses to seek treatment, it may be difficult to determine whether this decision is rational or irrational. To protect individual liberties, laws throughout the United States permit involuntary treatment only under stringent conditions, such as when an individual is determined to be imminently dangerous to self or others due to a mental illness. People who refuse treatment but are not judged to be imminently dangerous (a difficult and ambiguous standard) fall into a “gray zone” (Evans, 2013). Some individuals with serious mental illness pose a danger to self or others that is not imminent, and often it is not possible to monitor them adequately or determine precisely when they become dangerous and should be hospitalized on an involuntary basis. In other situations, the primary risk posed by the individual does not arise from mental illness but from his or her willingness to engage in criminal misconduct for personal gain.

Furthermore, when a person is committed to a psychiatric hospital on an involuntary basis, treatment is limited in scope. Once the person is no longer regarded as imminently dangerous (the criteria differ across states), he or she must be released from treatment even if not fully recovered; that person may be vulnerable to relapse into a dangerous state. In some cases of mass shootings, persons who committed the shooting were known to have a serious mental illness, but authorities could not require treatment when it was needed. In other cases, authorities were not aware of an individual’s mental illness before the attempted or actual mass shooting incident.

A related problem is that the onset or recurrence of serious mental illness can be difficult to detect. Symptoms of mental illness may emerge slowly, often in late adolescence or early adulthood, and may not be readily apparent to family members and friends. A person hearing voices or experiencing paranoid delusions may hide these symptoms and simply seem preoccupied or distressed but not seriously ill. A person who has been treated successfully for a serious mental illness may experience a relapse that is not immediately recognized. There is a great need for public education about the onset of serious mental illness, recognition of the symptoms of mental illness, and increased emphasis on the importance of seeking prompt treatment.

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2 The FBI (n.d.) defines mass murder as incidents that occur in one location (or in closely related locations during a single attack) and that result in four or more casualties. Mass murder shootings are much less common than other types of gun homicides. They are also not a new phenomenon. Historically, most mass murder shootings occurred within families or in criminal activities such as gang activity and robberies. Rampage killings is a term used to describe some mass murders that involve attacks on victims in unprotected settings (such as schools and colleges, workplaces, places of worship) and public places (such as theaters, malls, restaurants, public gatherings). However, these shootings are often planned well in advance and carried out in a methodical manner, so the term rampage is a misnomer.

Ellen Scrivner, PhD, ABPP; W. Douglas Tynan, PhD, ABPP; and Dewey Cornell, PhD

Prevention of violence occurs along a continuum that begins in early childhood with programs to help parents raise healthy children and ends with efforts to identify and intervene with troubled individuals who threaten violence. A comprehensive community approach recognizes that no single program is sufficient and there are many opportunities for effective prevention. Discussion of effective prevention from a community perspective should include identification of the community being examined. Within the larger community, many stakeholders are affected by gun violence that results in a homicide, suicide, or mass shooting.

Such stakeholders include community and public safety officials, schools, workplaces, neighborhoods, mental health and public health systems, and faith-based groups. When it comes to perpetrating gun violence, however, a common thread that exists across community groups is the recognition that someone, or possibly several people, may have heard something about an individual’s thoughts and/or plans to use a gun. Where do they go with that information? How do they report it so that innocent people are not targeted or labeled unfairly — and how can their information initiate a comprehensive and effective crisis response that prevents harm to the individual of concern and the community?

To date, there is little research to help frame a comprehensive and effective prevention strategy for gun violence at the community level. One of the most authoritative reviews of the body of gun violence research comes from the National Research Council of the National Academy of Sciences (see Wellford, Pepper, & Petrie, 2004). In reviewing a range of criminal justice initiatives designed to reduce gun violence, such as gun courts, enhanced sentencing, and problem-based policing, Wellford et al. concluded that problem-oriented policing, also known as place-based initiatives or target policing, holds promise, particularly when applied to “hot spots” — areas in the community that have high crime rates. They included studies on programs such as the Boston Gun Project (see Kennedy, Braga, & Piehl, 2001), more commonly known as Operation Ceasefire, in their review and concluded that although many of these programs may have reduced youth homicides, there is only modest evidence to suggest that they effectively lowered rates of crime and violence, given the confounding factors that influence those rates and are difficult to control. In other words, the variability in the roles of police, prosecutors, and the community creates complex interactions that can confound the levels of intervention and affect sustainability.

Wellford et al.’s (2004) conclusions were supported by the findings of the 2011 Firearms and Violence Research Working Group (National Institute of Justice, 2011), which also questioned whether rigorous evaluations are possible given the reliability and validity of the data. Wellford et al. advocated for continued research and development of models that include collaboration between police and community partners and for examination of different evaluation methodologies.

There are varied prevention models that address community issues. When it comes to exploring models that specifically address preventing the recent episodes of gun violence that have captured the nation’s attention, however, the inevitable conclusion is that there is a need to develop a new model that would bring community stakeholders together in a collaborative, problem-solving mode, with a goal of preventing individuals from engaging in gun violence, whether directed at others or self-inflicted. This model would go beyond a single activity and would blend several strategies as building blocks to form a workable systemic approach. It would require that community service systems break their tendencies to operate in silos and take advantage of the different skill sets already available in the community — for example:

• Police are trained in crisis intervention skills with a primary focus on responding to special populations such as those with mental illness.
• Community members are trained in skilled interventions such as Emotional CPR  and Mental Health First Aid — consumer-based initiatives that use neighbor-to-neighbor approaches that direct people in need of care to appropriate mental health treatment.
• School resource officers are trained to show a proactive presence in schools.

Each group may provide a solution to a piece of the problem, but there is nothing connecting the broad range of activities to the type of collaborative system needed to implement a comprehensive, community-based strategy to prevent gun violence. From a policy and practice perspective, no one skill set or one agency can provide the complete answer when it comes to developing a prevention methodology. However, some models developed through the community policing reform movement may be relevant because they are generally acknowledged to have been useful in reducing violence against women and domestic violence and in responding to children exposed to violence. These community policing models involve collaborative problem solving as a way to safeguard the community as opposed to relying only on arrest procedures. Moreover, they engage the community in organized joint efforts to produce public safety (Peak, 2013).

Another initiative, Project Safe Neighborhoods ( PSN ), is also relevant. PSN, a nationwide program that began in 2001 and was designed specifically to reduce gun violence, has some similarity to the community policing model. PSN involved the 94 U.S. attorneys in cities across the country in a prominent leadership role, ensured flexibility across jurisdictions, and required cross-agency buy-in, though there seems to have been less formalized involvement with mental health services. Nevertheless, it used a problem-solving approach that was aimed at getting guns off the streets, and the results of varied outcome assessments demonstrate that it was successful in reducing gun violence, particularly when the initiatives were tailored to the gun violence needs of specific communities (McGarrell et al., 2009).

A common approach used by PSN involved engaging the community to establish appropriate stakeholder partnerships, formulating strategic planning on the basis of identification and measurement of the community problem, training those involved in PSN, providing outreach through nationwide public service announcements, and ensuring accountability through various reporting mechanisms. The PSN problem-solving steps, with some adaptations, could provide a useful strategy for initiating collaborative problem solving with relevant community stakeholders in the interest of reducing gun violence and victimization through prevention.

The models discussed here illustrate how community engagement and collaboration helped break new ground in response to identified criminal justice problems, but they could be strengthened considerably by incorporating the involvement of professional psychology. The need for collaboration was again highlighted at a Critical Issues in Policing meeting (Police Executive Research Forum, 2012) as part of a discussion on connecting agency silos by building bridges across systems. Because police and mental health workers often respond to the same people, there is a need for collaboration on the best way to do this without compromising their roles. This emphasis takes the discussion beyond the student/school focus and expands it to include the use of crisis intervention teams (CIT) and community advocacy groups as additional resources for achieving the goal of preventing violence in the community.

The CIT model was another result of community policing reform that brought police and mental health services together to provide a more effective response to the needs of special populations, particularly mental health-related cases. Developed in Memphis in 1988 but now deployed in many communities across the country, the CIT model trains CIT officers to deescalate situations involving people in crises and to use jail diversion options, if available, rather than arrests. Although research on the effectiveness of CITs is generally limited to outcome studies in select cities, the model continues to gain prominence. In fact, the National Alliance on Mental Illness ( NAMI ) has established a NAMI CIT Center and is promoting the expansion of CIT nationwide. Studies by Borum (2000), Steadman, Deane, Borum, and Morrissey (2000), and Teller, Munetz, Gil, and Ritter (2006) have illustrated that high-risk encounters between individuals with mental illness and police can be substantially improved through CIT training, particularly when there are options such as drop-off centers, use of diversion techniques, and collaborations between law enforcement, mental health, and family members. Each plays a significant role in ensuring that city or county jails do not become de facto institutions for those in mental health crises.

Crisis intervention teams were also a major focus of a 2010 policy summit (International Association of Chiefs of Police [IACP], 2012). The summit, hosted by SAMHSA, the Bureau of Justice Assistance, and IACP, produced a 23-item action agenda. Although the summit focused on decriminalizing the response to persons with mental illness and was not directed specifically at dealing with people who perpetrate gun violence, some of their recommendations did apply. The central theme of the agenda encouraged law enforcement and mental health service systems to engage in mutually respectful working relationships, collaborate across partner agencies, and establish local multidisciplinary advisory groups. These partnerships would develop policy, protocols, and guidelines for informing law enforcement encounters with persons with mental illness who are in crisis, including a protocol that would enable agencies to share essential information about those individuals and whether the nature of the crisis could provoke violent behavior. They further recommended that these types of protocols be established and maintained by the multidisciplinary advisory group and that training be provided in the community to sensitize community members to signs of potential danger and how to intervene in a systematic way.

A Police Foundation (2013) roundtable on gun violence and mental health reported that some police departments have reached out to communities and offered safe storage of firearms when community members have concern about a family member’s access to firearms in the home. As a service to the community, the police would offer to keep guns secured in accessible community locations until the threat has subsided and the community member requests the return. The police would also confer with mental health practitioners regarding a designated family or community member on an as-needed basis. This strategy is consistent with a community threat assessment approach in which law enforcement authorities engage proactively with the community to reduce the risk of violence when an individual poses a risk.

Gun Violence in Schools

Gun violence in schools has been a national concern for more than two decades. Although school shootings are highly traumatic events and have brought school safety to the forefront of public attention, schools are very safe environments compared with other community settings (Borum et al., 2010). Less than 2 percent of homicides of school-aged children occur in schools. Over a 20-year period, there have been approximately 16 shooting deaths in U.S. schools each year (Fox & Burstein, 2010), compared with approximately 32,000 shooting deaths annually in the nation as a whole (Hoyert & Xu, 2012).

The Gun-Free Schools Act of 1994 made federal education funding contingent upon states requiring schools to expel for at least one year any student found with a firearm at school. This mandate strengthened the emerging philosophy of zero tolerance as a school disciplinary policy. According to the APA Zero Tolerance Task Force (2008), this policy was predicated on faulty assumptions that removing disobedient students would motivate them to improve their behavior, deter misbehavior by other students, and generate safer school conditions. The task force found no scientific evidence to support these assumptions and, on the contrary, concluded that the practice of school suspension had negative effects on students and a disproportionately negative impact on students of color and students with disabilities.

After the 1999 shooting at Columbine High School, both the FBI (O’Toole, 2000) and the U.S. Secret Service (Vossekuil et al., 2002) conducted studies of school shootings and concluded that schools should not rely on student profiling or checklists of warning signs to identify potentially violent students. They cautioned that school shootings were statistically too rare to predict with accuracy and that the characteristics associated with student shooters lacked specificity, which means that numerous nonviolent students would be misidentified as dangerous. Both law enforcement agencies recommended that schools adopt a behavioral threat assessment approach, which, as noted earlier, involves assessment of students who threaten violence or engage in threatening behavior and then individualized interventions to resolve any problem or conflict that underlies the threat. One of the promising features of threat assessment is that it provides schools with a policy alternative to zero tolerance. Many schools across the nation have adopted threat assessment practices. Controlled studies of the "Virginia Student Threat Assessment Guidelines" have shown that school-based threat assessment teams are able to resolve student threats safely and efficiently and to reduce school suspension rates (Cornell et al., 2012; Cornell, Gregory, & Fan, 2011; Cornell, Sheras, Gregory, & Fan, 2009).

The Role of Health and Mental Health Providers in Gun Violence Prevention

The health care system is an important point of contact for families regarding the issue of gun safety. Physicians’ counseling of individuals and families about firearm safety has in some cases proven to be an effective prevention measure and is consistent with other health counseling about safety. According to the 2012 policy statement of the American Academy of Pediatrics (AAP):

The AAP supports the education of physicians and other professionals interested in understanding the effects of firearms and how to reduce the morbidity and mortality associated with their use. HHS should establish a program to support gun safety training and counseling programs among physicians and other medical professionals. The program should also provide medical and community resources for families exposed to violence.

The AAP’s Bright Futures practice guide urges pediatricians to counsel parents who possess guns that storing guns safely and preventing access to guns reduce injury by as much as 70 percent and that the presence of a gun in the home increases the risk for suicide among adolescents. A randomized controlled trial indicates that health care provider counseling, when linked with the distribution of cable locks, has been demonstrated to increase safer home storage of firearms (Barkin et al., 2008). The removal of guns or the restriction of access should be reinforced for children and adolescents with mood disorders, substance abuse (including alcohol), or a history of suicide attempts (Grossman et al., 2005). Research is needed to identify the best ways to avoid unintended consequences while achieving intended outcomes.

In recent years, legal and legislative challenges have emerged that test the ability of physicians and other medical professionals to provide guidance on firearms. For example, in 2011 the state of Florida enacted the Firearm Owners’ Privacy Act, which prevented physicians from providing such counsel under threat of financial penalty and potential loss of licensure. The law has been permanently blocked from implementation by a U.S. district court. Similar policies have been introduced in six other states: Alabama, Minnesota, North Carolina, Oklahoma, Tennessee, and West Virginia. The fundamental right of all health and mental health care providers to provide counseling to individuals and families must be protected to mitigate risk of injury to people where they live, work, and play.

It is apparent that long before the events at Sandy Hook Elementary School, many public health and public safety practitioners were seeking strategies to improve responses to violence in their communities and have experienced some success through problem-solving projects such as PSN and CIT. Yet there is still a need to rigorously evaluate and improve these efforts. In the meantime, basic safety precautions must be emphasized to parents by professionals in health, education, and mental health.

Public health messaging campaigns around safe storage of firearms are needed. The practice of keeping firearms stored and locked must be encouraged, and the habit of keeping loaded, unlocked weapons available should be recognized as dangerous and rendered socially unacceptable. To keep children and families safe, good safety habits have to become the only socially acceptable norm.

Susan B. Sorenson, PhD, and Daniel W. Webster, ScD, MPH

The use of a gun greatly increases the odds that violence will result in a fatality. In 2010, the most recent year for which data are available, an estimated 17.1 percent of the interpersonal assaults with a gunshot wound resulted in a homicide, and 80.7 percent of the suicide attempts in which a gun was used resulted in death (CDC, 2013a). By contrast, the most common methods of assault (hands, fists, and feet) and suicide attempt (ingesting pills) in 2010 resulted in death in only 0.009 percent and 2.5 percent of the incidents, respectively (CDC, 2013a). 3

As shown in Figure 1, in the past 30 years, the percentage of deaths caused by gunfire has stabilized to about 68 percent for homicides and, as drug overdoses have increased, dropped to 50 percent for suicide. There are more gun suicides than gun homicides in the United States. In 2010, 61.2 percent (19,392) of the 31,672 gun deaths in the United States were suicides (CDC, 2013a).

Figure 1. Deaths Attributed to Firearms, 1981–2010

Note: Data are from the Web-Based Injury Statistics Query and Reporting System (WISQARS™), Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 2013. Retrieved from http://www.cdc.gov/injury/wisqars/fatal.html.

Much of the public concern about guns and gun violence focuses on interpersonal violence, and public policy mirrors this emphasis. Although there is no standard way to enumerate each discrete gun law, most U.S. gun laws focus on the user of the gun. Relatively few focus on the design, manufacture, distribution, advertising, or sale of firearms (Teret & Wintemute, 1993). Fewer yet address ammunition.

The focus herein is on the lifespan of guns — from design and manufacture to use — and the policies that could address the misuse of guns. It is critical to understand how policies create conditions that affect access to and use of guns. Because they constitute the largest portion of guns used in homicides (FBI, 2012a), handguns are the focus of most laws. Despite the substantial human and economic costs of gun violence in the United States and the ongoing debate about the effectiveness of gun regulations, scientifically rigorous evaluations are not available for many of these policies (Wellford et al., 2004). The dearth of such research on gun policies is due, in part, to the lack of government funding on this topic because of the political influences of the gun lobby (e.g., Kellermann & Rivara, 2013).

Design and Manufacture

The type of handguns manufactured in the United States has changed. Pistols overtook revolvers in manufacturing in the mid-1980s. In addition, the most widely sold pistol went from a .22 caliber in 1985 to a 9 mm or larger (e.g., .45 caliber pistols) by 1994 (Wintemute, 1996), with smaller, more concealable pistols favored by permit holders as well as criminals. This shift has been described as increasing the lethality of handguns, although, according to our review, no research has examined whether the change in weapon design has led to an increased risk of death. Such research may not be feasible given that the aforementioned weapons — that is, small, concealable pistols — still likely constitute a small portion of the estimated 283 million guns in civilian hands in the United States (Hepburn, Miller, Azrael, & Hemenway, 2007). The disproportionate appearance of such pistols among guns that were traced by law enforcement following their use in a crime has been attributed to the ease with which smaller guns can be concealed and their low price point (Koper, 2007; Wright, Wintemute, & Webster, 2010).

Ammunition, by contrast, is directly related to lethality. Hollow-point bullets are used by hunters because, in part, they are considered a more humane way to kill. The physics of hollow-point bullets are such that, upon impact, they will tumble inside the animal and take it down. Some bullets have been designed to be frangible, that is, to break apart upon impact and thus cause substantial internal damage. By contrast, the physics of full metal jacket bullets are such that, unless they hit a bone, they are likely to continue on a straight trajectory and pass through the animal, leaving it wounded and wandering. Hollow-point bullets are used by law enforcement to reduce over-penetration (i.e., when a bullet passes through its intended target and, thus, risks striking others).

Some design features would substantially reduce gun violence. One of the most promising ideas is that of “smart guns” that can be fired only by an authorized user. For example, young people, who are prohibited due to their age from legally purchasing a firearm, typically use a gun from their own home to commit suicide (Johnson, Barber, Azrael, Clark, & Hemenway, 2010; Wright, Wintemute, & Claire, 2008) and to carry out a school shooting (CDC, 2003). If personalized to an authorized adult in the home, the gun could not be operated by the adolescent or others in the home, thus rendering it of little use to the potential suicide victim or school shooter. During the Clinton administration, the federal government made a modest investment in the research and development of personalized firearms. There also was considerable private investment in technologies that would prevent unauthorized users from being able to fire weapons. Efforts to create these “smart guns” have resulted in multiple patent applications. Armatix GmbH, a German company, has designed and produced a personalized pistol that is being sold in several Western European nations and has been approved for importation to the United States. Although the cost of this new personalized gun is very high, it is believed that personalized guns can be produced at a cost that would be affordable by many (Teret & Merritt, 2013).

The assault weapons ban (the Violent Crime Control and Law Enforcement Act), enacted for a 10-year period beginning in 1994, provided a good opportunity to assess the effectiveness of restricting the manufacturing, sale, and possession of a certain class of weapons. “Assault weapons,” however, are difficult to conceal and are used rarely in most street crime or domestic violence. Assault weapons are commonly used in mass shootings in which ammunition capacity can determine the number of victims killed or wounded. Because multiple bullets are not an issue in suicide, one would not expect changes in such deaths either. Perhaps not surprisingly, an effect of the ban could not be detected on total gun-related homicides (Koper, 2013; Koper & Roth, 2001).

Unfortunately, prior research on the effects of the federal assault weapons ban did not focus on the law’s effects on mass shootings or the number of persons shot in such shootings. Assault weapons or guns with large-capacity ammunition feeding devices account for half of the weapons used in mass shootings such as at Sandy Hook Elementary School (see Follman & Aronson , 2013). Mass shootings with these types of weapons result in about 1.5 times as many fatalities as those committed with other types of firearms (Roth & Koper, 1997).

Distribution

The distribution of guns is largely the responsibility of a network of middlemen between gun manufacturers and gun dealers. When a gun is recovered following its use (or suspected use) in a crime, law enforcement routinely requests that the gun be traced — that is, the serial number is reported to the manufacturer, who then contacts the distributor and/or dealer who, in turn, reviews records to determine the original purchaser of a specific weapon. The number of gun traces is such that the manufacturers get many calls about their guns each day. One researcher estimated that Smith and Wesson, with about 10 percent of market share, received a call every seven to eight minutes about one of their guns (Kairys, 2008). Thus, one could reasonably expect that manufacturers would have some knowledge of which distributors sell guns that are disproportionately used in crime, and distributors would, in turn, know which retailers disproportionately sell guns used in crime.

Following in the footsteps of cities and states that had successfully sued the tobacco industry under state consumer protection and antitrust laws for costs the public incurred in caring for smokers, beginning in the late 1990s cities and states began to file claims against firearm manufacturers in an attempt to recover the costs of gun violence they incurred. In response, in 2005, Congress enacted and President George W. Bush signed the Protection of Lawful Commerce in Arms Act, which prohibits civil liability lawsuits against “manufacturers, distributors, dealers, or importers of firearms or ammunition for damages, injunctive or other relief resulting from the misuse of their products by others” ( 15 U.S.C. §§ 7901-7903 ). Thus, the option of using litigation, a long-standing and sometimes controversial tool by which to address entrenched public health problems (e.g., Lytton, 2004), was severely restricted.

Advertising

Advertisements for guns have largely disappeared from classified ads in newspapers. By contrast, advertising in magazines, specifically gun magazines, is strong (Saylor, Vittes, & Sorenson, 2004). Such advertising is subject to the same Federal Trade Commission (FTC) regulations as other consumer products. In 1996, several organizations filed a complaint with the FTC after documenting multiple cases of what they asserted to be false and misleading claims about home protection (for specific examples, see Vernick, Teret, & Webster, 1997). As of November 1, 2013, the FTC had not ruled on the complaint. However, the firearm industry changed its practices such that by 2002, self-protection was an infrequent theme in advertisements for guns (Saylor et al., 2004). To our knowledge, current advertising has not been studied. New issues relevant to the advertising of guns include online advertisements by private sellers who are not obligated to verify that purchasers have passed a background check, online ads from prohibited purchasers seeking to buy firearms, the marketing of military-style weapons to civilians, and the marketing of firearms to underage youth (for examples and more information, see Kessler & Trumble, 2013; Mayors Against Illegal Guns, 2013; McIntire, 2013; Violence Policy Center, 2011).

Sales and Purchases

Gun sales have been increasing in the United States. The FBI reported a substantial jump in background checks (a proxy for gun sales) in the days following the Sandy Hook Elementary School shootings. In fact, of the 10 days with the most requests for background checks since the FBI started monitoring such information, 7 of them were within 8 days of Sandy Hook (FBI, 2013). Guns can be purchased from federally licensed firearm dealers or private, unlicensed sellers in a variety of settings, including gun shows, flea markets, and the Internet.

Responsible sales practices (for examples, see Mayors Against Illegal Guns, n.d.) rely heavily on the integrity of the seller. And usually that responsibility is well placed: Over half (57 percent) of the guns traced (i.e., submitted by law enforcement, usually in association with a crime, to determine the original purchaser of the weapon) were originally sold by only 1.2 percent of federally licensed firearm dealers (Bureau of Alcohol, Tobacco and Firearms [ATF], 2000). However, there are problems. Sometimes a person who is prohibited from purchasing a gun engages someone else, who is not so prohibited, to purchase a gun for him or her. The person doing the buying is called a “straw purchaser.” Straw purchase attempts are not uncommon; in a random sample of 1,601 licensed dealers and pawnbrokers in 43 states, two thirds reported experiencing straw purchase attempts (Wintemute, 2013b).

Two studies tested the integrity of licensed firearm dealers by calling the dealers and asking whether they could purchase a handgun on behalf of someone else (in the studies, a boyfriend or girlfriend), a straw purchase transaction that is illegal. In the study of a sample of gun dealers listed in telephone directories of the 20 largest U.S. cities, the majority of gun dealers indicated a willingness to sell a handgun under the illegal straw purchase scenario (Sorenson & Vittes, 2003). In a similar study of licensed gun dealers in California, a state with relatively strong regulation and oversight of licensed gun dealers, one in five dealers expressed a willingness to make the illegal sale (Wintemute, 2010). Programs such as the ATF and National Sports Shooting Council’s “Don’t Lie for the Other Guy,” which provides posters and educational materials to display in gun stores as well as tips for gun dealers on how to identify and respond to straw purchase attempts, have not been evaluated.

It is important to be able to identify high-risk dealers because, in 2012, the ATF had insufficient resources to monitor federally licensed gun dealers (Horwitz, 2012); there were 134,997 unlicensed gun dealers in April 2013 (ATF, 2013). Some states have recognized the limited capacity of the ATF and the weaknesses of federal laws regulating gun dealers and enacted their own laws requiring the licensing, regulation, and oversight of gun dealers (Vernick, Webster, & Bulzacchelli, 2006) and, when enforced, these laws appear to reduce the diversion of guns to criminals shortly after a retail sale (Webster, Vernick, & Bulzacchelli, 2009). Undercover stings and lawsuits against gun dealers who facilitate illegal straw sales have also been shown to reduce the diversion of guns to criminals (Webster, Bulzacchelli, Zeoli, & Vernick, 2006; Webster & Vernick, 2013b).

To help ensure that guns are not sold to those who are prohibited from purchasing them, the National Instant Criminal Background Check System ([NICS], part of the Brady Law) was developed so that the status of a potential purchaser could be checked immediately by a federally licensed firearm dealer. Prohibited purchasers include, but are not limited to, convicted felons, persons dishonorably discharged from the military, those under a domestic violence restraining order, and, in the language of the federal law, persons who have been adjudicated as mentally defective or have been committed to any mental institution (see 18 U.S.C. § 922(g) (1)-(9) and (n)). About 0.6% of sales have been denied on the basis of these criteria since NICS was established in 1998 (FBI, 2012b).

A substantial portion of firearm sales and transfers, however, is not required to go through a federally licensed dealer or a background check requirement; this includes, in most U.S. states, private party sales including those that are advertised on the Internet and those that take place at gun shows where licensed gun dealers who could process background checks are steps away. Some evidence suggests that state policies regulating private handgun sales reduce the diversion of guns to criminals (Vittes, Vernick, & Webster, 2013; Webster et al., 2009; Webster, Vernick, McGinty, & Alcorn, 2013).

The ability to check the background of a potential purchaser nearly instantly means that in many states, someone who is not a prohibited purchaser can purchase a gun within a matter of minutes. Ten states and the District of Columbia have a waiting period (sometimes referred to as a “cooling-off” period) for handguns ranging from 3 (Florida and Iowa) to 14 (Hawaii) days (Law Center to Prevent Gun Violence, 2012). The efficacy of waiting periods has received little direct research attention.

With the exception of misdemeanor domestic violence assault, federal law and laws in most states prohibit firearm possession of those convicted of a crime only if the convictions are for felony offenses in adult courts. Research has shown that misdemeanants who were legally able to purchase handguns committed crimes involving violence following those purchases at a rate 2–10 times higher than that of handgun purchasers with no prior convictions (Wintemute, Drake, Beaumont, & Wright, 1998). Wintemute and colleagues (Wintemute, Wright, Drake, & Beaumont, 2001) examined the impact of a California law that expanded firearm prohibitions to include persons convicted of misdemeanor crimes of violence. In their study of legal handgun purchasers with criminal histories of misdemeanor violence before and after the law, denial of handgun purchases due to a prior misdemeanor conviction was associated with a significantly lower rate of subsequent violent offending.

Persons who are legally determined to be a danger to others or to themselves as a result of mental illness are prohibited by federal law from purchasing and possessing firearms. A significant impediment to successful implementation of this law is that the firearm disqualifications due to mental illness often are not reported to the FBI’s background check system. As mentioned earlier, in 2007 Connecticut began reporting these disqualifications to the background check system. In a ground-breaking study, Swanson and colleagues (2013) studied the effects of this policy change on individuals who would most likely be affected — that is, those who were legally prohibited from possessing firearms due solely to the danger posed by their mental illnesses. They found that the rate of violent crime offending was about half as high among those whose mental illness disqualification was reported to the background system compared with those whose mental illness disqualification was not reported.

Federal law allows an individual to buy several guns, even hundreds, at once; the only requirement is that a multiple-purchase form be completed (18 U.S.C. § 923(g)(3)(A)(2009)). Large bulk purchases have been linked to gun trafficking (Koper, 2005). Policies such as one-handgun-a-month have rarely been enacted. Evaluations of these laws document mixed findings (Webster et al., 2009, 2013;Weil & Knox, 1996).

The United States was one of the signers of the Geneva Convention, which prohibits the use of hollow-point bullets in war (the goal being to wound but not kill wartime enemies), but hollow-point bullets are available to civilians in the United States. A hunting license is not a prerequisite for the purchase of hollow-point bullets in the United States. California passed a law requiring a thumbprint for ammunition purchases; the law was ruled “unconstitutionally vague” by a Superior Court judge in 2011, but some municipalities (e.g., Los Angeles, Sacramento) have similar local ordinances in effect.

In 2004, a national survey found that 20 percent of the U.S. adult population reported they own one or more long-guns (shotguns or rifles), and 16 percent reported they own a handgun (Hepburn et al., 2007). Self-protection was the primary reason for owning a gun. Most people who have a gun have multiple guns, and half of gun owners reported owning four or more guns. In fact, 4 percent of the population is estimated to own 65 percent of the guns in the nation.

Nationally representative studies suggest that the mental health of gun owners is similar to that of individuals who do not own guns (Miller, Barber, Azrael, Hemenway, & Molnar, 2009; Sorenson & Vittes, 2008). However, gun owners are more likely to binge drink and drink and drive (Wintemute, 2011).

In perhaps the methodologically strongest study to date to examine handgun ownership and mortality, Wintemute and colleagues found a strong association between the purchase of a handgun and suicide: “In the first year after the purchase of a handgun, suicide was the leading cause of death among handgun purchasers, accounting for 24.5 percent of all deaths” (Wintemute, Parham, Beaumont, Wright, & Drake, 1999). The risk of suicide remained elevated (nearly twofold and sevenfold, respectively, for male and female handgun purchasers) at the end of the 6-year study period. Men’s handgun purchase was associated with a reduced risk of becoming a homicide victim (0.69); women’s handgun purchase, by contrast, was associated with a 55 percent increase in risk of becoming a homicide victim. A waiting period may reduce immediate risk but appears not to eliminate short- or long-term risk for suicide.

Risk can extend to others in the home. Efforts to educate children about guns (largely to stay away from them), when tested with field experiments, indicate they are generally ineffective (e.g., Hardy, 2002). Child Access Prevention (CAP) laws focus on the responsibilities of adults; adults are held criminally liable for unsafe storage of firearms around children. CAP laws have been associated with modest decreases in unintentional shootings of children and the suicides of adolescents (Webster & Starnes, 2000; Webster, Vernick, Zeoli, & Manganello, 2004).

Most gun-related laws focus on the user of the gun (e.g., increased penalties for using a gun in the commission of a crime). Some research suggests that having been threatened with a gun, as well as the perpetrator’s having access to a gun and using a gun during the fatal incident, is associated with increased risk of women becoming victims of intimate partner homicide (Campbell et al., 2003). Regarding sales, note that persons with a domestic violence misdemeanor or under a domestic violence restraining order are prohibited by federal law from purchasing and possessing a firearm and ammunition. Research to date indicates that firearm restrictions for persons subject to such laws have reduced intimate partner homicides by 6 percent to 19 percent (Vigdor & Mercy, 2006; Zeoli & Webster, 2010).

As with initial discussions about motor vehicle safety, which focused on what was then referred to as the “nut behind the wheel,” current discussions about gun users sometimes involve terms such as “good guys” and “bad guys.” Although intuitively appealing, such categories seem to assume a static label and do not take into account the fact that “good guys” can become “bad guys” and “bad guys” can become “good guys.” One way an armed “good guy” can become a “bad guy” is to use a gun in a moment of temporary despondence or rage (Bandeira, 2013; Wintemute, 2013a).

Research on near-miss suicide attempts among young adults indicates that impulsivity is of concern. About one fourth of those whose suicide attempt was so severe they most likely would have died reported first thinking about suicide five minutes before attempting it (Simon et al., 2001). Although an estimated 90 percent of those who attempt suicide go on to die of something else (i.e., they do not subsequently kill themselves; for a review, see Bostwick & Pankratz, 2000), for those who use a gun, as noted in opening paragraph of this chapter, there generally is not a second chance.

Given the complexity of the issue, a multifaceted approach will be needed to reduce firearm-related violence (see, for example, Chapman & Alpers, 2013). Not all ideas that on the surface seem to be useful actually are. For example, gun buyback programs may raise awareness of guns and gun violence in a community but have not been shown to reduce mortality (Makarios & Pratt, 2012). Such data can inform policy. President Obama’s January 2013 executive orders about gun violence include directing the CDC to research the causes and prevention of gun violence. The federal government has since announced several funding opportunities for research related to gun violence. And the recent Institute of Medicine and National Research Council (2013) report called for lifting access restrictions on gun-related administrative data (e.g., data related to dealers’ compliance with firearm sales laws, gun trace data) that could be used to identify potential intervention and prevention points and strategies. So perhaps more data will be available to inform and evaluate policies designed to reduce gun violence.

The focus of this section has largely been on mortality. The scope of the problem is far greater, however. For every person who dies of a gunshot wound, there are an estimated 2.25 people who are hospitalized or receive emergency medical treatment for a nonfatal gunshot wound (Gotsch, Annest, Mercy, & Ryan, 2001). And guns are used in the street and in the home to intimidate and coerce (e.g., Sorenson & Wiebe, 2004; Truman, 2011).

Single policies implemented by themselves have been shown to reduce certain forms of gun violence in the United States. Adequate implementation and enforcement as well as addressing multiple intervention points simultaneously may improve the efficacy of these laws even more. After motor vehicle safety efforts expanded to include the vehicle, roadways, and other intervention points (vs. a focus on individual behavior), motor vehicle deaths dropped precipitously and continue to decline (CDC, 1999, 2013a). A multifaceted approach to reducing gun violence will serve the nation well.

3 The 2010 data used to calculate current rates shown here are available at http://www.cdc.gov/injury/wisqars/ .

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APA Panel of Experts

Dewey Cornell, PhD Clinical Psychologist and Professor of Education Curry School of Education University of Virginia

Arthur C. Evans Jr., PhD Commissioner Department of Behavioral Health and Intellectual disAbility Services Philadelphia, Pa.   Nancy G. Guerra, EdD (Coordinating Editor) Professor of Psychology Associate Provost for International Programs Director, Institute for Global Studies University of Delaware   Robert Kinscherff, PhD, JD Associate Vice President for Community Engagement Massachusetts School of Professional Psychology Senior Associate National Center for Mental Health and Juvenile Justice   Eric Mankowski, PhD Professor of Psychology Department of Psychology Portland State University

Marisa R. Randazzo, PhD Managing Partner SIGMA Threat Management Associates Alexandria, Va.   Ellen Scrivner, PhD, ABPP Executive Fellow Police Foundation Washington, D.C.   Susan B. Sorenson, PhD Professor of Social Policy / Health & Societies Senior Fellow in Public Health University of Pennsylvania

W. Douglas Tynan, PhD, ABPP Professor of Pediatrics Jefferson Medical College Thomas Jefferson University   Daniel W. Webster, ScD, MPH Professor and Director Center for Gun Policy and Research Johns Hopkins Bloomberg School of Public Health

We are grateful to the following individuals for their thoughtful reviews and comments on drafts of this report:   Louise A. Douce, PhD Special Assistant, Office of Student Life Adjunct Faculty, Department of Psychology The Ohio State University   Joel A. Dvoskin, PhD, ABPP Department of Psychiatry University of Arizona   Ellen G. Garrison, PhD Senior Policy Advisor American Psychological Association   Melissa Strompolis, MA Doctoral Candidate University of North Carolina at Charlotte   Mathilde Pelaprat, PsyD , provided writing and research assistance on Chapter 2.

Rhea Farberman, APR Executive Director Public and Member Communications American Psychological Association

Editorial and Design Services Deborah C. Farrell, Editor │ Elizabeth F. Woodcock, Designer

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The Surprising Reality of Political Violence in America

After two apparent assassination attempts against Donald J. Trump, it’s easy to think our politics are becoming more violent. The research is not so clear.

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By Charles Homans

When Donald J. Trump was nearly assassinated in Pennsylvania in July, a Dartmouth political scientist named Sean Westwood happened to be in the middle of a research project asking Americans about political violence.

At the time, many feared that the shooting would lead to a growing appetite for more violence.

But Mr. Westwood and his colleagues found the opposite. In the weeks after the attack, Americans’ support for partisan violence, and murder specifically, diminished — and fell most sharply among Republicans who identify with Mr. Trump.

Americans are still exceptionally hostile about people who disagree with them on politics, but “an assassination attempt did not inflame the tensions,” the authors write in a forthcoming paper in The Proceedings of the National Academy of Sciences.

Two unsuccessful attempts on Mr. Trump’s life, a daily barrage of violent threats against public officials of all stripes and finger-pointing from both parties have fueled the impression that the country’s politics are spinning out of control.

But some common assumptions about political violence in America are not reinforced by recent data, according to several new studies.

Instances of extremist violence have actually declined in recent years by some key measures. Although some Americans continue to say they approve of political violence, support for the most serious types of violence has not increased amid election-related tensions this year.

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Sobering inaugural lecture unpacks years of research on gender-based violence, femicide

“How was it that this girl from Mitchell’s Plain came to do this work at a place like the University of Cape Town (UCT), where her experiences have vacillated between the extremes of alienation, isolation and exclusion to those of love, of joy, of belonging and of healing?”

It was with these words that Professor Floretta Boonzaier launched a gripping and sobering inaugural lecture, titled “Finding hope and healing while researching violence: Decolonial feminist explorations into gender-based violence (GBV) and femicide”. Held in the Chris Hani Lecture Theatre on upper campus on Wednesday, 11 September, the lecture marked Professor Boonzaier’s ascent to full professorship – a highlight in a scholar’s research career. The event also coincided with her 20th year in the academy at UCT; a celebration and milestone of its own.

For Boonzaier, the question of what it means to profess as black and as a woman has an answer of two interwoven stories: the story of her scholarship and the story of her. And when she contemplated which story best described her journey towards becoming a professor, she said she toyed with the idea of focusing solely on her scholarship. But she decided otherwise.

“I realised that doing that would be telling an incomplete story. A story that would leave out the large and important part of the narrative of how I came to do the work that I do,” she said.

So, Boonzaier took the audience on a journey that highlighted her years of research into the scourge of GBV and femicide in South Africa, and the role of the media when reporting on these atrocities. She also offered some valuable insight into the origins of her feminism.

Intro to feminism

As is the case in many families in South Africa and on the continent, Boonzaier said, feminism was practised in her home, but the word was never used. She learned the true meaning of feminism from her mother, Carol Veronica Boonzaier, who she described as “the strongest, most steadfast woman I know”.

She also learned feminism from many other women in her family who held the family together, and who displayed massive strength and resilience in the face of state and other forms of violence that inevitably shaped their lives. Boonzaier also learned feminism from the women in the different Cape Flats communities where she lived, in Heideveld and Mitchell’s Plain. Similarly, these women held it together while their families and communities were falling apart. And while doing so, they ensured that their loved ones were fed, provided shelter and meals to those who were destitute, and raised and educated others’ children when they were unable to do so themselves.

“I learned feminism from respected members of these different communities, [while] doing work underground to support the struggle against apartheid.”

“I learned feminism from respected members of these different communities, [while] doing work underground to support the struggle against apartheid. The feminism I [learned] was grounded in my own experiences of injustice and inequality, of poverty, of witnessing violence and trauma around me,” she said.

“It was learned from seeing the devastating effects of historical forms of trauma and the many psychological scars it has left on people around me.”

The early stages of her research career

When she started out as an early-career researcher whose work focused primarily on intimate partner violence, Boonzaier said, one of the questions that regularly occupied her mind was society’s obsession with why women stay in abusive relationships.

The question was everywhere, she said, and every article she read blamed women who stayed with their abusive partners – locating the question of abuse with the abused women rather than with the men who perpetuate that abuse. So, she shifted the question from ‘why do women stay in abusive relationships’ to deeper, more contextually relevant questions about these relationships. Boonzaier wanted to understand the context in which women in abusive relationships find themselves, how women stay, and how they navigate these relationships after suffering violence at the hands of a partner.

Her research found that women find multiple ways to resist violence, and to resist the gendered expectations of them as women. Their stories reflected the contradictory nature of their experiences. And her work showed that women straddle the gap between society’s social and gendered expectations of them and their own personal aspirations for independence and strength, which highlights their resistance.

“In my doctoral work, I was interested in the kinds of relational narratives told about violence in heterosexual relationships. I was interested [to find out] how two people in a relationship – with a man who is violent – talk about this relationship. How do their stories differ, where does it stay the same [and] how do they talk about violence and its impact?” she asked.

The power of storytelling

As she unpacked the question of women’s agency and resistance, Boonzaier said, her research next focused on how women relay their experiences of violence and abuse, and how these stories shape how they see themselves in the world.

“We were interested in how one asks about violence in the lives of women, where violence [perpetrated by] a partner is just one of the many things, one of the many difficulties that they face as women. How do you ask about violence in the lives of poor, black, marginalised women?” she said.

Opening safe spaces for storytelling aided this process. She said it allowed women to share the complexities of what it means to be poor, black and a woman, while facing intimate partner violence.

“Stories, we argued, are important for the expression of experience of identity.”

“Stories, we argued, are important for the expression of experience and identity. Telling stories about [the] violence they experienced allowed women to represent their inner realities, to interpret their past, to understand their present and to envision their futures,” she said. “Telling stories on their own terms allowed women the opportunity to reclaim their narratives in ways that challenge dominant ideas of what an abused woman is supposed to be.”

Stories as a means of resistance

During these and subsequent engagements, Boonzaier discovered that women’s stories and their experiences challenge the popular image regularly painted of a passive and helpless woman. Instead, she said, their experiences reveal “counter-stories” that challenge society’s focus on physical violence as the only form of legitimate violence. She said women indicated that they experience psychological abuse as being more harmful than physical abuse.

To those on the outside, women portray themselves as strong and in control of their lives. Yet, Boonzaier said, they are deeply limited by the intersectional forms of oppression such as gender, race and class that shape their lives.

“Collectively, this work was important for showing how – despite the fact that women survivors of violence often experience shame – women also use their stories as a means for resistance and empowerment.”

“Collectively, this work was important for showing how – despite the fact that women survivors of violence often experience shame – women also use their stories as a means for resistance and empowerment, even in the face of economic and other difficulties. They find ways to centre the feminist narrative of resistance against men’s violence,” she said.

“And they offer us an alternative reading of the popular image of abused women.”

A sobering recollection

As her lecture unfolded, Boonzaier also discussed the way in which the South African media report on GBV and intimate partner violence, and highlighted one example. She took her audience back to February 2013, when 17-year-old Anene Booysen was raped and murdered in Bredasdorp in the Western Cape’s Overberg region.

From day one, Boonzaier said, Booysen’s story was etched in her mind – and it still is. And when the South African Journal of Psychology issued a special call for contributions a few years after the murder, Boonzaier felt compelled to contribute to this tragic, heart-wrenching story. As she combed through media reports, she said, she realised that while so much had been written about Booysen’s death, the public knew very little about her life.

“All we really knew was the recollection of her movements on the night of the murder and the very graphic details about how she died,” she said.

With analysis, Boonzaier said, her research demonstrated that while reporting on Booysen’s murder, the media used colonial legacies that hyper-visiblise the bodies of black women in the most public ways and yet hid their identities. She said her research also showed how the media’s representation of GBV, particularly in the case of Booysen, dehumanised black women, “making them less deserving of our empathy”.

“I argued that the ways in which Anene [Booysen] was represented mirrored the colonial stories about Sarah Baartman,” she said.

A reflection

As she concluded her lecture, Boonzaier returned to the question she posed at the beginning, and asked: “What does it mean to profess while black and woman?”

“In this moment that I’m owning as a celebration, it’s hard to stand here and not recall the indignities I had to suffer in order [for me] to be considered full, a full professor. It’s hard not to recall the indignities of what it meant to be racialised [as] coloured in the apartheid and colonial imageries of fellow students when I was a student here,” she said. “[It’s] hard not to recall the snide remarks, forms of surveillance and racism I experienced from colleagues as I worked hard to move up the ranks.”

“For us, the practice of decolonial feminist psychology has centred radical hope, love and healing.”

And yet, she conceded, “Here I am, in celebration of this occasion, talking decolonial love, hope and joy. For us, the practice of decolonial feminist psychology has centred radical hope, love and healing – a methodology of decolonial love [and] a commitment to creating alternatives to the present,” she said.

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Violence in the United States

Associated data.

Interpersonal violence, which includes child abuse and neglect, youth violence, intimate partner violence, sexual violence, and elder abuse, affects millions of US residents each year. However, surveillance systems, programs, and policies to address violence often lack broad, cross-sector collaboration, and there is limited awareness of effective strategies to prevent violence.

To describe the burden of interpersonal violence in the United States, explore challenges to violence prevention efforts and to identify prevention opportunities.

DATA SOURCES

We reviewed data from health and law enforcement surveillance systems including the National Vital Statistics System, the Federal Bureau of Investigation’s Uniform Crime Reports, the US Justice Department’s National Crime Victimization Survey, the National Survey of Children’s Exposure to Violence, the National Child Abuse and Neglect Data System, the National Intimate Partner and Sexual Violence Survey, the Youth Risk Behavior Surveillance System, and the National Electronic Injury Surveillance System—All Injury Program.

Homicide rates have decreased from a peak of 10.7 per 100 000 persons in 1980 to 5.1 per 100 000 in 2013. Aggravated assault rates have decreased from a peak of 442 per 100 000 in 1992 to 242 per 100 000 in 2012. Nevertheless, annually, there are more than 16 000 homicides and 1.6 million nonfatal assault injuries requiring treatment in emergency departments. More than 12 million adults experience intimate partner violence annually and more than 10 million children younger than 18 years experience some form of maltreatment from a caregiver, ranging from neglect to sexual abuse, but only a small percentage of these violent incidents are reported to law enforcement, health care clinicians, or child protective agencies. Moreover, exposure to violence increases vulnerability to a broad range of mental and physical health problems over the life course; for example, meta-analyses indicate that exposure to physical abuse in childhood is associated with a 54% increased odds of depressive disorder, a 78% increased odds of sexually transmitted illness or risky sexual behavior, and a 32% increased odds of obesity. Rates of violence vary by age, geographic location, sex, and race/ethnicity, and significant disparities exist. Homicide is the leading cause of death for non-Hispanic blacks from age 1 through 44 years, whereas it is the fifth most common cause of death among non-Hispanic whites in this age range. Additionally, efforts to understand, prevent, and respond to interpersonal violence have often neglected the degree to which many forms of violence are interconnected at the individual level, across relationships and communities, and even intergenerationally. The most effective violence prevention strategies include parent and family-focused programs, early childhood education, school-based programs, therapeutic or counseling interventions, and public policy. For example, a systematic review of early childhood home visitation programs found a 38.9% reduction in episodes of child maltreatment in intervention participants compared with control participants.

CONCLUSIONS AND RELEVANCE

Progress has been made in reducing US rates of interpersonal violence even though a significant burden remains. Multiple strategies exist to improve violence prevention efforts, and health care providers are an important part of this solution.

Interpersonal violence is a pervasive public health, social, and developmental threat. It is a leading cause of death in the United States, particularly among children, adolescents, and young adults. Exposure to violence can cause immediate physical wounds that clinicians recognize and treat but can also result in long-lasting mental and physical health conditions that are often less apparent to health care providers. Violence directly affects health care expenditures. Indirectly, it stunts economic development, increases inequality, and erodes human capital.

Interpersonal violence is defined by the World Health Organization as the intentional use of physical force or power, threatened or actual, against another person or against a group or community that results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation. 1 Although violence has a long history of study by various fields, a focus on public health approaches to prevention has largely emerged over the past 3 decades. In 1992, the Centers for Disease Control and Prevention (CDC) established the National Center for Injury Prevention and Control as the focal point for advancing a public health approach to violence prevention in the United States.

The Burden of Violence

Status and progress made.

Homicide rates have varied over the past 50 years. Beginning in the 1960s, the homicide rate in the United States increased steadily from about 4 to 5 deaths per 100 000 persons to a peak of 10.7 deaths per 100 000 in 1980. 2 Homicide rates remained markedly elevated through the mid-1990s and raised the profile of violent crime in political and social discourse. Rates of aggravated assault were 86 per 100 000 in 1960, peaked at 442 per 100 000 in 1992, and decreased to 242 per 100 000 in 2012 ( Figure ).

The homicide rate is from the National Center for Health Statistics 3 and the assault rate is from the Federal Bureau of Investigation (FBI). 4 The case-fatality rate (or lethality rate) was conceptualized by Harris et al 5 and is calculated herein as the homicide rate divided by the homicide rate plus the assault rate (multiplied by 100 to display percentage). An aggravated assault is defined by the FBI as an unlawful attack by one person on another for the purpose of inflicting severe or aggravated bodily injury, usually accompanied by the use of a weapon or by means likely to produce death or great bodily harm.

The increase in homicides from the late 1960s to the 1990s ( Figure and Table 1 ) has been attributed to factors such as the elevated proportion of youth among the population resulting from the post–World War II baby boom; the spread of multiple drugs of abuse; the proliferation of more powerful firearms; and rapid changes in family structures, cultural norms, and societal dynamics. 6 Since the early 1990s, homicide rates have declined, but they still exceed rates in other high-income countries. The World Health Organization’s Global Status Report on Violence Prevention places the 2012 US homicide rate at 5.4 per 100 000, whereas the rate for Canada was 1.8; for the United Kingdom, 1.5; and for Australia, 1.1 per 100 000. 7

Status and Progress Made on Fatal and Nonfatal Violence, United States

Abbreviations: NatSCEV, National Survey of Children’s Exposure to Violence; NCANDS, National Child Abuse and Neglect Data System; NCVS, National Crime Victimization Survey; NISVS, National Intimate Partner and Sexual Violence Survey; NVSS, National Vital Statistics System; YRBS, Youth Risk Behavior Surveillance System; UCR, Uniform Crime Reports.

For many forms of nonfatal violence—including child maltreatment, youth violence, intimate partner violence, sexual violence, and elder abuse—progress has also been made, but the burden remains high ( Table 1 ). For example, from 1992 to 2012, official reports by child protective service agencies of substantiated sexual abuse declined by 62%, physical abuse by 54%, and neglect by 14%; however, an estimated 12.5% of US children still experience confirmed child maltreatment by age 18 years. 10 , 11 Furthermore, a recent analysis of national crime survey data indicates that from 1995 to 2010, rates of rape or sexual assault among females decreased 58% from 5.0 episodes to 2.1 episodes per 1000 population; however, nearly 1 in 5 women (19.3%) have experienced rape (completed or attempted unwanted penetration) at some point in their life and experience the sequelae of such violence. 15 , 17

The tables and figure in this report synthesize information from multiple, national violence data systems maintained by the CDC, the US Department of Justice, the US Administration for Children and Families, and other partners, including the National Vital Statistics System, the Uniform Crime Reports, the National Crime Victimization Survey, the National Survey of Children’s Exposure to Violence, the National Child Abuse and Neglect Data System, the National Intimate Partner and Sexual Violence Survey, the Youth Risk Behavior Surveillance System, and the National Electronic Injury Surveillance System–All Injury Program. These data sources are diverse and range from household surveys to official administrative data (see eTable 1 in the Supplement for a description of the major data systems used).

The Hiddenness of Violence

Nearly all homicides are reported to health and safety officials and are counted in public data sources, but nonlethal violence is often unreported ( eFigure 1 in the Supplement ). For example, in 2011, approximately 1570 children younger than 18 years died from child maltreatment. 18 In that year more than 3 million children received an investigation or response from state child protective services departments, 18 but it is estimated that most episodes of child maltreatment were not reported. National survey data from 2011 estimate that 13.8% of children (calculated to be >10 million youth), had experienced some form of maltreatment by a caregiver. 19 Child maltreatment can go undetected for a considerable amount of time; clinicians must be vigilant to avoid missed opportunities for detection and referral by recognizing symptoms and signs of maltreatment in clinical encounters. 20

Violence toward adults is also underreported. Survey data from the National Intimate Partner and Sexual Violence Survey estimate that more than 12 million women and men report experiencing some form of violence (rape, physical violence, or stalking) by an intimate partner each year, but only approximately 480 000 injuries are reported to police annually and 150 000 injuries receive medical treatment ( eFigure 2 in the Supplement ). The US Justice Department surveillance systems indicate that other forms of violent crime are underreported as well ( eFigure 3 in the Supplement ).

One reason that violence is underrecognized is that violence reporting systems are compartmentalized; the CDC’s National Violent Death Reporting System synthesizes information from several sources of data, but it only covers deaths and is currently operational in only 32 states. Medical, public health, police, judicial, child welfare, educational, correctional, and community agencies and organizations have also not yet built mechanisms for comprehensive, coordinated responses to violence.

Risk Factors for Perpetration of Multiple Types of Violence

Many forms of violence are interconnected at the individual level, across relationships and communities, and even intergenerationally. Traditionally, efforts to understand, prevent, and respond to interpersonal violence have been constrained by the way violence has been categorized—usually in terms of the relationship between the perpetrator and the survivor (eg, parent or caregiver-child, peer to peer, partner or spouse), but different categories of violence have similar risk factors or protective factors. A survivor of violence may also be a violence perpetrator. 21 Individuals experience multiple forms of violence and some perpetrators may perpetrate multiple types of violence. 22 A family may experience both child maltreatment as well as partner violence, 23 and perpetrators of family violence may also be violent toward nonfamily members. 24 Exposure to violence as a child (either directly or as a witness) is a strong and consistent predictor of future violence exposure as an adolescent or adult as well as the perpetration of violence as an adolescent or adult. 25 , 26

Table 2 shows select risk factors that may influence the perpetration of multiple forms of violence at different levels of the social ecology—individual, family, community, and society. With regard to individual-level risk factors for violence, there are certain neuropsychological deficits, such as hostile attributional biases and poor impulse control, that can be present among perpetrators of different forms of violence. 27 – 29 For example, poor impulse control can involve problems with excessive anger or hyperreactivity to a given stimulus, such as a child crying. 27 In meta-analyses, poor impulse control is associated with a 0.34 correlation with physical child abuse perpetration and a 0.15 correlation with youth violence perpetration. 27 , 28 These types of processing deficits may result from exposure to chronic stressors prenatally or in early childhood affecting the volume, connectivity, and chemistry of the brain. Though these changes do not directly lead to violence perpetration, they can leave an individual impaired in many areas of functioning, which can contribute to violence involvement. For example, with hostile attributional biases, individuals may incorrectly perceive an offense to themselves where none was intended—such as a youth who interprets a glance from peers or a collision in the hallway with another student to be a threat, where no insult was actually intended (correlation coefficient for youth violence of 0.13).

Select Individual, Family, Community, and Society-Level Factors Associated With the Perpetration of Multiple Forms of Interpersonal Violence a

There are many causes of stressors to children that can affect brain development or are associated with violence perpetration later in life, including child maltreatment and witnessing partner violence. Chronic stressors may result from living conditions that affect children directly, such as poverty. At the societal level, high levels of income inequality have been linked to multiple forms of violence. A study of income inequality across 3142 US counties detected a 0.17 correlation between county-level income inequality and official child maltreatment reports; cross-national studies have also found significant associations between income inequality and other forms of violence. 34 – 36 Additionally, stressors can occur indirectly by means of their effects on parental well-being and parenting behaviors. Structural disadvantage and racism can also contribute to the perpetration of multiple forms of violence. 38 Although most of the risk factors listed in Table 2 are associated with chronic stress in the lives of children, it is important to note that the variance explained by any 1 risk factor is generally small. Consequently, although these risk factors should be considered in exploring opportunities for prevention, intervening solely on 1 risk factor may have limited effect. Research suggests that it is the accumulation of multiple adverse experiences that is associated with the greatest risk of subsequent likelihood of violence involvement. In contrast to the effect of risk factors, adverse health outcomes may be buffered by protective factors, such as safe, stable, and nurturing family relationships and high levels of support and cohesion within communities. 31

Challenges for Violence Prevention

Rates of violence vary by age group, geographic location, sex, race, and ethnicity. For example, homicide is the leading cause of death for non-Hispanic blacks from age 1 through 44 years, whereas it is the fifth most common cause of death among non-Hispanic whites in this age range. This high rate among African Americans is primarily driven by exceptionally high rates among males between the ages of 15 and 34 years. 3 Child protective services reports from 2013 indicate that the rate of child maltreatment is 8.1 per 1000 children among white, 14.6 among black, and 8.5 among Hispanic children. 18 Differences in child maltreatment rates as well as other forms of violence are attributable to underlying risk factors, such as poverty. 39 Table 3 displays disparities in violence by race/ethnicity; disparities in rates of violence increase with the severity of violence (ie, homicide vs nonfatal violence).

Rates of Experiencing Violence by Race and Ethnicity a

Violence disproportionately affects younger individuals—rates of experiencing homicide among those between the ages of 15 and 39 years are more than 2-fold higher than those among individuals 40 years or older. 3 The increase in homicide rates from 1985 to 1993 was largely accounted for by an increase in homicide among individuals aged 15 to 24 years. 40 Rates of violence also vary by location; for example, metropolitan areas have greater homicide rates than suburban or rural areas. 8 Variation in rates of violence by geographic area may be attributable to social constructs such as inequality and poor social cohesion, which are elevated in urban areas. 41

Slowing Decrease in Case-Fatality Rates

The proportion of assaults resulting in the death of an individual (ie, the case-fatality rate) has declined markedly since the 1960s ( Figure ). This decline in the lethality of assaults is believed to be largely attributable to improvements in the quality and availability of trauma care. Over the past several decades, the number of hospitals, hospital capacity, physician availability and specialization, and technology used in caring for individuals who are critically ill has improved and such measures have been associated with lethality reductions on the county level. 5 Injured patients receiving care at trauma centers have a lower risk of death than those treated at other facilities. 42 However, since the mid-1990s, decreases in case-fatality rates have slowed ( Figure ). It appears that there is a limit to which skilled critical care can save patients’ lives; clinicians and health care systems should consider ways to become more involved in violence prevention.

Health Consequences of Violence

Beyond physical injuries, which are the most apparent consequences of violence, the association between violence and infectious diseases, especially sexually transmitted infections (STIs) such as human immunodeficiency virus (HIV), is well established. 43 , 44 For example, although forced sexual intercourse can directly transmit infectious agents, sexual and nonsexual violence are also associated with subsequent early sexual debut, multiple partners, failure to use condoms or other forms of protection, and other behaviors that increase the risk of STIs. In a recent meta-analysis, relative to children experiencing no abuse, the odds of contracting STIs or engaging in risky sexual behaviors ranged from 57% higher among those children experiencing neglect to 78% higher among children experiencing physical abuse. 44 Beyond the risk of STIs, exposure to abuse as a youth is also associated with adverse reproductive health outcomes, including fetal death and postpartum depression. 45

Experiencing violence (physical, sexual, psychological) is associated with increased risks of mental health and behavioral disorders such as depression, posttraumatic stress disorder, personality and conduct disorders, anxiety, sleep and eating disorders, substance abuse, and suicide and suicide attempts. 46 For example, meta-analyses indicate that children who were physically abused have a 54% increased odds of depressive disorders and a 92% increased odds of drug use. 44 Children experiencing emotional abuse or neglect can have even higher rates of psychological comorbidities (>300% increased odds of depressive disorders from emotional abuse and >200% increased odds from neglect, relative to children without abuse exposure). 44 Psychosocial outcomes in adulthood associated with past experiences of childhood violence may also include problems with finances, family, jobs, anger, and stress. 45

Lastly, violence is also associated with the development of major noncommunicable diseases, such as cardiovascular disease, cancer, chronic lung disease, and diabetes as well as key risk factors for several chronic diseases, including harmful alcohol use, tobacco use, physical inactivity, and obesity. 44 , 47 For example, data from meta-analyses, indicate that children who have experienced physical abuse have a 55% increased odds of tobacco smoking and a 32% increased odds of obesity, relative to nonabused children. 44 Although the relationship between childhood violence exposure and many noncommunicable diseases is still emerging, a growing number of prospective, longitudinal studies are establishing strong associations.

Opportunities for Prevention

Violence prevention programs are often developed to address certain forms of violence (eg, child maltreatment, partner violence, youth violence) rather than multiple forms of violence. By focusing on those strategies that can reduce multiple forms of violence, practitioners have the potential to maximize gains in violence prevention. In Table 4 and Table 5 , we highlight violence prevention strategies with some evidence for an effect on multiple forms of violence and that have been evaluated by major violence prevention evaluation bodies or possess other strong experimental evidence. The oldest and most tested violence prevention strategies are largely parent- and family-focused programs, early childhood education, therapeutic or counseling interventions, school-based programs, and public policy approaches.

Examples of Violence Prevention Strategies That Can Impact Multiple Forms of Violence a

Abbreviations: CBT, cognitive behavioral therapy; NA, not evaluated.

Promising Interventions a

Abbreviations: NA, not evaluated; RCTs, randomized clinical trials; SEEK, Safe Environment for Every Kid; WIC, Special Supplemental Nutrition Program for Women, Infants, and Children.

Parent- and family-focused programs provide education and training to parents with the goal of improving emotional bonds between parents and children and teaching participants how to effectively discipline, monitor, and supervise children as well as strengthen access to social support and other resources. Programs for young children with components that teach parents communication skills and positive parent-child interaction skills and that include active role play and practice produce greater preventive effects than those without these components. 62 Although parenting and family focused programs can vary substantially in content, method, and setting, a systematic review of early childhood home visitation programs detected a 38.9% reduction in episodes of child maltreatment in intervention participants compared with control participants. 63 The earlier parenting and family programs are delivered in a child’s life, the greater the benefits; however, significant benefits have also been demonstrated when delivered to adolescent populations. 64

The evidence also suggests that early childhood education can prevent future violence involvement. Early childhood education programs are associated with positive social and emotional development, lower rates of official reports of child abuse and neglect, less aggression and child behavior problems, and higher rates of secondary school completion and have also demonstrated long-term effects on violent and criminal behavior. 65 , 66 One example is the Chicago Child-Parent Center program, which provides a comprehensive educational program beginning in preschool, as well as other family support services to economically and educationally disadvantaged children. 67 A 15-year follow-up of preschool program participants across 25 sites in Chicago demonstrated statistically significant lower rates of juvenile arrests in the intervention vs control group (16.9% vs 25.1%, respectively). 67

There is also substantial evidence for therapeutic approaches and universal school-based violence prevention programs. Not only do therapeutic programs reduce the trauma-related harms of experiencing violence, but they also can prevent subsequent violence involvement. Cognitive behavioral therapy (CBT) and Multi-systemic therapy are 2 examples of therapeutic approaches. A Campbell Collaboration meta-analysis of CBT programs for criminal offenders demonstrated a crime recidivism reduction of 25% (recidivism rate of 0.30 in the intervention group compared with 0.40 in the control group over approximately 12 months after the intervention period). 53 As for universal school-based programs, such approaches are associated with a 15% relative reduction in violent behavior in students across all school years participating in these programs and a 29% reduction in violence among students in high school. 68 School-based programs have demonstrated reductions in both peer violence and teen dating violence and are also cost-effective. 48 , 69

Although many policy-level interventions for violence remain to be tested, there is some evidence for policies that aim to reduce alcohol-related harms. Given the strong association between alcohol use and violence involvement, reductions in alcohol consumption are expected to be associated with reduced levels of multiple forms of violence. Based on systematic reviews, the Community Preventive Services Task Force recommends increasing alcohol prices, limiting days and hours of sale, regulation of alcohol outlet density, upholding liability of establishments for alcohol-related harm committed by customers (dram shop liability), enhanced enforcement of laws prohibiting the sale of alcohol to minors, and screening and brief interventions for problem drinkers. 49

There are also other policy- and community-level approaches that represent promising strategies to prevent multiple forms of violence. Violence is higher in communities where there are limited economic opportunities; where there are high concentrations of poor and unemployed people; where people move frequently; and where there are limited public, mental health, and social services available to residents and fewer civic and voluntary associations. 31 Consequently, the evidence for other policy- and community-level approaches to address these characteristics points to income-strengthening approaches (eg, subsidies or cash transfers), urban upgrading (eg, improved transportation, lighting, buildings, green space), economic development strategies (eg, business improvement districts), and residential mobility programs that enable families living in disadvantaged environments to resettle in more advantaged neighborhoods. 70 – 72 Increasing family income through subsidies or cash transfers, for example, has been shown to reduce child abuse and neglect, youth violence, and partner violence. 58 , 59 , 71

Lastly, bystander strategies are increasingly being used to prevent sexual violence, teen-dating violence, and bullying. With this approach, participants are trained to recognize potentially violent situations or behaviors that they see occurring and are taught skills to safely intervene. This approach also seeks to change underlying social norms that promote violence. A meta-analysis of bystander education to prevent sexual assault on college campuses found moderate effects on both bystander efficacy and intentions to help others at risk; smaller but significant effects were seen on increasing actual bystander helping behaviors, decreasing acceptance of rape myths, and decreasing rape proclivity. 56 Additionally, a recent meta-analysis of bullying programs detected an increase in bystander interventions among program recipients (an increase of 20% of 1standard deviation more than control group participants). 57

Although less is known about the modifiable factors that serve as protective buffers in the face of disadvantage, previous research suggests that connectedness and community-level collective efficacy are protective factors that may offset many of the negative influences in disadvantaged environments. These factors also seem to be protective across multiple forms of violence, including child maltreatment, youth violence, intimate partner violence, and suicidal behavior. 73 Although, to date, few interventions in these areas have been tested and evaluated, it is a promising area for future research. It is also important to acknowledge the significant contributions to violence prevention and response elucidated by other domains, such as criminology. Strategies such as problem-oriented policing are also associated with important effects on violence reduction. The science of violence prevention has made significant progress over the last 2 decades. Widespread dissemination and adoption of available evidence-based strategies, however, is still needed.

Role of Health Care Systems and Clinicians

Many health care or clinical approaches to violence prevention are still early in development and, in general, there is limited experimental evidence for such approaches. However, a variety of strategies are being pursued and merit additional evaluation. Individuals exposed to violence can use health care services at a high rate and some clinicians have established programs designed to prevent their patients’ future involvement in violence and recidivism for violent injury ( Box ). 76 , 80 Such programs often are operated by emergency departments and trauma services 80 , 81 ; however, primary care clinics also have implemented programs to prevent violence, such as the Safe Environment for Every Kid (SEEK) model, a pediatric outpatient program. The SEEK program consists of identification of risk factors, offering brief counseling, and referring patients for services. A randomized clinical trial in which participants were followed up for more than 3.5 years found that children whose families were in the SEEK intervention had a significantly lower rate of official child protective services reports of child maltreatment (13.3%) than did those in the control group (19.2%). Intervention families also experienced improved health benefits such as lower rates of delayed immunizations. 54 In addition to the identification of risk factors for violence involvement, clinicians can be trained to recognize the signs and symptoms that may be associated with experiencing violence, such as injuries; unexplained chronic pain; gastrointestinal symptoms; genitourinary symptoms; repeated unintended pregnancies or sexually transmitted disease; symptoms of depression, anxiety, and sleep disorders; alcohol or other substance abuse 82 ; and behavioral problems in children.

Action Steps for Health Care Systems and Clinicians

Clinical trials in pediatric primary care settings suggest that identification of violence-associated risk factors, brief interventions, and referrals may reduce some forms of violence 54 , 55

The US Preventive Services Task Force recommends that clinicians screen women of childbearing age for intimate partner violence. Through appropriate training, clinicians can also improve their identification of women experiencing abuse even if they cannot screen all asymptomatic patients. 74 Electronic medical records can prompt physicians on appropriate language and response if a patient screens positive

With the Affordable Care Act insurers can no longer deny coverage to individuals by using domestic violence and related sequelae as a preexisting condition, more of these patients may be entering routine medical care 75

Create, expand, and evaluate emergency department, trauma, or other clinical programs that work with those patients presenting with injury; some such programs have been linked with subsequent decreased emergency department utilization or violent behavior 76

Use mental health interventions, particularly those designed to reduce trauma and other violence-related harms 77

Collaborate

Develop new community collaborations. For example, hospital and police department partnerships have led to promising interventions for violence prevention 78

Consider participating in and offering services as a part of coordinated centers, such as Family Justice Centers (the co-location of multiple agencies to facilitate patients receiving comprehensive, wrap-around services such as legal, medical, housing/shelter, child care, advocacy)

Provide training in trauma-focused care to all staff—trauma-focused care principles are to be aware of the widespread impact of trauma; understand paths for recovery; recognize signs and symptoms of trauma in patients, families, and even staff; respond in a way that incorporates knowledge about trauma into policies, procedures, and practices; and resist re-traumatization through avoiding harmful practices (eg, using restraints or seclusion rooms when not clearly indicated) 79

Incorporate violence-prevention awareness and principles into the curriculum of medical students, residents, and other health care professionals

Leverage health care system resources to create primary prevention programs. Some hospitals have sourced produce or goods from local business that employ disadvantaged populations as an attempt to address underlying socioeconomic determinants; others have used the health care system to provide job and skills training for high-risk youth. Some hospitals have funded community-based parenting or school-based classes that incorporate violence prevention 76

Investigate new strategies for primary prevention (ie, to prevent violence from happening in the first place); more research is needed to better understand effective health care-based approaches

New incentives and opportunities have been created to improve identification and assistance of patients at risk of violence and those presently experiencing violence. With the passage of the Affordable Care Act, screening adolescent and adult women for interpersonal violence and counseling must now be covered by many health plans with no cost sharing for patients. 75 Reimbursement rates and implementation details are likely to differ across plans, but this may facilitate identification of such patients and support on-going efforts. Large trials have shown little efficacy if the intervention for patients who screened positive for intimate partner violence involved providing them a resource list or informing their clinician with subsequent discussion and referral left to the discretion of the clinician. 83 , 84 Programs that have followed a positive screen result with more intensive support, such as a clinic-based CBT intervention, have noted improved outcomes. 85 One such program, which screened minority women at prenatal care clinics and then provided CBT, demonstrated a reduction in subsequent intimate partner violence (23.3% in intervention group vs 37.8% in control group overall follow-up interviews; intervention participants also gave birth to a lower proportion of infants with very preterm birth [1.5% vs 6.6%]). 85 More research is needed to better identify elements of programs that most effectively assist individuals found to be experiencing intimate partner violence or to identify other novel strategies. For example, medical-legal partnerships, an approach that attempts to better integrate legal services for patients into clinical care, can potentially assist clinicians with interventions not typically considered by the medical community. For example, in 1 retrospective cohort study, at the 12-months follow-up, women who had obtained permanent protection orders had a rate of police-reported physical abuse that was 20% of those women without protection orders (rate of 2.9 incidents per 100 person-years in intervention vs 14.0 incidents per 100 person-years in control). 86

Some health systems have also attempted to address underlying risk factors by various forms of community engagement. For example, hospital systems have funded school-based educational programs that attempt to modify early risk factors for violence. 76 Other health care systems have begun to intentionally purchase produce, goods, or services from local businesses in high-risk communities in an attempt address underlying economic risk factors for violence involvement. 76 These strategies represent early engagement of health care systems with more population-level preventive approaches; evaluation of such strategies is needed to best guide efforts.

Conclusions

The scientific literature indicates quite clearly that preventing interpersonal violence is strategic from a health and public health perspective. It is strategic because of the consistently documented high levels of violence to which young children, adolescents, and young adult women and men are exposed. Furthermore, exposure to violence plays an important role, not just in causing physical injuries and homicide, but also in the etiology of mental illness, chronic disease, and infectious diseases such as HIV. Thus, preventing exposure to violence can have downstream effects on a broad range of health problems. Finally, there is a substantial and rapidly growing evidence base on what works to prevent violence. This evidence suggests that priority should be given to interventions that can affect multiple forms of violence, particularly those that seek to prevent violence among children and youth. The effects of violence and the probability of involvement in future violence are dose dependent; thus, considerable gains can be made by early intervention.

Supplementary Material

Supplemental content at jama.com

CME Quiz at jamanetworkcme.com and CME Questions page 514

Author Contributions: Dr Sumner had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Acquisition, analysis, or interpretation of data: Sumner, Mercy, Dahlberg, Hillis.

Drafting of the manuscript: All the authors.

Critical revision of the manuscript for important intellectual content: All the authors.

Statistical analysis: Sumner.

Administrative, technical, or material support: Sumner, Hillis, Houry.

Study supervision: Sumner, Mercy, Hillis, Houry.

Conflict of Interest Disclosures: All the authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.