By Philip J. Candilis, MD and Edmund G. Howe, MD, JD with the GAP Committee on Professionalism and Ethics.
A 29-year-old woman visits a mental health clinic, telling her therapist she is terrified by recent reports of gun accidents in the home. She works from home while caring for her toddler and heard news reports of the Illinois and Ohio children who had accidentally shot household members, including one who fatally shot his pregnant mother. She had never spoken previously either to her primary care doctor or therapist about firearms, largely because her family’s gun ownership was a matter of pride and one of her community’s values.
This fictional example conveys both the terror and angst patients and clinicians may experience when a family has weapons at home. Shared anxiety is especially intense when it is known there is unsecured access to a lethal instrument. Preparing for such scenarios requires attention to an often-neglected aspect of public health: gun safety at home.
Unfortunately, it is rare for discussions about managing firearms in the home to take place–even though it is a discussion that can benefit adults and children at the same time. Fewer than 10% of US adults have conversations about guns with their doctors or mental health practitioners—even though it is a conversation that can enhance family safety.
Further, household firearms elevate the risk of anyone in the home being killed, with bullets killing approximately 35,000 people in the US every year. Half of those who commit suicide die from gunshot wounds. Indeed, guns are the second leading cause of death in children and teenagers and the leading cause of death in African American teens. Consequently, guns target the young people most vulnerable in society, furthering inequality.
What Can Be Done?
It is advisable that patients and those treating them review general home safety measures with child development in mind—starting when babies are born and later when children begin walking, biking, swimming, or driving. Doing such reviews at these milestones can offer increased opportunities for protecting children and families.
As in the example above, individual patients may be moved by alarming news reports to take disregarded but nevertheless, common safety precautions taught by firearms instructors, for example, locking guns in a safe while keeping bullets locked in a separate place entirely.
Talking about safes and safety locks in a way that supports child safety while still protecting a treasured item may put the evidence supporting safes and locks directly at the patient’s service: rates of gun death are lower in households that apply these fundamental practices.
Many gun owners feel they need their guns to be readily available for personal protection. They may live in rural settings where they love to hunt and fish. Ranching and farming are, of course, staples of a robust economy, so guns may be a part of everyday life.
Consequently, talking about guns should be respectful of context and values, or else risk appearing judgmental or uninformed. It should be kept in mind that patients and families may refuse to collaborate in gun safety discussions if they perceive their family doctor, pediatrician, or therapist doesn’t understand their commitment to gun ownership. Whatever the context, access to weapons is an established public health priority in the assessment of family safety.
Suicide and Intimate Partner Violence
Respectful discussion may anticipate other common gun risks: suicide and intimate partner violence. When patients are at risk for harming themselves or others, the risk of using their own weapon increases dramatically. This risk has been amplified by the increasing number of gun owners nationwide. In fact, between 2015 and 2019 US gun ownership almost doubled.
The risk of suicide may be particularly difficult to mitigate when patients have immediate access to a weapon and are unwilling to give it up. Having a safety lock or keeping the gun’s ammunition in a separate place may decrease their risk of dying because protective measures simply require them to take more time to act.
With impulsivity being one of the negative behaviors rising during the COVID pandemic, extra time during a household crisis may be lifesaving. Guns remain the leading weapon among domestic violence killings in the US, so taking basic safety measures may allow time for de-escalation, for help to arrive, or for escape.
Talking Gun Safety Should be Routine—and Respectful
Because patients themselves most commonly report that they have guns, direct communication about risk remains the most critical safety tool. Familiarity among families and their clinicians with the common features of gun ownership can lead to productive conversations about safety options like cabinets or plastic locks for people who are aware of safety measures but are unable to afford typical gun safes.
What, then, can and should people expect when they talk to their doctors or therapists about guns in the home? They might expect their doctors or therapists to talk about this fraught topic in a way that respects the essential place these weapons hold in patients’ lives. Even during a crisis—a difficult time to talk about any charged issue—a tempered, technical, and thorough approach may improve a patient’s safety and that of the people around them.
In a household crisis, for example, modifying a common inquiry into whether a friend or family member is available to hold onto the firearm, one might hear a question on whether the gun can briefly go “on vacation.” This phrasing respects the patient’s perception that guns are needed but uses a nonjudgmental approach and tone to open the door to a temporary alternative.
Family doctors, pediatricians, and therapists may already favor approaching gun safety indirectly, asking patients first about safety at home—a common screening approach for those who ask about child safety and intimate partner violence. Patients may have already noticed such questions being adopted by doctors, clinics, and hospitals worldwide. This safety consciousness allows a more general question like “Where does your family keep any guns you have.” This is much like asking patients, “How much alcohol do you drink?” instead of, “Do you drink alcohol?” It’s that nonjudgmental wording that makes it easier for patients to respond.
Clinicians, in general, hold informed consent discussions when they first meet their patients, saying that they may have to discuss personal matters, insurance coverage, and alternate decision-makers. This consent framework can easily extend to the safety of family life (“I often ask about home safety”), perhaps in the way discussions of seatbelts, bike helmets, and childproofing have become more commonplace.
In the worst-case scenario of a crisis that risks suicide or violence, patients and family members may well consider vacations from their guns when their providers speak in terms that are undogmatic, respectful, and collaborative.
Anestis MD, Bandel SL, Butterworth SE, Bond AE, Daruwala SE, Bryan CJ. Suicide risk and firearm ownership and storage behavior in a large military sample. Psychiatry Res. 2020 Sep;291:113277. doi: 10.1016/j.psychres.2020.113277. Epub 2020 Jul 2. PMID: 32886959.