James E. Bailey, MD, MPH; Arthur L. Kellermann, MD, MPH; Grant W. Somes, PhD;. Joyce G. Banton, MS; Frederick P. Rivara, MD, MPH; Norman P. Rushforth, ...
Risk Factors for Violent Death of Women in the Home James E. Bailey, MD, MPH; Arthur L. Kellermann, MD, MPH; Grant W. Somes, PhD; Joyce G. Banton, MS; Frederick P. Rivara, MD, MPH; Norman P. Rushforth, PhD
Objectives: To determine risk factors for violent death of women in the home, and particularly, to assess the
strength and direction of any association between domestic violence or keeping firearms and homicide or
suicide in the home.
Methods: Subgroup analysis of a large population\x=req-\ based case-control study database was performed, defining cases as all homicides and suicides occurring in the homes of female victims in 3 metropolitan counties: Shelby County, Tennessee; King County, Washington; and Cuyahoga County, Ohio. Randomly selected control subjects were matched to the victims by neighborhood, sex, race, and age range. Exposures to potential risk factors were ascertained by interviewing a proxy for the victim 3 to 6 weeks after the violent death occurred. These answers were compared with those obtained from controls using matched-pairs methods. Results: All cases (n=266) were identified in the 3-county including 143 homicides and 123 suicides, during a 5-year period. Matching controls (n=266) were also identified. Firearms were involved in 46% of the homicides and 42% of the suicides. Independent risk factors for suicide in the home included a history of mental illness (odds ratio [OR], 258.8; 95% confidence interval [CI], 18.2\x=req-\ 3679.8), living alone (OR, 13.4; 95% CI, 2.0-87.8), and havarea,
From the Departments of Preventive Medicine (Drs Bailey and Somes and Ms Banton) and Medicine (Dr Bailey), Division of
General Internal
Medicine, University of Tennessee, Memphis; Center for Injury Control, Rollins School of Public Health, Emory University, Atlanta, Ga (Dr Kellermann); Harborview Injury Prevention and Research Center, University of
Washington,
Seattle
(Dr Rivara); and Department
of Biology,
Reserve
Case Western
University, Cleveland,
Ohio (Dr
Rushforth).
Murders
1 or more guns in the home (OR, 4.6; 95% CI, 1.2\x=req-\ 17.5). Independent risk factors for homicide included living alone (OR, 5.1; 95% CI, 2.0-13.2), illicit drug use by any member of the household (OR, 4.9; 95% CI, 1.3-15.9), prior domestic violence (OR, 4.0; 95% CI, 1.5-10.5), 1 or more guns in the home (OR, 3.4; 95% CI, 1.6- 7.1), and previous arrest of any member of the household (OR, 3.0; 95% CI, 1.3-6.6). The increased risk of homicide associated with
ing
domestic violence, firearms, or illicit drugs was attributable to the homicides at the hands of a spouse, intimate acquaintance, or close relative.
Conclusions: Among women, mental illness and living alone increase the risk of suicide in the home, and household use of illicit drugs and prior domestic violence increase the risk of homicide. Instead of conferring protection, keeping a gun in the home is associated with increased risk of both suicide and homicide of women. Household use of illicit drugs, domestic violence, and readily available firearms place women at particularly high risk of homicide at the hands of a spouse, an intimate acquaintance, or a close relative. Many factors place women at increased risk of violent death in the home. Community- and clinic-based interventions should target those with identifiable risk factors.
Arch Intern Med. 1997;157:777-782 OF women
have focused national attention on domestic violence (US News and World Report. July 4, 1994:24-28; Time. July 4,1994:19-25; The New York Times. May 28, 1994:19) and have led some to promote gun owner¬ ship for self-protection14 (Guns Maga¬ zine. September 1989;39:56-61, 76, 7882). Although battering and other forms of domestic violence have long been rec¬ ognized as preludes to homicide, neither the degree of risk imposed by a history of domestic violence nor the level of protec¬ tion afforded by keeping a gun in the home have been assessed systematically.36 De¬
spite common misconceptions regarding the risk of victimization,
women are
known to be at much lower risk for ho¬ micide than men, particularly at the hands of strangers.7 9 Women are most likely to be killed by someone they know, usually a spouse or an intimate acquaintance.8"10 A firearm is often used.10"12 Women also have lower suicide rates than men, even though they make more suicide attempts.7,13,14 Some research¬ ers1315 suggest that women have a lower completed suicide rate because they are less likely to choose a gun as a suicide method. This may be particularly true among women who live alone, since most firearms are owned by men.16 To clarify the relationship between domestic violence, gun ownership, and a woman's risk of violent death, we reana¬ lyzed the results of 2 population-based,
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PARTICIPANTS AND METHODS DATABASE PARTICIPANTS
The database used for this analysis contains incident in¬ formation and interview data for 442 suicides and 389 ho¬ micides that took place in the home of victims who lived in 3 metropolitan counties (Shelby County, Tennessee; King
household drink alcoholic beverages?" Response to alcohol problems was considered positive if alcohol had ever caused problems at home, at work, or with health for any member of the household. Response to prior arrest was considered positive if either the victim or any member of the house¬ hold reported ever being arrested. Home security summa¬ rized responses to 7 questions and the response was con¬ sidered positive if the household had any of the following measures: a
burglar alarm, security doors, electronically con¬
County, Washington; and Cuyahoga County, Ohio). The suicides studied occurred in either Shelby County or King County between August 23, 1987, and April 30, 1990, and the homicides studied occurred in either Shelby County or King County between August 23, 1987, and August 23, 1992, or Cuyahoga County between January 1, 1990, and August 23, 1992. Epidemiological information was ob¬ tained by interview of a proxy respondent for the victim, after each case of violent death occurred. Proxy respon¬ dents were selected using a standardized heirarchy and were interviewed for 80% of the 554 eligible suicides and 93% of the 420 eligible homicides available for study. The database also contains interview data from match¬ ing controls or their proxies for 438 (99.1%) of the sui¬ cide and 388 (99.7%) of the homicide case interviews. A randomly selected control subject was matched to each vic¬ tim by age range, sex, race, and neighborhood, using a pre¬ viously validated method for random selection of match¬ ing households within a given neighborhood.2122 To identify eligible households, interviewers used a block-walking sche¬ matic to approach a randomly selected string of house¬ holds, adjacent to a 1-block avoidance zone. The first house¬ hold found to contain an individual of the same race, sex, and age range as the victim was asked to consent to an interview. Whenever possible, a proxy for the matching control subject was interviewed to obtain information in a comparable manner. The interviews were designed to as¬ certain exposure of a variety of individual, household, and environmental risk or protection factors for violent death in the home. Detailed descriptions of the methods used in this study can be found elsewhere.17,18 The final database contained information on 826 matched pairs of cases and controls. Two hundred sixtysix (32%) of these pairs were women. This subset formed the basis for our present analysis.
trolled access, burglar bars, dead bolt locks, window stick¬ ers, or a dog. Response to mental illness was considered posi¬ tive if the victim or any member of the household had ever suffered from or required medication for depression or other psychiatric problems. Response to illicit drug use was con¬ sidered positive if the victim or any member of the house¬ hold used illicit drugs. Response to gun in home was con¬ sidered positive if a firearm of any type was present in the home at the time the violent death occurred. Descriptive statistics were used to summarize incident information. Mantel-Haenszel x2 analysis was used for univariate analysis of matched pairs. Multivariate analyses used conditional logistic regression, the appropriate technique for a matched-pairs design.23 Conditional logistic-regression analysis requires that data on all the variables of interest be available for both case subjects and their matched controls. Therefore, pairs with missing data on any of the variables of interest were excluded from this analysis. To identify and control for multicollinearity, we constructed models that se¬ lected those variables that remained significant after we con¬ trolled for the effects of the remaining variables in each model. The modeling procedure retained variables that were sig¬ nificant at the P
