Firearm-Facilitated Sexual Assault: Using Emergency Department Data to Provide a Novel Perspective of the Problem

Introduction

Firearm-related injury is a leading cause of death in the United States, disproportionally impacting youth and underserved populations. Persons aged 15–34 are especially affected, wherein injury and violence are among the top three causes of death overall, with firearms utilized as the top method in both suicide and homicide deaths (Centers for Disease Control and Prevention 2015). Although firearm mortality data are reasonably well understood, large gaps exist in understanding the magnitude of nonfatal shootings and other key firearm-related injury risks in the community (Cambell and Nass 2019). It is estimated for every gun homicide in the United States there are approximately six nonfatal shootings (Papachristos et al. 2015), of which only 61% are reported to law enforcement (Planty and Truman 2013). From a criminal justice perspective, a 2017 Canadian study interviewing convicted sex offenders revealed offender weapon possession was the strongest predictor of victim injury and death when sexually assaulted by a stranger; however, little research has explored this phenomenon in the health care setting (Reid and Beauregard 2017). More locally, the policing records in Atlanta indicate 5–10% of firearm injury incidents may not be identified by health care providers or public health officials (Wu et al. 2019).

Further complicating the issue, not all firearm-associated injuries involve ballistic injuries. Local surveillance data revealed 17% of patients presenting to Grady Memorial Hospital Emergency Department (ED) for a firearm-associated injury were struck (“pistol whipped”) with a firearm (National Electronic Injury Surveillance System [NEISS]). In addition, 2% of patients presented with indirect injuries sustained by threat of firearm, such as firearm-facilitated sexual assault (FFSA) and injury sustained from fleeing gunfire (NEISS 2018). This local review process prompted the investigators to examine the national burden of FFSA within the NEISS data set to reveal the context of these injury events (Fig. 1). An initial review of the NEISS data set in its early years revealed that nonfatal nonballistic firearm injuries contribute significantly to the burden of firearm-related injuries (Hootman et al. 2000). However, given there is no continued centralized system to track nonfatal firearm-related injuries, especially those that are not directly used in the injury-related occurrence (such as FFSA, defensive use of firearms, and robbery), injury prevention practitioners are left with little contemporary data to analyze the scope of the problem or to design evidence-based intervention and prevention efforts.

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FIG. 1.

National Electronic Injury Surveillance System 1993–2015 overall nonfatal firearm injuries.

Materials and Methods

The data utilized in this review were primarily sourced from the NEISS database, which samples injury data from participating hospitals across the United States and produces nationwide estimates of consumer product-related injuries. The variables included in the NEISS data set are comprehensive, collecting firearm-specific characteristics (type of firearm, manufacturer/model of firearm, and caliber/gauge of firearm involved) as well as injury-related circumstances (incident involved argument, fight, drugs, or crime) (Hootman et al. 2000). These firearm-specific variables are included alongside the usual NEISS coded variables, allowing for a focused consumer product review of firearm-injured patients (Hootman et al. 2000). The data obtained from NEISS allow for analysis of difficult to assess variables such as blunt injury from firearms and indirect injury from firearms.

For this report, the investigators focused specifically on nonballistic injuries involving a firearm between the years 1993 and 2015 (Fig. 1). FFSA is defined as a report where the victim's chief injury was sexual assault, and where the patient stated a firearm was used to coerce or facilitate the sexual assault. Reports involving FFSA were identified through the comment section of the data set, which required manual coding and natural language processing software within the JMP statistical software package (JMP^®, Version 14; SAS Institute, Inc., Cary, NC, 1989–2019) to abstract. Reports with comments that mentioned the presence of a firearm and the words “rape” or “sexual assault” were considered FFSA, whereas all other reports were not.

Once reports detailing FFSA were identified, the demographics of all nonballistic firearm injuries and of FFSA were calculated. Specifically, the investigators focused on the age, gender, and race demographics of FFSA and non-FFSA reports. In addition, the team identified the demographics of disposition of FFSA victims and of all nonballistic firearm injuries, as noted in the ED of each selected hospital. Finally, the investigators calculated the breakdown of injury mechanism for all nonballistic firearm injuries, and also noted any additional injury mechanism present in FFSA victims. All calculations were performed using SAS 9.4.

Results

Of the FFSA patients presenting to the NEISS-participating hospitals, 48% were between the ages of 15 and 24, and were overwhelmingly female (91%). In total 45% of patients identified as white, 30% black, 16% other, and 9% Hispanic. The majority of cases (82%) did not report injuries other than the associated sexual assault. However, patients reported or were documented as being hit/struck by a gun in 14% of cases. The disposition from the ED was also reviewed, where the majority of cases (91%) were treated and released, 4% were hospitalized, 3% transferred to another facility, and 1% were held for observation. One percent of patients left without being treated by a provider or left against medical advice (AMA/LWBS) (Table 1).

Discussion

The investigators discovered a larger than expected proportion of FFSA patients within the NEISS data set when compared with anecdotal experience treating this population in the ED. Although NEISS data set captures this population through a free text comment section, there is no FFSA-specific coding. This issue prevents simple abstraction, and effectively masks the impact of firearms on this vulnerable patient population. The process of manually abstracting cases of FFSA using natural language processing software revealed novel epidemiological data, including demographics, injuries sustained, and hospital disposition data that could assist injury prevention practitioners in understanding the magnitude of the problem in this elusive area.

However, the approach was limited in several ways, including lack of knowledge surrounding the NEISS-sampled hospitals' rape crisis center designation status, annual volume of sexual assault patients, and the investigators nonvalidated secondary coding of FFSA within the NEISS data. The next steps for research include proposing the creation of a specific code for FFSA within the NEISS, or developing a centralized firearm injury surveillance strategy to facilitate a clearer understanding of the magnitude of the injury burden. In addition, other types of coercive firearm-associated violent behavior, or deterring behavior, are critical to understanding the larger context of firearm-related violence. Further research and data collection strategies should focus on capturing these significant elements.