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In the U.S., firearms kill more people through suicide than homicide.
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The nation's foremost public health agency shies away from discussing the important link in this country between suicide and access to guns.
That's according to documents obtained by NPR that suggest the Centers for Disease Control and Prevention instead relies on vague language and messages about suicide that effectively downplay and obscure the risk posed by firearms.
Guns in the United States kill more people through suicide than homicide.
Almost 40,000 people died from guns in 2017 alone — 60% of those deaths were suicides. Guns are the most common method used for suicide.
Suicide rates are going up in nearly every state, even though research shows that suicide is preventable. Access to guns is such an important risk factor that any effective public education campaign to prevent suicide would surely need to address it.
The trouble is, the CDC is operating under something known as the Dickey Amendment, legislation passed by Congress in 1996 that prohibits the CDC from spending any of its funds to "advocate or promote gun control."
A lot of attention has been paid to how this has stopped the CDC from funding certain kinds of gun violence research. The law also had another effect: It led the CDC to tiptoe around guns as it tries to tackle the increase in suicides.
"CDC staff do their best to provide the very latest science and evidence-based data to the public so they can protect their health," a CDC spokesperson told NPR, declining to make any agency official available for an interview.
NPR reviewed early drafts and editing notes of a major 2018 CDC suicide report and a guide on suicide prevention, obtained through a Freedom of Information Act request, along with the agency's public anti-suicide messages.
The internal documents reveal detailed staff deliberations over wording that resulted in the agency weakening language that might suggest restricting access to guns as a way to prevent suicides.
Guns get used in slightly more than half of all suicides. And people who try to kill themselves with a gun almost always die.
But the word "gun" is frequently absent when the CDC presents information on suicide prevention.
A CDC fact sheet published in 2018 on "Preventing Suicide" does not include the word "gun" or "firearm." Instead, it advises people to "reduce access to lethal means among persons at risk of suicide."
Where the CDC's website lists the risk factors for suicide, it also does not include the word "gun." It says instead "easy access to lethal methods."
Internal texts exchanged between CDC suicide researchers show why a generic term like "lethal means" is preferred: It "is probably less likely to create issues compared to using the f-word," which is firearms. A phrase like "access to firearms" would "raise a few red flags."
Here is one text exchange:
LiKamWa, Wendy (CDC/CCEHIP/NCIPC) 2:56 PM:
haha one of the police articles I saw listed "access to firearms" and I was like, that would raise a few red flags!
Stone, Deborah (CDC/ONDIEH/NCIPC) 2:56 PM:
it's ok. that's fair territory!
that's a big reason why their rates are so high.
we aren't saying take away their guns!
at least not explicitly!
LiKamWa, Wendy (CDC/CCEHIP/NCIPC) 2:57 PM:
actually, the tiesman et al article (i.e. NIOSH) talks about firearms and access to firearms a lot
Stone, Deborah (CDC/ONDIEH/NCIPC) 2:59 PM:
yeah, it's more of an issue if we are advocating for gun control. it's a fact that access is a risk factor.
LiKamWa, Wendy (CDC/CCEHIP/NCIPC) 3:00 PM:
still, "lethal means" is probably less likely to create issues compared to using the F-word
Stone, Deborah (CDC/ONDIEH/NCIPC) 3:00 PM:
In the past, members of Congress have asked the CDC if agency staffers were told to avoid using the word "gun." Here's how the CDC replied:
"To ensure scientific integrity, technical accuracy, consistency with appropriations language, and usefulness to the intended audience, CDC has a standard agency review process for any manuscript or report produced by CDC scientists. ... In the course of reviewing manuscripts or reports on firearm violence, CDC has asked employees to use correct terminology — for example, to say 'died as a result of a firearm-related injury' vs. 'died from a firearm' in the same way as one would write 'died as a result of a motor-vehicle crash' vs. 'died from a car.' "
But one former CDC official told NPR that of course employees know to censor themselves when it comes to guns.
"There were staff who would say you couldn't even say the word 'gun,' " recalls Linda Degutis, who used to serve as director of the CDC's National Center for Injury Prevention and Control. "They would tell other people, or even new people sometimes, you can't say the word 'gun' here."
She says higher-ups would review documents, "because there would be a thought that if guns were mentioned too often, that would be violating this intent not to do any kind of research or work around guns."
She says the problem with language like "lethal means" is that it doesn't convey what people should actually be worried about and what actions they should take when it comes to suicide prevention, such as offering to remove guns from the home of a friend or relative who is going through a personal crisis.
"I think when you say 'lethal means' to the general public, they don't know what you're saying," adds Degutis. "They don't know that you might mean guns."
"Safe storage" vs. "restricting access"
Another noticeable feature of the CDC's suicide prevention messaging is the emphasis on "safe storage."
By that, the agency means keeping guns and ammunition securely locked in a safe. Unlike other measures that could make it more difficult to obtain a gun, "safe storage" isn't likely to be politically controversial.
Consider the edits made to one internal document prepared to help guide CDC staff in responding to questions about suicide.
The original answer included the words "restricting access to lethal means among those at risk for suicide has been proven effective for preventing suicide."
One passage got edited to remove any reference to "restricting access." Instead, the revised answer focused on "safe storage," saying, "safe storage practices can help reduce the risk for suicide by separating vulnerable populations from easy access to lethal means."
In a teleconference that the CDC held with reporters in June 2018, when the CDC released a report on rising suicide rates, CDC Principal Deputy Director Anne Schuchat said that "one of our recommendations is assuring safe storage of medications and firearms as one of the approaches to prevention. Very important to — you know, have safe storage."
Research does show that locking up guns and ammunition can prevent suicidal adolescents from being able to access their parents' guns.
But the "safe storage" approach doesn't address the suicide risk that a gun poses to its owner, who presumably has the key or combination to a locked safe or cabinet.
And most gun suicides happen when the owner of the gun turns it on himself or herself.
"I'm a little bit dubious that safe storage will be relevant to the vast majority of suicides with firearms. Because the owners of those firearms are the ones storing the guns and locking the guns," says Daniel Webster, director of the Johns Hopkins Center for Gun Research and Policy. "I certainly don't know of any research that shows that safe storage of firearms reduces risks for adult suicide."
David Gunnell, an epidemiologist at the University of Bristol, was perplexed by the CDC's focus on safe storage.
"It was all about, if you like, putting the blame on the owners, making them store their firearms safely," says Gunnell, "rather than seeing this large pool of firearms available in the community in the United States contributing to the heightened use of firearms for suicide."
In his research on a common means of suicide in Sri Lanka, pesticide ingestion, Gunnell has found that providing locked storage boxes hasn't been an effective form of prevention. Eventually, he says, families just stop bothering to use the secure box.
What has produced dramatic reductions in suicide rates, he says, has been regulatory bans that took the most dangerous pesticides off the market in certain places.
"So there's a body of evidence that if you regulate, to make the environment safer by taking out of the broader environment the most toxic products, that results in a fall in deaths," says Gunnell, because suicide research shows that people do not tend to substitute one suicide method for another.
In fact, Gunnell says, most international reviews of the research literature on suicide have found that the strongest evidence about how to bring down death rates "is around those interventions that restrict access to commonly used, high lethality suicide methods."
In other countries, that approach has lowered suicide rates by as much as 30% to 50%.
These dramatic decreases are not mentioned in the CDC's main guide to preventing suicide, described as "a resource to guide and inform prevention decision-making in communities and states."
It does talk about the need to create "protective environments" and includes the example of "safe storage" of guns. But as the document got edited inside the CDC, its message about the importance of restricting access to "lethal means" got weakened. One early draft stated:
"The evidence for the effectiveness of means restriction and other ways to establish protective environments is some of the strongest in the field."
The sentence got changed to:
"The evidence for the effectiveness of preventing suicide by reducing access to lethal means and otherwise establishing protective environments for individuals at risk of suicide is strong, particularly compared to existing evidence for other prevention strategies."
Additional changes produced the final, published version, in which the evidence merely "suggests":
"The evidence suggests that creating protective environments can reduce suicide and suicide attempts and increase protective behaviors."
It's possible to read the CDC's materials on suicide and come away not understanding what science shows about how to significantly reduce suicide rates, and the important connection between guns and suicide.
"Half of all suicide deaths in the states are from firearms," says Gunnell, "and so, as a policymaker, my first step would be to say, 'Well, what can we do to restrict access to firearms?' "
The CDC's own research shows that simply having a gun in the home is associated with increased risk for suicide, but that isn't highlighted in its public messages about suicide.
In addition, states that have higher gun ownership rates see higher rates for suicide, "even after you've controlled for a range of other factors known to be correlated with suicide risk," says Webster. "Access to firearms does increase suicide risk. I recognize that is a conclusion that will make people uncomfortable. But that is simply what the facts are."
When people are going through difficult times or grappling with substance use or mental health issues, says Webster, "it could be, at least temporarily, you can mitigate that risk by having someone else hold the firearms for them."
Other possible measures might include waiting periods before purchasing guns, licensing processes for gun buyers, or laws that keep firearms from those who are deemed a risk to themselves or others ("red flag" laws).
None of those legislative options get mentioned in the CDC's guide to strategies for suicide prevention for states and communities.
A spokesperson for the CDC told NPR that "some laws or policies to potentially reduce firearm suicides (e.g., red flag laws) have not been rigorously evaluated. CDC selected examples with ample evaluation using the criteria for inclusion in the front of the technical package. We are always reassessing the evidence and will update the evidence as it becomes available."
She pointed to one CDC study of firearms and suicides in major metropolitan areas that does briefly mention "safely storing firearms or temporarily removing them from the home." It also mentions policies to keep firearms away from people under a restraining order for domestic violence, as well as efforts to strengthen the background check system for gun purchases.
Draft documents of the CDC's guide to suicide prevention show that some researchers at the agency feel that suicide prevention has been hindered by "hesitation to take up strategies known to be effective but perhaps unpopular":
"Unfortunately, suicide prevention is impeded by barriers including: stigma related to help-seeking, mental illness, being a survivor, or someone with lived experience; fear related to asking about suicidal thought, hesitation to take up strategies known to be effective but perhaps unpopular; misinformation about suicide preventability, harmful messaging about suicide, and disproportionate funding given its public health burden."
In the final version of that section that was published, some of those barriers to reducing suicide rates go unmentioned:
"There are a number of barriers that have impeded progress, including, for example, stigma related to help-seeking, mental illness, being a survivor and fear related to asking someone about suicidal thoughts."
What's actually allowed?
Webster believes that CDC officials have made the choice that it is safest for the agency to tread lightly when it comes to anything related to guns, since Congress controls the CDC's funding.
"I think that's a very unfortunate environment that they've had to operate in," says Webster. "But I want people to understand that there is no law in place now that says that CDC can't talk about the research and what's been learned about the connection between firearms and suicide risk."
The exact meaning of what the CDC is or is not allowed to do under the Dickey Amendment has been ambiguous ever since Congress passed the legislation decades ago.
Officials seem inclined to err on the side of caution. The minutes of one meeting to review a report on rising suicide rates showed that one CDC employee told researchers not to mention the often impulsive nature of suicides.
Apparently the official worried that mentioning this fact might turn "it into a removal of lethal means issue," given that about half the people in the study who killed themselves were not previously known to have a mental health issue. She noted, "I don't want it to be overly politicized."