Introduction

Concerning trends in military and veteran suicide have led the White House [1], Department of Defense [2], and Department of Veteran Affairs [3] to identify suicide prevention as a leading clinical and public health priority. Despite this, suicide rates among military-affiliated women are increasing at rates that far outpace both military-affiliated men and non-military affiliated women. From 2020–2021, suicide rates among women veterans spiked 24.1% before returning to prior year levels, compared to a 6.3% rise for veteran men [3–5]. During this same period age-adjusted suicide rates for veteran women were 166.1% higher than for non-veteran women, while the difference between veteran and non-veteran men was only 43.4% [5]. Further, suicide was identified as the second leading cause of death among active duty women service members between 2015 and 2019 [6]. Women are the fastest growing military cohort, with 2.5 million women who have served or are currently serving [7,8]. As women continue to join the military at increasing rates, suicide prevention for military-affiliated women warrants further attention.

Women veterans and service members are subject to unique, interconnected experiences that may contribute to suicide risk due to their gender, military identities, and trauma exposures, including military sexual trauma (MST) and intimate partner violence (IPV) [9–11]. For example, military-affiliated women experience increased suicidal ideation and behaviors compared to military-affiliated men [12] and elevated suicide risk during deployment [13]. Further, premilitary and military sexual violence is associated with suicide attempts among veteran women [14], while MST-related PTSD is over three times more likely to be associated with suicidal ideation compared to combat/deployment-related PTSD [15].

Lethal means restriction is an evidence-based approach to suicide prevention [16], and lethal means safety counseling (LMSC) interventions have been shown to result in safe storage behavior changes [17]. However, current best-practices in LMSC have taken a gender-neutral approach which does not consider the gender-specific needs and preferences of women [11,18–20]. Patterns in lethal means selection among military-affiliated women who die by suicide differ drastically when compared to both non-military affiliated women and military-affiliated men. Approximately 50% of suicide deaths among veteran women involve firearms, a rate 281.1% higher than among non-veteran women in 2021 [5]. Conversely, the other 50% of veteran women use non-firearm means, including asphyxiation and poisoning, at higher rates than veteran men [5].

Persistent misconceptions among clinicians about the way women, particularly women who have served in the armed forces, engage in suicide behaviors may lead to incomplete firearm risk assessments and overlooked opportunities for LMSC. For example, firearm screening often focuses on ownership, but women veterans have higher rates of household access to firearms they do not personally own [21,22] and may not report when queried about ownership [23]. Additionally, current best-practices do not address the impacts of MST and IPV on firearms safety discussions, both of which are notable suicide risk factors among veteran women [14,24–26]. Furthermore, clinical guidance for non-firearms means is lacking, disproportionately impacting military-affiliated women [23].

Firearms related LMSC has been identified as a priority within suicide prevention efforts for service members and veterans due to the high rates of firearm suicides (over 70%) [2,3]. However, there remains a limited understanding of women’s perspectives on firearms and LMSC and therefore an absence of tailored approaches for military-affiliated women in clinical interventions [19,20,23]. The effectiveness of LMSC may be limited without addressing stakeholder perspectives and lived experiences. For example, there remains a lack of clinical guidance for navigating means safety in the context of IPV [27]. There is an urgent need to identify and adapt best practices for this rapidly growing and high-risk population.

The aim of this review is to synthesize existing literature on military-affiliated women’s perspectives on lethal means safety and how this topic should be addressed in suicide prevention conversations, such as LMSC. In this systematic review we ask: what are the perspectives and preferences of military-affiliated women regarding the safe storage, use, access, and ownership of firearms and other lethal means, including how these topics should be addressed in suicide prevention efforts?

Methods

In this systematic review, we included quantitative, qualitative, and mixed-methods studies which specifically examined the perspectives and preferences of military-affiliated women in relation to our research question outlined above. Our thematic synthesis was guided by recommendations from Thomas and Harden [28] and reporting followed PRISMA [29] and ENTREQ [30] guidelines. The protocol for this review was published on OSF (https://doi.org/10.17605/OSF.IO/Z8DJH).

Quality appraisal

Quality appraisal was conducted by authors with relevant expertise using three assessments. The Critical Appraisal Skills Programme (CASP) contains 10 questions across three sections, evaluating methodological validity, analytical rigor, and value of the results [33]. The Consolidated Criteria for Reporting Qualitative Research (COREQ) Checklist contains 32 questions across three domains, research team and reflexivity, study design, and analysis and findings [34]. Qualitative studies were appraised using both the CASP and COREQ checklist (ML/MAL). Mixed-methods and quantitative studies were appraised using the Mixed Methods Appraisal Tool (MMAT; SL/DL) [35]. The MMAT contains two questions relating to clarity of research questions and adequacy of data collection methods which are used to screen all studies as well as sections for different types of publications. The section for quantitative descriptive studies contains five questions relating to sampling strategy, measures, nonresponse bias, and appropriateness of statistical analysis. The section for mixed-methods studies contains five questions relating to study design, integration of findings, and appropriateness of qualitative and quantitative methodologies. Quality appraisals (Table 1) were used to inform our confidence in study results rather than informing inclusion in the review.

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Table 1. Summary of quality appraisals.

https://doi.org/10.1371/journal.pone.0344104.t001

Results

Characteristics of included studies

The total results from the search are depicted in Fig 1. PRISMA Flow Diagram. A total of 4164 total records were deduplicated resulting in 3782 records being screened in the first screening stage. Seven articles (Table 2), all published since 2018, were identified for inclusion, including three qualitative articles arising from two studies, three quantitative studies, and one mixed methods study. Two articles included mixed sex samples but reported some of the findings by sex. Only findings specific to female participants were extracted and included in this analysis. Sample sizes of included articles varied widely, including relatively small sample sizes in qualitative and mixed-sex quantitative studies. Any frequencies or percentages reported in the thematic synthesis are intended to provide context for synthesized themes and should be interpreted within the methodological and analytical contexts of their own studies.

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Fig 1. PRISMA flow diagram for identification, screening, and inclusion.

https://doi.org/10.1371/journal.pone.0344104.g001

All articles focused on perspectives relating to firearms, with no research relating to other means identified. Research largely focused on women veterans eligible or enrolled in VA care, with two quantitative articles whose samples were entirely or predominantly active duty service members. Notably, research presented in six of the articles was conducted within the VA, including research staff, funding, and participants. Research questions across these seven articles were diverse, capturing perspectives on personally owned firearms, household firearms, means safety messengers, and means safety interventions.

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Table 2. Characteristics of included studies.

https://doi.org/10.1371/journal.pone.0344104.t002

Discussion

In this systematic review, we synthesized research examining the perspectives and preferences of military-affiliated women on firearms and other lethal means, including views on ownership, access, use, storage, and suicide prevention interventions. Seven articles were identified, including three qualitative articles arising from two study populations, one mixed methods study, and three quantitative studies. All studies focused on firearm ownership and behaviors and/or firearm related screening and counseling, with six themes identified relating to perspectives on firearms and LMSC. Government-directed focus on suicide prevention and firearm safety campaigns have led to concerted research efforts over the past decade in efforts to bolster clinical care and interventions [41–43]. However, research relating to lethal means safety approaches for women veterans remains severely limited, despite rising suicide rates and elevated firearm-related suicide risk in this growing population.

Notably, this review failed to identify any literature relating to military and veteran women’s perspectives on non-firearm means safety. This gap echoes finding of other systematic reviews, which demonstrate significant literatures in areas relating to firearm means safety and restriction, limited publications relating to medication restrictions, and an absence of literature relating to other household means such as ligatures and sharps [17,44,45]. This emphasis on firearm safe storage is also reflected in military LMSC guidance [46–48], which provide minimal recommendations for medication restriction and, when acknowledged, generic advice to restrict access to other household means. The lack of research on perspectives of military-affiliated women on means safety strategies beyond firearms is particularly concerning given the elevated rates of completed and attempted suicides by strangulation and overdose in this community. This point is echoed in a recent review of the scope of LMSC delivered in EDs, which calls for additional support for non-firearm means safety given differences in suicidal behavior among different age groups and gender identities [44]. This finding demonstrates the critical need for additional research on stakeholder perspectives in this area.

Research relating to military and veteran women’s perspectives on firearms has increased over the last five years, following calls for additional attention to this population. Qualitative research in the review provided rich insights from veteran women relating to: their motivations for firearm ownership and storage decisions, experiences navigating firearm storage decisions with more (or less) concerned significant others, and their preferences and experiences with suicide prevention and lethal means counseling in the context of the VA [26,27,38,37]. Broadly, quantitative data supported findings from qualitative interviews relating to firearms as tools for personal protection [26,38,39] and effectiveness of means restriction interventions [40]. Women shared complex and nuanced perspectives on firearms that highlighted their importance as tools for personal protection, while acknowledging that firearms had the potential to harm those they sought to protect [27,37–39]. Perspectives on lethal means counseling in clinical settings were similarly nuanced. Participants expressed broad support for the effectiveness and acceptability of lethal means counseling in suicide prevention contexts but also shared significant apprehensions about discussing firearms in VA contexts due to experiences of institutional betrayal and fears relating to firearm seizure and involuntary hospitalization [26,27,38,36,37,40]. These findings point to several important clinical implications when conducting lethal means safety counseling with women veterans.

Institutional distrust and fears of involuntary hospitalization and firearm seizure are well documented barriers to disclosure of suicidal thoughts and behaviors and firearm access in military and veteran communities [49–52]. Provider perceptions of client barriers to engagement with LMSC and apprehensions surrounding responses may lead providers to avoid the subject [53]. In a study of recent VHA users, only 14% reported discussing firearm safety [54]. However, research among veterans and service members consistently demonstrates that firearm discussions are acceptable in the context of suicide prevention with trusted, culturally competent providers [50,51,55]. Trust was fostered through quality clinical care, including conveying genuine care and concern, actively listening without judgement, providing a rationale for LMSC focused on patient safety, educating around limits of confidentiality, and delivering culturally informed care informed by a basic understanding of firearm and military culture. These behaviors are frequently cited by service members and veterans as essential elements of suicide risk assessment and LMSC [51,52,55–58] and also recognized by mental health clinicians as strategies that promote trust and facilitate disclosure of suicidal thoughts and behaviors [59]. Women veterans also emphasized the importance of trauma-informed care, including providers’ respect for personal space, attention to the risks and impacts of intimate partner violence on means safety, and access to women’s groups and dedicated spaces, which helped alleviate concerns about harassment and service-related trauma while fostering connection with others who shared similar military experiences [38,37].

Women veterans experience elevated rates of MST and IPV [60] and sexual violence among women veterans has been linked to suicidal ideation and suicide attempts [14]. In a recent national cross-sectional survey, over half of veteran women experienced MST, nearly one-quarter experienced military sexual assault, and nearly half experienced lifetime IPV [60]. Histories of violence impacted participants in included studies at even higher rates, in some cases exceeding 80% [26,38,39], offering deep insights into the roles both MST and IPV play in firearm ownership and storage decisions and understandings of safety. While protection is consistently identified as a primary motivation for firearm ownership among veterans [21,61,62], articles reviewed here highlight the complexity of how veteran women conceptualize firearms, safety, and protection in the wake of histories of violence. For many participants with these experiences, safety means protection from external threats and sexual violence and necessitated quick access to their firearms [26,38,37]. For other participants, safety concerns centered around self-harm or accidental harm inflicted by a household firearm. Many women shared how mental health concerns, including those stemming from MST, past suicide attempts, and fears of escalating IPV led them to remove or securely store household firearms for their own protection [26,27,38,37]. Similar findings have been noted among women in the general US population, where histories of both sexual assault and IPV, particularly IPV involving firearms, motivated some women to own and carry firearms [63,64], while others reported fears that firearms may be used against them or be accessed by their children [64]. Diverging understandings of firearm safety between firearm owners and health care providers contribute to miscommunications that hamper harm reduction efforts [45,65]. It is important for clinicians to recognize and be prepared to address these differences, including psychoeducation around the relative risks of unsecured firearms in the home [66].

While hesitations persisted regarding firearm discussions in VA contexts, included studies demonstrate many women veterans support family and spousal involvement in lethal means safety conversations [27,38,37]. These findings follow evidence for widespread veteran support of family involvement in care, including safety planning for suicide prevention [67] and PTSD treatment [68,69], as well as findings from a recent systematic review of stakeholder perspectives on LMSC [45]. Qualitative research with spouses of women veterans offers preliminary evidence that partners are willing to help reduce firearm access but need additional support and guidance on actionable strategies to improve household firearm safety [70]. Conversely, many women reported resistance or dismissal when they attempted to discuss firearm storage with their spouses, who were often perpetrators of IPV [27]. While treatment modalities for IPV exist, they require relationship commitment, commitment to end relationship violence, and expertise on the part of clinicians [71]. Notably, these modalities are not appropriate in relationships where violence is used as a mechanism for intimidation and control [71], where access to firearms dramatically increases the risk of intimate partner homicide [72]. Decisions about involving family members in LMSC should carefully consider the relationship between the client and family member and should include assessment for IPV [27].

Rich qualitative insights provide a foundation for developing gender-informed means safety counseling for military-affiliated women, including a large mixed-methods project with qualitative survey responses from over 500 participants relating to firearm beliefs during the COVID-19 pandemic [26]. While the related quantitative research generally supports qualitative findings, most of the quantitative literature pre-dates the recent qualitative work. Future quantitative research building directly on qualitative insights is vital to identify broadly acceptable and effective lethal means safety interventions tailored to this elevated risk military subpopulation. Notably, nearly three-quarters of recent literature (2016–2023) relating to women veterans’ mental and physical wellness was funded by VA sources [73], with all qualitative research relating to military-affiliated women’s perspectives on lethal means conducted in a VA context with VA samples. While this research produces critical insights on mental health care and suicide prevention for women veterans, its focus fails to capture the perspectives and needs of active duty service members and the approximately 50% of women veterans who receive care outside of the VA due to either ineligibility or preference [74]. Given barriers to care around institutional mistrust, additional research on perspectives, needs, and opportunities for non-VA connected care are essential in developing holistic and comprehensive interventions for military-affiliated women.

Another key area for future research is the role of partners and other family or friends in lethal means safety interventions. Included studies demonstrated support for family involvement in LMSC among many participants [27,38,37]. However, research and guidance on how to best incorporate familial support into mental health care or engage support personnel outside of care remains limited. Moreover, many women shared circumstances where spouses introduced barriers to safe household firearm storage, ranging from dismissing safety concerns to using firearms as tools for intimidation and IPV [27,37]. Given the prevalence of IPV among women veterans, additional research is needed to identify circumstances in which it is appropriate to involve spouses in LMSC or to extend psychoeducation to them, and when partner involvement may further increase risk. In situations complicated by IPV, additional work is essential to develop means safety approaches that reduce firearm related suicide and homicide risk without escalating the potential for harm.

These review findings should be considered alongside several limitations, all of which highlight the limited scope of research in this area. Most notably, only seven articles met review criteria, with all qualitative analysis conducted by the same research team and two articles drawing from the same study participants. In addition, qualitative findings from three articles were based on small sample sizes and two quantitative studies had limited inclusion of women participants. Finally, while the diversity of research questions provides breadth to qualitative findings, it also limits thematic synthesis across a broader pool of participants. While generalizability is not the aim of qualitative research, the limited scope of research in this area points to the necessity of expanded research to better inform clinical practice.

This systematic review highlights the critical need for trauma-sensitive, gender-informed lethal means safety counseling tailored to military-affiliated women, a population which is at elevated risk for suicide but often overlooked in the peer reviewed literature [11,20]. Despite growing recognition of lethal means safety as a suicide prevention priority, research remains limited in scope, with few studies explicitly examining women’s perspectives. The few extant studies included in this review emphasize the complex relationship between personal protection, trauma history, MST/IPV, and trust in institutions, all of which impact perspectives on lethal means safety and firearm safe storage decisions. Future research must expand its focus beyond VA-based populations, to address the full range of military-affiliated women in the interest of enhanced understanding and generalizability. Future efforts should also consider and further elucidate the roles of family and intimate partners, including the risks posed by IPV and should pursue development of practical, acceptable, and effective strategies to serve this population. Finally, research must expand beyond firearms to include women’s perspectives on means safety for other means that are commonly involved in suicide deaths in this community. Through targeted clinical, research, and implementation strategies we can tailor means safety counseling and firearm safe storage interventions while fully acknowledging and contextualizing the lived experiences of military-affiliated women.

Supporting information