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Disparities in Firearm Injury: Consequences of Structural Violence


Purpose of Review

This review focuses on disparities in firearm injuries and deaths in the United States (US), specifically looking at imbalances between different races/ethnicities, socioeconomic statuses, genders, sexual orientations, geographic locations, firearm ownership, laws, and intents.

Recent Findings

There are regional differences within the US between firearm deaths, firearm legislation, gun ownership rates, and Black-White disparities. Firearm injury intent varies by race/ethnicity, age, and gender. Data remain limited due to continued restrictions on funding for firearm research.


The studies highlighted in this review show that firearm injuries and deaths remain a public health crisis in the US, and that certain populations are affected more than others. By identifying and targeting these inequities with specific interventions, we can work toward lessening preventable firearm deaths and disabilities.


Injuries consistently rank within the top five causes of death for those aged < 1 to 64 years in the United States (US). Firearms are responsible for a large proportion of these deaths, ranking as one of the top five leading causes of injury deaths in the US for people aged 5 to 65 + years in 2017 [1]. Annual firearm deaths have been on the rise since 2014, with 39,773 people losing their lives in 2017, the most recently available data [1]. Yet these statistics fail to capture the many more who suffer nonfatal gunshot wounds frequently with resultant life-long physical and mental sequelae [2]. Data from 2001 to 2013 showed one-third of all firearm injuries were fatal and two-thirds were nonfatal. Although fatal firearm injury rates remained stable over this time period, there was a significant increase in nonfatal firearm injuries from 22.1 to 26.7 per 100,000 population, mainly driven by homicidal intent [3]. Besides the psychologic toll, firearm deaths and injuries caused over $48 billion in combined lifetime work loss and medical costs between 2010 and 2012, with 91% of these costs attributed to fatal injuries and the majority of costs due to work loss [2].

Although firearm violence and deaths affect people across genders, races, and life stages, there is significant variation between demographic and geographic subsets of the US population, as well as by mechanism [2, 4]. Overall, firearm homicides disproportionately impact young males of racial/ethnic minorities, while firearm suicides typically affect older, White males [2]. “Disparity” is defined as “a lack of equality and similarity, especially in a way that is not fair” [5]. The term “health disparity” first appeared in the 1990s in the US with the purpose of denoting worse health among certain people, specifically members of systematically marginalized racial/ethnic, religious, age, mental health, gender or gender identity, disability, sexual orientation, geographic location, economic, or other historically discriminated groups. At the heart of health disparities is not just a difference in health status between populations, but issues of social justice as they relate to health and healthcare. Health disparities are a metric by which progress toward health equity is measured. Health equity embodies the elimination of health disparities and achievement of the highest possible level of health for all [6].

Health disparities are created and exacerbated by “structural violence,” a term coined by Norwegian mathematician and sociologist Dr. Johan Galtung in 1969 to refer to violence that “is built into the structure and shows up as unequal power and consequently as unequal life chances” [7]. “The structure” refers to our society’s embedded social arrangements, including economic, legal, religious, political, and cultural, which can be violent due to the potential harm they cause [8]. Structural violence is synonymous with social injustice, referring to avoidable and unnecessary suffering, and its power lies in that it is all around and therefore is interpreted as normal, “as natural as the air around us” [7, 9]. Paul Farmer et al. introduced the concept to clinical medicine and public health in 2006, linking the aforementioned structures as upstream causes of social determinants of health (e.g., neighborhood, education, employment, food access) and the subsequent health outcomes produced [8, 10]. It then follows that structural violence can be seen as “the upstream ‘causes of the causes’ of gun violence” that disproportionately affects the health of certain populations [11].

This review focuses on disparities in firearm injuries and death in the US as seen through the lens of structural violence. We specifically look at disparities between different races/ethnicities, socioeconomic statuses, genders, sexual orientations, geographic locations, firearm ownership, laws, and intents. By highlighting subsets of the population most affected by firearm violence, we hope to identify high yield targets for effective interventions to lessen the burden of firearm injuries on these populations, and move closer to health equity for all. Table 1 provides summaries on select firearm disparity studies included in this review.

Table 1 Summary of selected studies on firearm injury disparities

Racial and Socioeconomic Disparities

Firearm injury and related death in the US is unfortunately commonplace. In a study by Kalesan et al., the rates of fatal and nonfatal gun injury rates were assessed using the Centers for Disease Control and Prevention’s (CDC) Web-based Injury Statistics Query and Reporting System (WISQARS) from 2013. Using the generally accepted population estimates about the size of an individual’s social network, researchers determined the likelihood that any given person would know someone in their personal network who was a victim of gun violence over their lifetime. There were 33,636 gun-related deaths and 84,258 nonfatal gun injuries in 2013 out of 2,596,993 deaths overall in the US population. The average likelihood of knowing a gun violence victim within a personal network over a lifetime was 99.85% for all racial ethnic groups. The likelihood among White race, Black race, and Hispanic ethnicity were 97.1%, 99.9%, and 99.5%, respectively, highlighting the pervasiveness of gun violence in this country [12]. While nearly all Americans of all racial and ethnic groups are likely to know a victim of gun violence, some groups are disproportionately more likely to be victims themselves.

Both fatal and nonfatal firearm injuries result in emergency department visits and hospitalizations, increasing healthcare costs. In a retrospective cohort study National (Nationwide) Inpatient Sample from 2004 to 2013 by Cook et al., the trends in hospitalization for gunshot wounds and inpatient mortality were assessed. There were 292,595 patients admitted over the study period with approximately 45% (N = 117,038) being Black. About 30,000 patients were hospitalized annually with 2500 dying in the hospital each year. Twice as many Blacks were hospitalized for gunshot wounds as compared with non-Hispanic whites. Most gunshot wounds were the result of assaults, which overwhelmingly involved Blacks. In-hospital mortality for Blacks and non-Hispanic whites was similar when controlled for other demographic and injury-related factors. During the study period, the annual rate of hospitalizations for gunshot wounds remained stable at 80 per 100,000 hospital admissions. Median hospital charges steadily increased by approximately 20% annually from $30,000 to $56,000 per hospitalization, leading to increased hospital charges for a largely preventable injury [13•].

Firearm injury is an avoidable cause of death. In a comparative analysis of firearm mortality in multiple countries using national vital statistics data from 1990 to 2015, the mortality and overall population were used to calculate the age-specific and sex-specific firearm deaths by race and ethnicity. The analysis was then stratified by intent, including homicide, suicide, and unintentional. Between 1990 and 2015, there were a total of 851,000 firearm injury deaths in the US. Firearm mortality was highest among men aged 15 to 34 years, accounting for up to half of the total risk of death in that age group. The risk of firearm homicide was 14 times higher in Black men in the US aged 25 to 34 years without a high school education as compared with White men of similar educational status (1.52% [99% CI 1.50–1.54] vs 0.11% [0.10–0.12]). While educational attainment including high school affected the overall risk of firearm homicide, it also widened the disparity between Blacks and Whites further, where risk of firearm homicide was 30 times higher in Black men versus comparably educated White men [14]. Disparities secondary to race are intimately intertwined with sociodemographic factors in the setting of systematic oppression.

Hemenway and colleagues sought to investigate this further via the relationship between racial residential segregation and differences in Black-White disparities in firearm fatal and nonfatal injuries in Massachusetts. Between 1995 and 2010, Massachusetts had 1157 fatal assault cases due to firearms (55.9% of total fatal assaults) and 7229 nonfatal injuries due to firearms (25.0% of total weapons-related injuries). Cases were more likely to reside in census tracts with high rates of similarity between Black versus White occupants [15]. Expanding the study to the entire US and limiting the outcome to firearm homicides, Knopov et al. retrospectively probed national vital statistics available through the CDC. The established index of dissimilarity was used to determine residential segregation. Using a linear regression, they evaluated the relationship between the index of dissimilarity and the Black-White firearm homicide disparity ratio in 32 states from 1991 to 2015. After controlling for measures of deprivation including incarceration and unemployment rates, multivariate analysis showed that racial segregation was positively associated with the Black/White firearm homicide disparity. For each 10-point increase in the index of dissimilarity, the ratio of Black to White firearm homicide rates in a state increased by 39%. These studies highlighted a significant association with living in a residentially segregated Black neighborhood and firearm injury homicide [16].

Focusing specifically on the association of income to disparities in firearm deaths, a study by Rowhani-Rahbar et al. examined the link between income inequality and firearm homicides at the US county level. Of 3106 US counties examined, those counties with higher Gini indices, meaning greater income inequality, had higher rates of firearm homicide among individuals aged 14 to 39 years, and higher levels of both violent and non-violent crime, as well as higher percentages of Black residents, higher deprivation, and lower social capital levels as compared with counties with lower levels of inequality. After controlling for additional determinants of firearm homicide, income inequality continued to be associated with higher rates of firearm homicide among Black individuals [17].

Many studies addressing firearm injury have focused on children to highlight child welfare, neglect, and overall years of life lost. To analyze the trends in child and adolescent firearm injury, Olufajo and colleagues performed a retrospective analysis of the National Trauma Data Bank from 2010 to 2016 for patients less than 20 years of age. Children and adolescents who required trauma center admission represented 45,075 injuries (18.7%) and were mostly males (87.4%), Black (60.7%), and victims of assault (76.0%) [18]. The trend of older adolescent victims of firearm injury being Black and involved in incidents related to violence is seen throughout the literature. This was exhibited by one study looking at firearm injury-associated fractures from 2003 to 2012 in the Kids’ Inpatient Database, and another single center study of a large level I pediatric trauma center from 2009 to 2014 [19, 20]. The frequency and reproducibility of this result identifies a target population for intervention, as the detrimental outcomes from gun violence do not stop at the initial bullet.

To disentangle the complex relationship in the US between race and socioeconomic factors, and to better understand the effects of race, ethnicity, and neighborhood poverty on pediatric firearm injuries in the US, Kalesan and colleagues compared overall and intent-specific firearm hospitalizations with those of pedestrian motor vehicle crash hospitalizations using the National (Nationwide) Inpatient Sample from 1998 to 2011. Using a case-control study design, children aged 0 to 15 years were matched 1:1 by age, year of injury, and region of the country. The risk of firearm hospitalization versus pedestrian motor vehicle crash was 64% higher among Black children (p < 0.0001, OR 1.64 (95% CI 1.44–1.87)) as compared with White children, which did not vary by neighborhood poverty. There was a higher risk of intentional firearm injury among Black children but lower risk for unintentional firearm injury for both Blacks (OR 0.73, 95% CI 0.62–0.87) and Hispanics (OR 0.60, 95% CI 0.49–0.74) when compared with Whites. Intent-specific risks attributed to race also did not vary by neighborhood poverty. Black children had a greater likelihood of firearm hospitalization compared with White children regardless of neighborhood economic status [21].

Further assessing the relationship between sociodemographic factors and gun violence, Carter and colleagues investigated individual and neighborhood characteristics of children seeking emergency care for firearm versus non-firearm injuries in a retrospective, multicenter, cross-sectional analysis and also evaluated recidivism. Children less than 19 years of age presenting to 16 pediatric emergency departments from 2004 to 2008 were included in the study. Neighborhood variables were derived from registry home address data. A total of N = 1758 pediatric emergency department visits for firearm injuries were analyzed. In terms of intent, assault accounted for 51.4% (N = 904) and unintentional injury for 33.2% (N = 584). Compared with other injured children, children with firearm injuries were older (15 to 19 years), predominantly male (82.3%) and Black (68.2%), and had public insurance or were uninsured (76.3%). Multivariable regression analysis identified male sex (p < 0.001), non-White race/ethnicity (p < 0.001), public payer/uninsured status (p < 0.001), and higher levels of neighborhood disadvantage (p < 0.001) as independent firearm injury risk factors. Among children with firearm injuries, 12-month emergency department recidivism for any reason was 22.4% (N = 385), highlighting the need for intervention [22].

While studies vary for race being independently associated with firearm injury irrespective of socioeconomic status, identifying intervenable risk factors to curb the epidemic of gun violence is critical. Along these lines, Beardslee et al. prospectively assessed whether childhood socioeconomic disadvantage was associated with adolescent gun violence, and whether early symptoms of conduct disorder or exposure to delinquent peers accounted for the link. Participants were mostly Black and White boys (N = 503) recruited in the first grade from public schools. Assessments were conducted regularly from ages seven to 20 years and connected with initial census tract sociodemographic data from childhood. Latent growth curve models assessed parent/teacher-reported conduct problems and youth-reported peer delinquency through age 10 years, and youth-reported engagement in gun violence through age 20 years. Childhood socioeconomic disadvantage was associated with greater affiliation with delinquent peers in early childhood, early peer delinquency promoted a greater increase in conduct problems across childhood, and these conduct problems led to an increased risk for adolescent gun violence by age 20 years [23]. Results suggest that intervening at an early age to reduce conduct problems and peer group affiliation might be able to reduce future gun violence.

In a study investigating in-hospital and long-term mortality after firearm injury, Shaahinfar and colleagues performed a multicenter, retrospective cohort study from 2000 to 2009 of pediatric patients aged 0 to 16 years who presented to trauma centers in California. They used data linked to the Social Security Death Master File and the California Department of Public Health Vital Statistics to identify those who died after being discharged alive. After multivariable adjustment, adolescent age, male sex, Black race/ethnicity, and public insurance were independent risk factors for long-term mortality. Being assaulted with or without a firearm was an independent risk factor for long-term mortality among adolescents (HR = 1.9, 95% CI 1.01–3.6) [24]. In an effort to curtail the epidemic of gun violence, Shetgiri and colleagues identified protective and risk factors for weapon use by adolescents using the nationally representative National Longitudinal Study of Adolescent to Adult Health survey. Emotional distress and substance use were risk factors for all racial and ethnic groups. Gun availability in the home was associated with weapon use for Blacks only. High educational aspirations were protective for Blacks and Hispanics, but higher family connectedness was protective for Hispanics only [25]. These results highlight sociodemographic changes that can be implemented to address gun violence.

Sexual Orientation, Gender, and Intimate Partner Violence Disparities

Sexual Orientation

Only one publication exists that mentions epidemiologic data potentially related to firearms within the lesbian, gay, bisexual, transgender, and queer (LGBTQ) community, presented within the context of suicide in transgender veterans. Transgender veterans receiving care in the Veterans Affairs (VA) system have double the rate of suicide deaths compared with the general VA population and over five times the rate of the general public; however, the contribution of firearms as suicide mechanism is not known. Yet given 67% of veteran suicide deaths are due to firearms [26], potentially a reflection of ease of access, this is a population that warrants greater attention.

When considering the LGBTQ population, the most well-known attack is likely the Orlando Pulse gay nightclub mass shooting in 2016. It became the deadliest mass shooting in American history at the time with 49 deaths and 53 wounded [27]. A handful of studies have since looked at the repercussions of this event on the LGBTQ community, including examining perceptions of safety via a cross-sectional analysis of LGBTQ respondents to a survey administered in the weeks following the shooting [28], and a qualitative study collecting the responses of LGBT people of color to the shooting [29]. The latter investigation found four major themes: violence and discrimination are not new for LGBT people of color, personal identification with the victims in that respondents felt attacked themselves, a lack of intersectionality across gender, sexual orientation, and race/ethnicity in others’ responses to the shooting in Orlando, while also recognizing intersectionality across LGBT people of color [29]. The above highlights the dearth of studies looking at firearm violence in the LGBTQ community, especially in those where sexual, gender, and racial identities intersect and interact. The historic marginalization of these individuals demands further study to first determine prevalence of firearm violence, as well as associated risk factors for intervention.

Gender and Intimate Partner Violence

As has been discussed in other sections, men are more likely to be both fatal and nonfatal victims of firearm violence versus women irrespective of intent [2]. However, women are disproportionately affected by intimate partner violence (IPV), which is the focus of this section. IPV is defined as, “physical violence, sexual violence, stalking, or psychological harm by a current or former partner or spouse” [30], with intimate partner homicide being the most severe outcome. Most recent data from the CDC’s 2015 National Intimate Partner and Sexual Violence Survey showed around one in four women and one in ten men reported an IPV-related impact during their lifetime [31], but the report lacked specific data on violence involving firearms. Given the inherent difficulty in measuring nonfatal firearm IPV, most studies focus on intimate partner homicide (IPH) as the study outcome.

One group recognized this fact and sought to examine firearm use in nonfatal intimate partner violence, as negative outcomes can result even when a gun is not fired or a person does not die. A 2018 systematic review of the prevalence of nonfatal gun use in intimate partner violence returned 10 articles, which collectively showed the incidence to be quite rare, but the overall volume to be significant. Extrapolating one study’s results to the 2016 US population indicates around 4.5 million women have had an intimate partner threaten them with a gun, and roughly one million have had the gun actually used against them. Three of the included studies reporting on gun use by gender showed intimate partner gun use was higher against women than for men, with more women being hospitalized for having been pistol whipped or shot by a current or former spouse than men. One study of hospitalized patients noted that compared with men, women had a 3.6 higher likelihood of being shot and 3.9 higher chance of being struck by a gun by a spouse or ex-spouse than by a stranger. The authors noted difficulty in comparing data across studies due to inconsistent methodologies [32], but despite this, the results presented necessitate further consideration.

Shifting to IPH as the outcome, a 2018 retrospective review of the National Violent Death Reporting System from 2003 to 2015 looked at the incidence of IPH, and risk factors by gender and relationship type. Out of N = 6131 homicides in opposite sex pairings, 79% of cases were female victims of male suspects, who were more likely to be non-Hispanic white (55%) followed by Black (28%) race. Male victims of female perpetrators were mostly Black (45%). Firearms were the most common mechanism across victim gender (59% female, 47% male), and where the suspect completed a concomitant suicide, the weapon used was overwhelmingly a firearm (88% female, 96% male victims) [33•]. These data highlight a shift in the racial disparity to non-Hispanic white women within a subpopulation of firearm violence victims, but still shows a persistent effect on Black individuals, and the high prevalence and success rate of firearms in IPH.

Given that most of the literature examining IPV and IPH is in adults, a group from Harborview Medical Center decided to look at its prevalence in adolescents (aged 11 to 18 years). Using National Violent Death Reporting System surveillance data from 32 states over 13 years (2003 to 2016), 6.9% of adolescent homicides were classified as IPH. Ninety percent of the victims were girls, 42% were White, and the median age was 17.0 years (IQR 16.0–18.0), while the perpetrators were 89.9% male, 48.2% Black, with a median age of 19.0 years (IQR 18.0–22.0). 61.2% of the examined IPHs were caused by firearms, with handguns being the most common type (82.6%). Given the varying applicability of protective laws in this age group, the authors argued for more research and expansion of protection orders to help this vulnerable population [34].

In light of varying laws at the state level, Sivaraman et al. looked at the association of state firearm legislation and female IPH in 16 states with complete data from 2010 to 2014. Data on state laws were obtained from the State Firearm Law Database (SFLD), a resource containing all state-level firearm legislation enacted since 1991. Only legislation intended to restrict firearms as designated by the SFLD was included in the analysis, totaling 11 categories. During the 5-year study, period there were 1693 IPHs, of which 1025 (60.5%) were firearm-specific. There was a median of 15 legislative previsions per state (range 4 (Alaska) to 95 (Massachusetts)). When adjusting for confounders and restricting to firearm-specific homicides, states with over 40 legislative provisions had 67% lower total IPH rates (IRR 0.33, 95% CI 0.18, 0.59) and 82% lower homicide-only IPH rates (IRR 0.18, 95% CI 0.08, 0.40) compared with states with fewer laws. The homicide-suicide IPH rate was 43% lower in states with over 40 firearm laws, but was attenuated when adjusting for confounders and limiting to firearm-specific deaths ((IRR 0.57, 95% CI 0.23, 1.43) vs (IRR 0.42, 95% CI 0.22, 0.81)), which the authors argued may be due to higher levels of premeditation and perpetrator characteristics that are likely more resistant to legislation [35]. However, these data show that stricter firearm legislation is likely protective in most IPH situations.

Another group looked at the association between state-level firearm ownership by proxy measure and domestic versus nondomestic homicides based on the Supplemental Homicide Reports of the Federal Bureau of Investigation’s Uniform Crime Reports from 1990 to 2016. Domestic homicide was defined as homicides involving an intimate partner or other family member. While women were only 22.4% (SD 8.3) of firearm homicide victims, they accounted for 72.2% (SD 6.6) of IPHs by firearm, highlighting their persistent increased risk for IPV and IPH. Ownership of a firearm was significantly associated with domestic firearm homicide rates in both sexes (IRR 1.013, 95% CI 1.008, 1.018), with no association with nondomestic firearm or non-firearm domestic homicides. There were higher domestic firearm homicide rates in Southern states, with lower rates in the Northeast, likely reflecting a variety of factors including population demographics, socioeconomic status, and legislation. There was a 64.6% increased incident rate of domestic firearm homicide in states in the highest quartile of firearm ownership compared with those in the lowest quartile (IRR 1.646, 95% CI 1.356, 1.998) [36], highlighting the well-known but complicated association between firearm ownership and risk of death by firearm.

Geographic Disparities

As briefly highlighted for IPH, firearm violence is not distributed evenly across the US. The Southern region has an increased burden, accounting for nearly half of all firearm deaths in the US irrespective of intent [2]. When examining intents (homicide and suicide) at the state level, there was no correlation between states with high rates of firearm homicide and firearm suicide. However, generally low suicide and low homicide states were in New England, high suicide and low homicide states were in the rural Northwest, and high suicide and high homicide states were in the Southeast [4]. These disparities suggest potentially unique factors by location that must be examined and targeted for more effective interventions.


Riddell et al. looked at how firearm and non-firearm homicide and suicide rates in Black and White non-Hispanic men differed by US state from 2008 to 2016, and if there were any associations between these deaths and gun ownership levels. For states meeting inclusion criteria (20 or more deaths for a race group), the difference in firearm homicide rates between Black and White men varied significantly by state, with differences ranging from nine to 57 additional homicides per 100,000 per year in Black men, which was mainly due to large between-state variations in firearm homicides of Black men. States with the highest rates of firearm homicide for Black men were Missouri, Michigan, Illinois, Indiana, and Pennsylvania, which also had the largest differences in Black and White homicide rates [37], reflecting some of Knopov et al.’s results [16]. In contrast, firearm suicides were higher among White men across all states except in the District of Columbia, ranging from − 2 to 16 additional suicides per 100,000 per year. States with the largest White-Black difference in firearm suicide rates were located in the south or west and included Mississippi, Nevada, Arkansas, New Mexico, Arizona, and Alabama. Most of these states also had the highest firearm suicide rates for White men. While firearm homicide and suicide were strongly correlated in White men (r = 0.72), they were less so in Black men (r = 0.34), suggesting different characteristics contributing to the between-state variations for these two mechanisms in Black men. While level of state gun ownership appeared to be strongly tied to firearm suicide across both races, the effect on homicides was more mixed, and requires further investigation [37].

In a study mentioned previously, Knopov et al. sought to examine the potential role of racial residential segregation to explain the Black-White disparities in firearm homicides at the state level over 25 years (1991 to 2015). While controlling for factors of White advantage and Black disadvantage, racial residential segregation, measured using the index of dissimilarity, still had a significant, independent impact on the Black-White homicide disparity. The index of dissimilarity is measured on a scale from 0 to 100, with 0 corresponding to the least spatial segregation by race and 100 corresponding to the most spatial segregation by race. Out of 42 states examined, those with the highest Black-White firearm homicide rate ratios also had a high median index of dissimilarity of 81.6 (IQR 79.3, 82.8), and included Wisconsin (21.2), Minnesota (19.5), Michigan (19.3), Nebraska (18.8), and Pennsylvania (16.2). Those with the lowest Black-White homicide rate ratios were South Carolina (4.1), New Mexico (3.8), Texas (3.6), Arizona (3.2), and Hawaii (0.8) with a lower median index of dissimilarity of 67.3 (IQR 63.1, 69.6) [16].

While state-level analyses are important due to variations in laws and levels of firearm ownership, given that most gun regulation is done at the local level, it is important to identify within-state variations for targeted interventions for high-risk populations. Kalesan et al. examined patterns of firearm fatalities across US counties and potentially associated sociodemographic factors using the CDC’s Wide-ranging Online Data for Epidemiologic Research (WONDER) over a 15-year time period (1999 to 2013). A 15-year gun death rate was determined for each county with 10 or more gun deaths, and counties were organized into quartiles ranging from “relatively safe” to “extremely violent.” Relatively safe counties were concentrated in the northeast, where there were also few unsafe or violent counties. Seven states (Alabama, Alaska, Mississippi, Nevada, New Mexico, South Carolina, Wyoming) and the District of Columbia had no relatively safe counties. Unsafe and violent counties were dispersed throughout the US, but Alaska contained most of the violent gun counties, along with concentrations in the southeast and western regions. When moving from relatively safe to extremely violent counties, the mean proportion of White, Hispanic, and Asian populations decreased while proportions of Black and American Indian/Alaskan native populations increased. Extremely violent counties were mainly rural, had higher levels of poverty, higher mean unemployment rate, lower median household income, and higher homicide rates compared with relatively safe counties. The high rate of gun deaths in rural counties was thought to be driven by suicides, especially given the decreasing strength of association between homicide and gun death rates when moving from relatively safe to extremely violent counties [38].

Building on this, an analysis by Pear et al. in 2018 looked at within-state variation in firearm homicide and suicide rates over 16 years specifically in California, with data on intent, age, race/ethnicity, and gender. Firearm homicide rates ranged from 1.05 to 10.40 deaths per 100,000 and firearm suicide rates varied from 2.12 to 21.03 deaths per 100,000 residents when looking at a 1-year snapshot in 2015. While there were no significant differences in firearm homicide rates by county urban-rural status in 2015, due to sharp declines in homicides in urban settings over the study period, firearm suicide rates were three times higher in rural versus urban counties. When looking at yearly changes over time, firearm homicide rate increases were clustered in Northern and Central California counties, while decreases were centered in Southern California and the state’s five most populous counties, with rural counties having greater increases in homicide rates than urban counties. Changes in firearm suicide rates over time did not exhibit a geographic pattern nor variation by urban or rural county status [39]. These data highlight important differences in the distribution of firearm violence across locations over time and by intent, which can inform targeted policies and interventions that aim to alleviate these disparities and decrease overall firearm injuries and deaths.

Firearm Legislation

Responding to the lack of a reliable resource on American firearm legislation, Siegel et al. compiled 133 firearm legal provisions at the state level over 26 years (1991 to 2016) into a comprehensive database, finding over an order of magnitude difference in the amount of firearm laws between the 50 states. The median number of provisions across all states was N = 15.5. States with the largest number of laws included California (N = 104), Massachusetts (N = 100), and Connecticut (N = 89), while those with the least were Alaska, Idaho, and Montana (all N = 4) [40••]. A greater number of firearm laws at the 1991 baseline were associated with a larger increase in new laws, while states with fewer laws at baseline had much smaller increases (27 vs < 1 new laws, respectively). Although there was an overall increase in firearm laws over the study period, the change was not consistent across states, with a widening disparity as nearly a third of states decreased their number of laws or shifted to those protective of gun rights or manufacturers [40••].

A study looking at the correlation between firearm-related fatality rates (FFR) over 15 years (1999 to 2013) and strength of firearm legislation across all 50 states found higher overall FFR in states with the least restrictive versus most restrictive firearm legislation [41]. However, this correlation was not uniform across populations. Although higher FFRs were found in certain population subsets in the least restrictive states, including across both genders, White race, pediatric victims, and unintentional and suicide intents, there was no correlation between level of legislation and homicides or Black FFRs [41]. These findings suggest legislation enacted to protect all does not do so equally, and requires the examination of other factors contributing to FFRs of homicides and Black individuals, such as proximity to less restrictive states as a contributor to increased firearm access [41].

To examine this problem further, Olson et al. looked at the association between state-level firearm fatality and homicide rates and both individual and neighboring state firearm legislation. When neighboring state firearm legislation was taken into account, there was a stronger correlation between overall firearm fatality and homicide rates and level of state firearm legislation. For black Americans, increasing levels of individual state firearm legislation were associated with higher firearm homicide rates (IRR 1.26, 95% CI 1.20–1.30), yet when adjusting for neighboring state legislation, more restrictive laws correlated with lower firearm homicide rates (IRR 0.79, 95% CI 0.73–0.85). Albeit perplexing, these findings can potentially be explained by differences in factors causing homicides in the white and black US populations. Forty-nine percent of firearms traced to states outside of where they were recovered [42•].

Gun Ownership

In light of there being no direct survey of annual gun ownership across all 50 states, percentage of suicides committed with a firearm was initially found to be the best measure of gun ownership by state among 24 potential indicators [43]. However, a new proxy measure with improved correlation with survey-measured gun ownership includes a state’s hunting license rate in addition to the ratio of firearm suicides to all suicides [44]. Using this new proxy for gun ownership and assessing the association between age-adjusted homicide and suicide rates and 10 state firearm laws over 26 years (1991 to 2016), Siegel et al. found no association between household gun ownership and overall homicide or suicide rates. This conflict with previous literature is possibly explained by the study’s methods of analysis, and a low variability in levels of household gun ownership that precludes measuring any association between changes in homicide or suicide rates and gun ownership. Positive predictors of homicide included violent crime rate, percentage males, and population density, while those predicting suicide included the unemployment rate, poverty rate, violent crime rate, and per capita alcohol consumption. Both homicides and suicides were negatively associated with overall population [45], highlighting the increasing incidence of firearm deaths in more rural locations.

Embedded within a study examining the association of state-level firearm ownership and domestic versus nondomestic homicides, Kvisto et al. found firearm ownership rates from 1990 to 2016 across the US ranged from 10.4% to 68.8%, with a mean of 39.2% (SD = 12.9). There were higher levels of gun ownership in the South and West, and lower rates in the Northeast [36], correlating with previous observations of higher levels of firearm violence in states with higher levels of firearm ownership.

Disparities in Firearm Injury Intent

Case fatality rates vary significantly by intent, with firearm-related self-harm being highest, followed by firearm-related assaults, and unintentional firearm injuries [2]. As mentioned previously, populations at highest risk also vary by intent, meriting research into the identification of these at-risk groups and the development of individualized interventions that target the drivers of these disparities.

Unintentional Injury

Firearm injuries among children are a major clinical and public health concern that have a complex etiology and long-term outcomes. To investigate differences in predictors and clinical outcomes by intent of pediatric firearm injuries, Monuteaux et al. conducted a retrospective cohort study of patients aged 0 to 21 years who were treated in emergency departments from 2004 to 2014. Patients were classified into the injury intent categories of self-inflicted, violent, and unintentional firearm by ICD-9 codes. Of the 9628 firearm injuries identified over the study period, the vast majority were due to unintentional injuries in younger children (N = 7125 (74%)). Intentional violent injuries were associated with male sex, increasing age, public insurance, and non-White race. Self-inflicted intentional injuries had the highest risk for hospital admission and mortality [46].

Intentional Injury: Suicide

Homicide as a result of intentional firearm injury was extensively discussed in a previous section, with young, Black males being the most affected. According to the most recent data from 2017 in the CDC WISQARS, there were 23,854 suicide firearm deaths, accounting for 60% of all firearm deaths [1]. These deaths are mostly older non-Hispanic white males [13•]. According to the 2017 CDC Morbidity and Mortality Weekly Report, suicide continues to be one of the top 10 leading causes of death in the US with suicides in rural areas occurring at much higher rates than urban areas. Trends over the 15-year CDC observation period indicated that suicide rates for non-Hispanic Blacks were the opposite of common trends, that is being lowest in rural counties and highest in more urban counties. For mechanism of death, rates of suicide by firearms in rural counties were almost two times that of rates in larger urban counties [47•]. Given the variability in socioeconomic factors in communities, interventions to prevent suicide such as access to healthcare, including mental health services, and limits on firearm access in these high-risk settings, should be ongoing.

Nestadt and colleagues assessed whether the use of firearms explains rural/urban differences in suicide rates by performing a retrospective, cohort analysis on N = 6196 adult suicides in Maryland from 2003 through 2015, incorporating census data with adjustment for age and race. They found suicide rates were higher in rural versus urban settings, but more specifically that the higher rural suicide rates were limited to firearm suicides (IRR 1.66, 95% CI 1.20–2.31). Non-firearm suicide rates were not significantly higher in rural settings [48].

Limiting firearm access to those with mental illness is widely recommended. However, a study of adolescents with known risk factors for suicide, including any mental health disorder or suicidality, found there was equal reported access to firearms compared with adolescents without any risk factors. Additionally, adolescents with firearm access also had a higher lifetime prevalence of alcohol abuse (10.1% vs 3.8%, P < 0.001) and drug abuse (11.4% vs 6.9%, P < 0.01) compared with those without firearm access [49]. Being that firearm use increases the lethality of suicide attempts, more should be done to limit access in high-risk settings.

Law Enforcement Intervention

Although extensively reported on in recent years, gunshot wounds inflicted by police represent few hospitalizations and even fewer deaths per national vital statistics [13•]. One reason for this may be underreporting of these injuries. In a cross-sectional study by Feldman and colleagues, they created a new US dataset by matching cases reported in non-governmental, news media-based datasets to identifiable national vital statistic mortality records for 2015. Using a multivariable mixed effects logistic regression model that controlled for all individual and county-level covariates, they found that the lower the socioeconomic status of the injured individual, the more likely the incident was to not be reported (OR 10.1, 95% CI 2.4–42.8; p < 0.01). There was, however, no statistically significant difference in the odds of underreporting by race or ethnicity [50]. In terms of race, there is also variability in a police officer’s decision to shoot. Image-based tests of implicit bias indicate that Black race is a factor in the initial decision, with the choice to shoot being made more quickly and frequently for Blacks holding weapons versus similar White targets [51].

Consistent with these findings, a study of Black individuals in California found they were at the highest risk of legal intervention injury per capita in a 10-year cross-sectional study starting in 2005 compared to Whites (OR 2.90, 95% CI 2.74–3.06). The proportion of injuries involving firearms did overall decline over the study period from 7.0% of law enforcement-related admissions in 2005 and 2006 to 3.7% in 2014 and 2015 [51]. Further investigation is warranted to elucidate the associations and inconsistencies of the current available data on law enforcement interventions.


As exhibited by the studies highlighted in this chapter, firearm injuries and deaths are a public health crisis in the US. Yet all people are not at the same risk. Certain populations are affected more than others, which vary by intent and location. The southern and western regions of the US have some of the highest incidences of firearm deaths [2, 4, 38], as well as some of the lowest levels of firearm legislation [40••], highest gun ownership rates [36], and biggest Black-White disparities [37]. Homicides continue to disproportionately affect young, Black men [13•, 14] while suicides disproportionately affect older, White males [2, 13•]. Potential explanations for the homicide disparities are components of structural violence, including racial segregation [15, 16], income inequality [17], neighborhood disadvantage [22], and socioeconomic disadvantage [23], among others. Women continue to predominate as victims of IPV and IPH, although male victims are a significant proportion whose risk factors should not be ignored [31, 33•]. Injuries secondary to legal intervention largely affecting minority individuals continue to dominate the news despite an overall low incidence, yet this is likely due to underreporting [13•, 50].

Of note, most of the data used in the cited studies are from a handful of imperfect sources with incomplete capture or old data, or use proxies or are based on modeling due to data gaps, limiting the conclusions that can be drawn. Measurements of nonfatal firearm injuries are from the National Electronic Injury Surveillance System – All Injury Program, overseen by the Consumer Product Safety Commission, which is comprised of data from a nationally representative sample of US hospital emergency departments that is then extrapolated [52]. Calculating firearm ownership requires a complex proxy based on the ratio of firearm suicide deaths to all suicides and a state’s hunting license rate. Nonfatal firearm injury data are only available up until 2015 [1]. These examples only strengthen the argument for more funding and resources to be dedicated to enhanced measurement of this significant cause of morbidity and mortality in the US.

When it was noted that electronic cigarettes and vaping were linked to an outbreak of N = 1479 lung injury cases and N = 33 deaths over 8 months, the CDC activated their emergency operations center [53], and the President of the United States announced an immediate plan to ban flavored e-cigarettes [54]. When romaine lettuce contaminated with E. coli sickened N = 62 people across 16 states over 2 months but caused no deaths, the CDC acted quickly to contain the issue with multiple media statements and mobilization of resources [55]. With firearms causing over 1200 times more deaths, frequently among the most marginalized and disadvantaged in our society, it is time gun violence is paid the attention and support it is due, to work to lessen this preventable cause of deaths and disabilities. It will require not only data but also innovative solutions targeting entrenched institutions, divides, and inequities within our society that move us closer to equity in health and social justice for all.


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Correspondence to Andre Campbell.

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Boeck, M.A., Strong, B. & Campbell, A. Disparities in Firearm Injury: Consequences of Structural Violence. Curr Trauma Rep (2020). https://doi.org/10.1007/s40719-020-00188-5

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  • Firearm injury
  • Gun violence
  • Disparity
  • Structural violence
  • Health equity: Race