literature review on gun violence

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Reviewing the Literature on the Impact of Gun Violence on Early Childhood Development

Kayla holloway.

1 Department of Child and Adolescent Psychiatry & Behavioral Sciences, Children’s Hospital of Philadelphia, 2716 South Street, Philadelphia, PA 19146 USA

Gina Cahill

Tiffany tieu, wanjikũ njoroge.

2 Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA USA

Purpose of Review

To examine the impacts of gun violence on early childhood development including early childhood mental health, cognitive development, and the assessment and treatment of survivors.

Recent Findings

The literature reflects that gun violence exposure is often associated with significant mental health outcomes including anxiety, post-traumatic stress, and depression in older youth. Historically, studies have focused on adolescents and their exposures to gun violence through proximity to gun violence within their communities, neighborhoods, and schools. However, the impacts of gun violence on young children are less known.

Gun violence has significant impacts on mental health outcomes of youth aged 0–18. Few studies focus specifically on how gun violence impacts early childhood development. In light of the increase in youth gun violence over the past three decades with a significant uptick since the onset of the COVID-19 pandemic, continued efforts are needed to better understand how gun violence impacts early childhood development.

Introduction

Many children and adolescents are directly and indirectly exposed to gun violence each year through their communities, home, school, and the media. Exposure to gun violence can have devastating impacts on children associated with later psychiatric and physical health problems extending into adulthood [ 1 ]. One common finding for increased risks for adverse outcomes includes being in close proximity to violence as a child or adolescent. The traumatic implications of gun violence extend beyond the immediate survivor, with consequences impacting the surrounding communities, neighborhoods, and support systems [ 2 ]. While the effects of gun violence are most commonly associated with older youth and adults, increased incidents involving young children have made it impossible to ignore how pervasive its effects are within this population [ 3 ••].

Even with increasing exposures, a dearth of information known on precisely how gun violence impacts very young child development or how to mitigate the development outcomes caused by experiencing gun violence raises cause for concern. The aim of this review is twofold. The first aim is to assess and summarize the current literature on the impacts of gun violence on early childhood development. And the second is to highlight commonalities and trends across the extant literature around risk factors of early childhood gun violence exposure. Importantly, for the purposes of this review, early childhood development broadly refers to mental health and cognitive development.

Trends in the Literature

The literature reviewed, focused primarily on work published from 2020 to 2023, though highly relevant literature from previous years has been included to provide a more comprehensive understanding of gun violence and its impact on early childhood (see Fig.  1 ). In the past several years, the prominent trends in gun violence research including young children have identified associations between gun violence and race, gender, socioeconomic status, and community environment [ 2 , 4 – 7 ]. Extant literature supports the associations between neighborhood conditions, community level factors, and the influence that these contexts have on a child’s cognitive, emotional, and social health. Taken in culmination, these findings illustrate potential associations between various factors that may increase a young child’s exposure to gun violence.

PRISMA flow chart demonstrating the literature search, screening process, and the results of the review

Studies aimed at identifying the racial associations for gun violence prevalence among young children include Rajan and Branas’ study on pre and post pandemic gun violence exposures and Kwon and Iverson’s study on pediatric gun violence injuries. Rajan et al. study [ 6 ] on the racial disparities in childhood exposure to gun violence before and after the pandemic was the most prominent study that assessed the association between race and gun violence and included young children, aged 5 to 8, in their participant sample. Rajan and Branas identified that children under 17, including young children who live in more socially vulnerable communities, are disproportionally impacted by violence, such as gun violence. They further found that Black children were more likely than non-Latinx white children to be exposed to neighborhood firearm violence and that children in the South experienced higher baseline levels of violence exposure than children in the Northeast and Midwest [ 6 ]. Similarly, Kwon et al. study on the exposure of pediatric patients to violence, which included children aged 0 to 8, found that Black children were more likely to experience firearm-related injuries and that children living in socially vulnerable communities were disproportionately impacted by violence, including gun violence [ 8 ].

In the same way that race is associated with heightened exposure to gun violence among young children in these studies, community environment has also been found to have a prominent association with gun violence exposure. Tracy and Miller’s study on how community environment is associated with gun violence found that community socioeconomic distress significantly predicts pediatric exposure to gun violence [ 9 ]. This finding highlights that children in under resourced communities have an increased risk of being exposed to gun violence. Relatedly, Beardslee and Dorchery’s research on childhood socioeconomic disadvantage and its association found that childhood disadvantage shown as early as 7 was strongly associated with adolescent gun violence exposure [ 10 ]. Both of these studies highlight that socioeconomic status and community environment have relevant, and often overlapping, associations with the exposure of young children to gun violence.

Trends in Gun Violence Incidence

Until 2020, motor vehicle crashes (both traffic-related and non-traffic-related) were the leading cause of death among children and adolescents [ 11 ]. However, in 2020, firearm-related injuries passed motor vehicle crashes as the leading cause of death in this group [ 11 ]. While the majority of firearm-related fatalities are among adolescents, there is still a substantial amount among young children [ 11 ]. Kalesan and colleagues found increasing trends in the number of school shootings between 2013 and 2015, with 154 during this time period (35, 55, and 64, respectively, per year) [ 12 ]. Despite this, school shootings still make up less than 1% of all firearm deaths in school-aged children and adolescents. However, children are still increasingly involved in firearm deaths, with the number of 0–4 year olds killed by firearms increasing from 87 in 2019 to 135 in 2020. In 2020, 63% of these deaths were due to homicide and 30% were unintentional [ 11 , 13 ].

The public health crisis of gun violence escalated even more during the COVID-19 pandemic with multiple studies reporting increased gun violence [ 3 ••, 14 – 16 ]. The literature attributes this increase to several potential factors including an increase in firearm purchases during the pandemic, children staying at home during the pandemic where they might be in close proximity to guns, and increases in firearm-related urban and interpersonal violence [ 3 ••, 11 ]. Khubchandani and Price also found that people living with children at home were more likely to purchase firearms during the pandemic [ 17 ]. In a cross-sectional study conducted by Peña and Jena analyzing gun-related deaths of children (17 and under) between 2014 and 2022, the 28 day moving averages for the number of children killed during this timeframe has a clear upward trend [ 14 ]. Notably, the number of deaths increased from March 16th 2020 onwards with an estimated 1.12 additional children killed each day [ 14 ]. In a similar study conducted by Donnelly et al. that also evaluated firearm violence before and after the pandemic, it was found that not only did shooting incidents involving children (< 18 years old) drastically increase in 2020 during the COVID-19 pandemic, but that states with stronger gun laws had a decrease in the number of child-involved gun violence [ 7 , 16 ]. During the pandemic, it was also shown that gun-related deaths increased in areas with low median income or a high percentage of Black or Hispanic population, which corresponds with other literature on the impact of the pandemic on historically marginalized communities [ 14 , 15 ]. In sum, the number of children impacted by gun violence drastically increased during the pandemic and this disproportionately impacted Black and Hispanic communities.

Major disparities in gun violence fatality also exist by gender and race. Male children and adolescents overall died at higher rates for all major causes of death when compared to their female counterparts, and this was most noticeable for firearm deaths. Firearm deaths among male children and adolescents were 5.1 times the rate for female children and adolescents [ 11 ]. Byrnes et al. found that boys are more likely to engage in risk-taking behavior, which could be contributing to this difference [ 18 ]. Additionally, the disparities in firearm fatalities with respect to race and ethnic group are also very striking. Firearm fatalities in Black children and adolescents are 3.7 times as high as the rate for non-Latinx white children and adolescents [ 11 ].

Exposure to Gun Violence

Turner and Jones conducted a multivariable study on gun violence exposure among children aged 2 to 18 and found that for all children the most common form of gun exposure was hearing shots in a public place, and that there was a demographic pattern with respect to age, socioeconomic status, race, and sex, that emerged when analyzing the youth impacted by this exposure. The demographic pattern demonstrated that lower income children, Black and Hispanic children, and male children had increased risk of being exposed to gun violence. Other literature demonstrates the most prominent predictors for youth exposure to gun violence are socioeconomic class, community environment, age, gender, and race [ 2 , 4 , 7 ]. For very young children, literature reflects the most common route of exposure was through their immediate community surroundings, such as neighborhoods or schools [ 8 ]. This same literature reflects that the increasing exposure experienced by children and adolescents has noted widespread consequences ranging from impaired cognitive development to increased mental health morbidity [ 1 ]. Common findings for young children who have been exposed to gun violence include demonstrating post-traumatic stress symptoms, anxiety, and depression [ 19 ••]. The traumatic implications of gun violence extend beyond the immediate survivor, with consequences impacting the surrounding communities, neighborhoods, and support systems [ 2 ].

Childhood Development

The early years of a child’s life are crucial for brain development, as the brain is growing rapidly and has high plasticity making it extremely sensitive to environmental influences [ 20 ]. Exposure to chronic stressors such as lack of home stability and poverty has been shown to negatively impair early brain development [ 21 , 22 ]. Additionally, several studies have discussed the impacts that toxic stress and early adversity can have on learning, behavior, and physical and mental health [ 22 , 23 ]. Toxic stress is defined by the magnitude and duration of the biological response to the stressor and is the result of strong, frequent, or prolonged activation of stress response systems in the absence of a buffer [ 23 , 24 ]. A buffer in this context refers to supportive elements, such as protective caregiving or a supportive environment, that can curtail the effects of stressors [ 23 ,  24 ]. When experiencing adversity or prolonged stressors in the prenatal stage, both human and animal studies have shown that this leaves the brain and body more at risk to the impacts of additional physiological and psychosocial factors that occur later in age [ 25 – 27 ]. Occasionally, the body is unable to recover after a stressor occurs leaving the body in a hyper stimulated state, which can be associated with later development of a depressive or anxiety disorder [ 26 ]. In addition, toxic stress has been associated with persistent inflammation, elevated blood pressure, and obesity [ 28 – 30 ]. In a detailed analysis conducted by Janusek et al. that investigated the impacts of childhood trauma on two key inflammatory markers in adults (IL-6 and TNF-α), it was found that there is a significant association with experiencing childhood trauma and these biomarkers, which indicates that exposure to childhood adversity increases the adult proinflammatory response to stress. The literature did not directly distinguish a difference between IL-6 and TNF-α in reference to childhood adversity; however, increased amounts of the IL-6 biomarker in adults was found to be associated with increased exposure to neighborhood violence as a child. The majority of participants in this study also reported being victims of or witnesses to community violence (both directly and indirectly), which includes witnessing a suicide or homicide [ 30 ]. This suggests that childhood exposure to gun violence both directly and indirectly can increase inflammation in the body [ 25 ]. Thus, with increasing awareness that environmental stressors such as gun violence can negatively impair childhood brain development, it is essential to reduce children’s exposure to these devastating events.

Mental Health Outcomes from Gun Violence

The literature surrounding the mental health outcomes of children and adolescents who have experienced gun violence is limited and most focused on older youth [ 33 ]. The few studies from the last 3 years that have focused on the mental health outcomes of young children aged 0 to 8 who have been exposed to gun violence provide little detail on the psychopathology of young children.

In the only original study that analyzed mental health outcomes in young children who have been exposed to gun violence, Vasan and HK conducted a study on the association of neighborhood violence with mental health–related utilization of the pediatric emergency department [ 31 ]. Study population included 54,341 pediatric patients aged 1 to 11 who lived near individuals who were shot, and the primary measure was Emergency Department encounters for mental health–related complaints in children. This study suggests that exposure to gun violence was associated with an increase in acute mental health symptoms within young children [ 31 ]. The symptoms observed included increased stress, harmful psychologic disturbances, and promotion of maladaptive coping behaviors [ 9 ]. Vasan and HK do note that while their findings are not robust enough to prove a causal relationship between gun violence exposure and children’s mental health, it does aid in elucidating several mechanisms that may underlie the association that they observed.

Literature reviews related to mental health outcomes have provided more context into mental health outcomes in young children. In a review on the effects of mass shootings on the mental health of children, Cimolai et al. found that the majority of young survivors will experience acute stress reactions and a subset of these survivors will go on to develop long-term outcomes that can impact their function. The primary child mental health outcomes that they identified across literature from past 10 years included anxiety, depression, post-traumatic stress disorder (PTSD), and other internalizing symptoms [ 19 ••]. Their review included a discussion on the dearth of literature on specific mental health outcomes caused by gun violence in young children, and in response to this highlighted how PTSD can present in young children, aged 0 to 6, as a result of traumatic experiences in general. In younger children, PTSD presents through the persistence of behavioral interactions which include, sadness, lack of interest, development of new fears, aggression, and increased anxiety [ 32 ].

Much of the current literature including young children also focuses on analyzing the effects of school shootings on development. Reeping’s study on school shootings among youth aged K–12 found that these events have significant effects on mental health and the emotional well-being of impacted students within the school community [ 1 ]. These impacts included increased depression, PTSD, and anxiety in young children [ 33 ]. Shonfield and Domeria’s study on supporting children after school shootings found that these events can also cause trauma symptoms within effected individuals [ 34 ]. As mass shootings are considered to be traumatic experiences, Cimolai and Schmitz discussed ways that these mental health outcomes from young children who have experienced generally traumatic events could apply to young children who have specifically experienced mass shooting events. In a scooping review about the long-term consequences of youth exposure to firearm injury, Ranney and Ehrlich proposed a similar connection between how young children respond to traumatic events and children exposed to mass shootings. In their review, Ranney and Ehrlich found that children exposed to mass shootings have higher rates of post-traumatic stress than control populations [ 35 ].

Prominent literature reviews related to mental health outcomes in young children are shown in Table ​ Table1 1 .

Recent literature reviews that highlight the effects of gun violence on young children

Conclusions

The current literature on the impacts of gun violence on child development heavily focuses on older adolescents, with those focused on the impacts of such exposure on early childhood presented in this review. Young children have different cognitive and developmental markers than other demographics and it is necessary to understand the impact of gun violence on this cohort of children [ 9 ]. As Bancalari and Sommer found in their 2021 literature review, it is imperative that more research is done into the impacts of gun violence exposure across different developmental stages [ 5 ]. The steadily increasing exposure of young children to gun violence reflected in the current trends and statistics demonstrates the need for more research to be conducted into how gun violence exposure impacts early childhood development.

The literature presently suggests that exposure to gun violence is associated with an increase in children’s mental health distress, with young children experiencing increased post-traumatic stress symptoms and anxiety [ 36 ••]. Based on this, a potential future direction for the field could be further investigating the associations between gun violence as a traumatic experience with mental health outcomes in young children aged 0 to 8. Additional research is needed to assess the treatment of young children exposed to gun violence and identify effective methods for working with this young population to mitigate negative mental health outcomes for those exposed.

Potential future research directions include analyzing how young children respond to media pertaining to gun violence, school-based discussions pertaining to gun violence, and non-school-based communal discussions to gun violence. More research is also needed to assess the psychobiological outcomes, such as neuroinflammation and physiological stress indicators, of gun violence on young children. Additionally, future literature directions could include investigating the psychopathology associated with how young children respond to other forms of gun violence exposure, such as hearing gunshots or being around a survivor of gun violence. Lastly, future directions could include implementing protective factors that can aid in reducing childhood exposure to gun violence. In sum, gun violence is ubiquitous with very young children increasingly exposed. With increased and targeted research efforts addressing this specific population, clinicians can better help parents and caregivers navigate the various exposures, with the intended outcome of ensuring young children’s optimal development in the face of unremitting stressors and exposures.

Compliance with Ethical Standards

The authors declare no competing interests.

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Contributor Information

Kayla Holloway, Email: ude.nnepu.sas@alyakh .

Gina Cahill, Email: [email protected] .

Tiffany Tieu, Email: ude.pohc@tueit .

Wanjikũ Njoroge, Email: ude.pohc@wegorojn .

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Article Contents

Introduction, the burden of firearm violence, understanding and reducing firearm violence is complex and multi-factorial, interventions and recommendations, conclusions, research ethics.

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Firearm Violence in the United States: An Issue of the Highest Moral Order

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Chisom N Iwundu, Mary E Homan, Ami R Moore, Pierce Randall, Sajeevika S Daundasekara, Daphne C Hernandez, Firearm Violence in the United States: An Issue of the Highest Moral Order, Public Health Ethics , Volume 15, Issue 3, November 2022, Pages 301–315, https://doi.org/10.1093/phe/phac017

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Firearm violence in the United States produces over 36,000 deaths and 74,000 sustained firearm-related injuries yearly. The paper describes the burden of firearm violence with emphasis on the disproportionate burden on children, racial/ethnic minorities, women and the healthcare system. Second, this paper identifies factors that could mitigate the burden of firearm violence by applying a blend of key ethical theories to support population level interventions and recommendations that may restrict individual rights. Such recommendations can further support targeted research to inform and implement interventions, policies and laws related to firearm access and use, in order to significantly reduce the burden of firearm violence on individuals, health care systems, vulnerable populations and society-at-large. By incorporating a blended public health ethics to address firearm violence, we propose a balance between societal obligations and individual rights and privileges.

Firearm violence poses a pervasive public health burden in the United States. Firearm violence is the third leading cause of injury related deaths, and accounts for over 36,000 deaths and 74,000 firearm-related injuries each year ( Siegel et al. , 2013 ; Resnick et al. , 2017 ; Hargarten et al. , 2018 ). In the past decade, over 300,000 deaths have occurred from the use of firearms in the United States, surpassing rates reported in other industrialized nations ( Iroku-Malize and Grissom, 2019 ). For example, the United Kingdom with a population of 56 million reports about 50–60 deaths per year attributable to firearm violence, whereas the United States with a much larger population, reports more than 160 times as many firearm-related deaths ( Weller, 2018 ).

Given the pervasiveness of firearm violence, and subsequent long-term effects such as trauma, expensive treatment and other burdens to the community ( Lowe and Galea, 2017 ; Hammaker et al. , 2017 ; Jehan et al. , 2018 ), this paper seeks to examine how various evidence-based recommendations might be applied to curb firearm violence, and substantiate those recommendations using a blend of the three major ethics theories which include—rights based theories, consequentialism and common good. To be clear, ours is not a morally neutral paper wherein we weigh the merits of an ethical argument for or against a recommendation nor is it a meta-analysis of the pros and cons to each public health recommendation. We intend to promote evidence-based interventions that are ethically justifiable in the quest to ameliorate firearm violence.

It is estimated that private gun ownership in the United States is 30% and an additional 11% of Americans lived with someone who owed a gun in 2017 ( Gramlich and Schaeffer, 2019 ). Some of the reported motivations for carrying a firearm include protection against people (anticipating future victimization or past victimization experience) and hunting or sport shooting ( Schleimer et al. , 2019 ). A vast majority of firearm-related injuries and death occur from intentional harm (62% from suicides and 35% from homicides) versus 2% of firearm-related injuries and death occurring from unintentional harm or accidents (e.g. unsafe storage) ( Fowler et al. , 2015 ; Lewiecki and Miller, 2013 ; Monuteaux et al. , 2019 ; Swanson et al. , 2015 ).

Rural and urban differences have been noted regarding firearms and its related injuries and deaths. In one study, similar amount of firearm deaths were reported in urban and rural areas ( Herrin et al. , 2018 ). However, the difference was that firearm deaths from homicides were higher in urban areas, and deaths from suicide and unintentional deaths were higher in rural areas ( Herrin et al. , 2018 ). In another study, suicides accounted for about 70% of firearm deaths in both rural and urban areas ( Dresang, 2001 ). Hence, efforts to implement these recommendations have the potential to prevent most firearm deaths in both rural and urban areas.

The burden of firearm injuries on society consists of not only the human and economic costs, but also productivity loss, pain and suffering. Firearm-related injuries affect the health and welfare of all and lead to substantial burden to the healthcare industry and to individuals and families ( Corso et al. , 2006 ; Tasigiorgos et al. , 2015 ). Additionally, there are disparities in firearm injuries, whereby firearm injuries disproportionately affect young people, males and non-White Americans ( Peek-Asa et al. , 2017 ). The burden of firearm also affects the healthcare system, racial/ethnic minorities, women and children.

Burden on Healthcare System

Firearm-related fatalities and injuries are a serious public health problem. On average more than 38 lives were lost every day to gun related violence in 2018 ( The Education Fund to Stop Gun Violence (EFSGV), 2020 ). A significant proportion of Americans suffer from firearm non-fatal injuries that require hospitalization and lead to physical disabilities, mental health challenges such as post-traumatic stress disorder, in addition to substantial healthcare costs ( Rattan et al. , 2018 ). Firearm violence and related injuries cost the U.S. economy about $70 billion annually, exerting a major effect on the health care system ( Tasigiorgos et al. , 2015 ).

Victims of firearm violence are also likely to need medical attention requiring high cost of care and insurance payouts which in turn raises the cost of care for everyone else, and unavoidably becomes a financial liability and source of stress on the society ( Hammaker et al. , 2017 ). Firearm injuries also exert taxing burden on the emergency departments, especially those in big cities. Patients with firearm injuries who came to the emergency departments tend to be overwhelmingly male and younger (20–24 years old) and were injured in an assault or unintentionally ( Gani et al. , 2017 ). Also, Carter et al. , 2015 found that high-risk youth (14–24 years old) who present in urban emergency departments have higher odds of having firearm-related injuries. In fact, estimates for firearm-related hospital admission costs are exorbitant. In 2012, hospital admissions for firearm injuries varied from a low average cost of $16,975 for an unintentional firearm injury to a high average cost of $32,237 for an injury from an assault weapon ( Peek-Asa et al. , 2017 ) compared with an average cost of $10,400 for a general hospital admission ( Moore et al. , 2014 ).

Burden on Racial/Ethnic Minorities, Women and Children

Though firearm violence affects all individuals, racial disparities exist in death and injury and certain groups bear a disproportionate burden of its effects. While 77% of firearm-related deaths among whites are suicides, 82% of firearm-related deaths among blacks are homicides ( Reeves and Holmes, 2015 ). Among black men aged 15–34, firearm-related death was the leading cause of death in 2012 ( Cerdá, 2016 ). The racial disparity in the leading cause of firearm-related homicide among 20- to 29-year-old adults is observed among blacks, followed by Hispanics, then whites. Also, victims of firearms tend to be from lower socioeconomic status ( Reeves and Holmes, 2015 ). Understanding behaviors that underlie violence among young adults is important. Equally important is the fiduciary duty of public health officials in creating public health interventions and policies that would effectively decrease the burden of gun violence among all Americans regardless of social, economic and racial/ethnic backgrounds.

Another population group that bears a significant burden of firearm violence are women. The violence occurs in domestic conflicts ( Sorenson and Vittes, 2003 ; Tjaden et al. , 2000 ). Studies have shown that intimate partner violence is associated with an increased risk of homicide, with firearms as the most commonly used weapon ( Leuenberger et al. , 2021 ; Gollub and Gardner, 2019 ). However, firearm threats among women who experience domestic violence has been understudied ( Sullivan and Weiss, 2017 ; Sorenson, 2017 ). It is estimated that nearly two-thirds of women who experience intimate partner violence and live in households with firearms have been held at gunpoint by intimate partners ( Sorenson and Wiebe, 2004 ). Firearms are used to threaten, coerce and intimidate women. Also, the presence of firearms in a home increases the risk of women being murdered ( Campbell et al. , 2015 ; Bailey et al. , 1997 ). Further, having a firearm in the home is strongly associated with more severe abuse among pregnant women in a study by McFarlane et al. (1998) . About half of female intimate partner homicides are committed with firearms ( Fowler, 2018 ; Díez et al. , 2017 ). Some researchers reported that availability of firearms in areas with fewer firearms restrictions has led to higher intimate partner homicides ( Gollub and Gardner, 2019 ; Díez et al. , 2017 ).

In the United States, children are nine times more likely to die from a firearm than in most other industrialized nations ( Krueger and Mehta, 2015 ). Children here include all individuals under age 18. These statistics highlight the magnitude of firearm injuries as well as firearms as a serious pediatric concern, hence, calls for appropriate interventions to address this issue. Unfortunately, children and adolescents have a substantial level of access to firearms in their homes which contributes to firearm violence and its related injuries ( Johnson et al. , 2004 ; Kim, 2018 ). About half of all U.S. households are believed to have a firearm, making firearms one of the most pervasive products consumed in the United States ( Violano et al. , 2018 ). Consequently, most of the firearms used by children and youth to inflict harm including suicides are obtained in the home ( Johnson et al. , 2008 ). Beyond physical harm, children experience increased stress, fear and anxiety from direct or indirect exposure to firearms and its related injuries. These effects have also been reported as predictors of post-traumatic stress disorders in children and could have long-term consequences that persist from childhood to adulthood ( Holly et al. , 2019 ). Additionally, the American Psychological Association’s study on violence in the media showed that witnessing violence leads to fear and mistrust of others, less sensitivity to pain experienced by others, and increases the tendency of committing violent acts ( Branas et al. , 2009 ; Calvert et al. , 2017 ).

As evidenced from the previous sections, firearm violence is a complex issue. Some argue that poor mental health, violent video games, substance abuse, poverty, a history of violence and access to firearms are some of the reasons for firearm violence ( Iroku-Malize and Grissom, 2019 ). However, the prevalence and incidence of firearm violence supersedes discrete issues and demonstrates a complex interplay among a variety of factors. Therefore, a broader public health analysis to better understand, address and reduce firearm violence is warranted. Some important factors as listed above should be taken into consideration to more fully understand firearm violence which can consequently facilitate processes for mitigation of the frequency and severity of firearm violence.

Lack of Research Prevents Better Understanding of Problem of Firearm Violence

A major stumbling block to understanding the prevalence and incidence of firearm related violence exists from a lack of rigorous scientific study of the problem. Firearm violence research constitutes less than 0.09% of the Centers for Disease Control and Prevention’s annual budget ( Rajan et al. , 2018 ). Further research on firearm violence is greatly limited by the Dickey Amendment, first passed in 1996 and annually thereafter in budget appropriations, which prohibits use of federal funds to advocate or promote firearm control ( Rostron, 2018 ). As such, the Dickey Amendment impedes future federally funded research, even as public health’s interest in firearm violence prevention increased ( Peetz and Haider, 2018 ; Rostron, 2018 ). In the absence of rigorous research, a deeper understanding and development of evidence-based prevention measures continue to be needed.

Lack of a Public Health Ethical Argument Against Firearm Use Impedes Violence Prevention

We make an argument that gun violence is a public health problem. While some might think that public health is primarily about reducing health-related externalities, it is embedded in key values such as harm reduction, social justice, prevention and protection of health and social justice and equity ( Institute of Medicine, 2003 ). Public health practice is also historically intertwined with politics, power and governance, especially with the influence of the states decision-making and policies on its citizens ( Lee and Zarowsky, 2015 ). According to the World Health Organization, health is a complete physical, mental and social well-being that is not just the absence of injury or disease ( Callahan, 1973 ). Health is fundamental for human flourishing and there is a need for public health systems to protect health and prevent injuries for individuals and communities. Public health ethics, then, is the practical decision making that supports public health’s mandate to promote health and prevent disease, disability and injury in the population. It is imperative for the public health community to ask what ought to be done/can be done to curtail firearm violence and its related burdens. Sound public health ethical reasoning must be employed to support recommendations that can be used to justify various public policy interventions.

The argument that firearm violence is a public health problem could suggest that public health methods (e.g. epidemiological methods) can be used to study gun violence. Epidemiological approaches to gun violence could be applied to study its frequency, pattern, distribution, determinants and measure the effects of interventions. Public health is also an interdisciplinary field often drawing on knowledge and input from social sciences, humanities, etc. Gun violence could be viewed as a crime-related problem rather than public health; however, there are, of course, a lot of ways to study crime, and in this case with public health relevance. One dominant paradigm in criminology is the economic model which often uses natural experiments to isolate causal mechanisms. For example, it might matter whether more stringent background checks reduce the availability of guns for crime, or whether, instead, communities that implement more stringent background checks also tend to have lower rates of gun ownership to begin with, and stronger norms against gun availability. Therefore, public health authorities and criminologists may tend to have overlapping areas of expertise aimed to lead to best practices advice for gun control.

Our paper draws on three major theories: (1) rights-based theories, (2) consequentialism and (3) the common good approach. These theories make a convergent case for firearm violence, and despite their significant divergence, strengthen our public health ethics approach to firearm. The key aspects of these three theories are briefly reviewed with respect to how one might use a theory to justify an intervention or recommendation to reduce firearm injuries.

Rights-Based Theories

The basic idea of the rights framework is that people have certain rights, and that therefore it is impermissible to treat people in certain ways even if doing so would promote the overall good. People have rights to safety, security and an environment generally free from risky pitfalls. Conversely, people also have a right to own a gun especially as emphasized in the U.S.’s second amendment. Another theory embedded within our discussion of rights-based theories is deontology. Deontological approaches to ethics hold that we have moral obligations or duties that are not reducible to the need to promote some end (such as happiness or lives saved). These duties are generally thought to specify what we owe to others as persons ( rights bearers ). There are specific considerations that define moral behaviors and specific ways in which people within different disciplines ought to behave to effectively achieve their goals.

Huemer (2003) argued that the right to own a firearm has both a fundamental (independent of other rights) and derivative justification, insofar as the right is derived from another right - the right to self-defense ( Huemer, 2003 ). Huemer gives two arguments for why we have a right to own a gun:

People place lots of importance on owning a gun. Generally, the state should not restrict things that people enjoy unless doing so imposes substantial risk of harm to others.

People have a right to defend themselves from violent attackers. This entails that they have a right to obtain the means necessary to defend themselves. In a modern society, a gun is a necessary means to defend oneself from a violent attacker. Therefore, people have a right to obtain a gun.

Huemer’s first argument could be explained that it would be permissible to violate someone’s right to own or use a firearm in order to promote some impersonal good (e.g. number of lives saved). Huemer’s second argument also justifies a fundamental right to gun ownership. According to Huemer, gun restrictions violate the right of individual gun owners to defend themselves. Gun control laws will result in coercively stopping people to defend themselves when attacked. To him, the right to self-defense does seem like it would be fundamental. It seems intuitive to argue that, at some level, if someone else attacks a person out of the blue, the person is morally required to defend themselves if they cannot escape. However, having a right to self-defense does not entail that your right to obtain the means necessary to that thing cannot be burdened at all.

While we have a right to own a gun, that right is weaker than other kinds of rights. For example, gun ownership seems in no way tied to citizenship in a democracy or being a member of the community. Also, since other nations/democracies get along fine without a gun illustrates that gun ownership is not important enough to be a fundamental right. Interestingly, the UK enshrines a basic right to self-defense, but explicitly denies any right to possess any particular means of self-defense. This leads to some interesting legal peculiarities where it can be illegal to possess a handgun, but not illegal to use a handgun against an assailant in self-defense.

In the United States, implementing gun control policies to minimize gun related violence triggers the argument that such policies are infringements on the Second Amendment, which states that the rights to bear arms shall not be infringed. The constitution might include a right to gun ownership for a variety of reasons. However, it is not clear from the text itself that the right to bear arms is supposed to be as fundamental as the right to freedom of expression. Further, one could argue, then, that any form of gun regulation is borne from the rationale to retain our autonomy. Protections from gun violence are required to treat others as autonomous agents or as bearers of dignity. We owe others certain protections and affordances at least in part because these are necessary to respect their autonomy (or dignity, etc.). We discuss potential recommendations to minimize gun violence while protecting the rights of individuals to purchase a firearm if they meet the necessary and reasonable regulatory requirements. Most of the gun control regulations discussed in this article could provide an opportunity to ensure the safety of communities without unduly infringing on the right to keep a firearm.

Consequentialism

Consequentialism is the view that we should promote the common good even if doing so infringes upon some people’s (apparent) rights. The case for gun regulation under this theory is made by showing how many lives it would save. Utilitarianism, a part of consequentialist approach proposes actions which maximize happiness and the well-being for the majority while minimizing harm. Utilitarianism is based on the idea that a consequence should be of maximum benefit ( Holland, 2014 ) and that actions are right in proportion as they tend to promote happiness as the ultimate moral norm. If one believes that the moral purpose of public health is to make decisions that will produce maximal benefits for most affected, remove or prevent harm and ensure equitable distribution of burdens and benefits ( Bernheim and Childress, 2013 ), they are engaging in a utilitarian theory. Rights, including the rights to bear arms, are protected so long as they preserve the greater good. However, such rights can be overridden or ignored when they conflict with the principle of utility; that is to say, if greater harm comes from personal possession of a firearm, utilitarianism is often the ethical theory of choice to restrict access to firearms, including interventions that slow down access to firearms such as requiring a gun locker at home. However, it is important to note that utilitarians might also argue that one has to weigh how frustrating a gun locker would be to people who like to go recreationally hunting. Or how much it would diminish the feeling of security for someone who knows that if a burglar breaks in, it might take several minutes to fumble while inputting the combination on their locker to access their gun.

Using a utilitarian approach, current social statistics show that firearm violence affects a great number of people, and firearm-related fatalities and injuries threaten the utility, or functioning of another. Therefore, certain restrictions or prohibitions on firearms can be ethically justifiable to prevent harm to others using a utilitarian approach. Similarly, the infringement of individual freedom could be warranted as it protects others from serious harm. However, one might argue that a major flaw in the utilitarian argument is that it fails to see the benefit of self-defense as a reasonable benefit. Utilitarianism as a moral theory would weigh the benefits of proposed restrictions against its costs, including its possible costs to a felt sense of security on the part of gun owners. A utilitarian argument that neglects some of the costs of regulations wouldn’t be a very good argument.

One might legitimately argue that if an individual is buying a firearm, whether for protection or recreation, they are morally responsible to abide by the laws and regulations regarding purchasing that firearm and ensuring the safety of others in the society. Additionally, vendors and licensing/enforcement authorities would have the responsibility to ensure the safety of the rest of the society by ensuring that the firearm purchase does not compromise the safety of the community. Most people who own firearms would not argue against this position. However, arguments in support of measures that will reduce the availability of firearms center around freedom and liberty and are not as well tolerated by those who argue from a libertarian starting point. Further, this would stipulate that measures against firearm purchase or use impinge upon the rights of individuals who have the freedom to pursue what they perceive as good ( Holland, 2014 ). However, it seems as though the state has a fundamental duty to help ensure an adequate degree of safety for its citizens, and it seems that the best way to do that is to limit gun ownership.

Promoting the Common Good

A well-organized society that promotes the common good of all is to everyone’s advantage ( Ruger, 2015 ). In addition, enabling people to flourish in a society includes their ability to be healthy. The view of common good consists of ensuring the welfare of individuals considered as a group or the public. This group of people are presumed to have a common interest in protection and preservation from harms to the group ( Beauchamp, 1985 ). Health and security are shared by members of a community, and guns are an attempt to privatize public security and safety, and so is antithetical to the common good. Can one really be healthy or safe in a society where one’s neighbors are subject to gun violence? Maybe not, and so then this violence is a threat to one’s life too. If guns really are an effective means of self-defense, they help one defend only oneself while accepting that others in one’s community might be at risk. One might also argue that the more guns there are, the more that society accepts the legitimacy of gun ownership and the more that guns have a significant place in culture etc., and consequently, the more that there is likely to be a problem.

Trivigno (2018) suggests that the willingness to carry a firearm indicates an intention to use it if the need arises and Branas et al (2009) argue that perpetually carrying a firearm might affect how individuals behave ( Trivigno, 2018 ; Branas et al. , 2009 ). When all things are equal, will prudence and a commitment to the flourishing of others prevail? Trivigno (2013) wonders if such behaviors as carrying or having continual access to a firearm generates mistrust or triggers fear of an unknown armed assailant, allowing for aggression or anger to build; the exact opposite of flourishing ( Trivigno, 2013 ). One could suggest, then, that the recreational use of firearms is also commonly vicious. Many people use firearms to engage in blood sport, killing animals for their own amusement. For example, someone who kicks puppies or uses a magnifying glass to fry ants with the sun seems paradigmatically vicious; why not think the same of someone who shoots deer or rabbits for their amusement?. Firearm proponents might suggest that the fidelity (living out one’s commitments) or justice, which Aristotle holds in high regard, could justify carrying a firearm to protect one’s life, livelihood, or loved ones insofar as it would be just of a person to defend and protect the life of another or even one’s own life when under threat by one who means to do harm. Despite an argument justifying the use of a firearm against another for self-defense after the fact, the action might not have been right when evaluated through the previous rationale, or applying the doctrine of double effect as described by Aquinas’ passage in the Summa II-II, which mentions that self-defense is quite different than taking it upon one’s self to mete out justice ( Schlabach, n.d. ). The magistrate is charged with seeing that justice is done for the common good. At best, if guns really are an effective means of self-defense, they help one defend only oneself while accepting that others in one’s community might be at risk. They take a common good, the health and safety of the community, and make it a private one. For Aquinas and many other modern era ethicists, intention plays a critical part in judgment of an action. Accordingly, many who oppose any ownership of firearms do so in both a paternalistic fashion (one cannot intend harm if they don’t have access to firearms) and virtuous fashion (enabling human flourishing).

Classical formulations of the double doctrine effect include necessity and proportionality conditions. So, it’s wrong to kill in self-defense if you could simply run away (without giving up something morally important in doing so), or to use deadly force in self-defense when someone is trying to slap you. One thing the state can do, in its role of promoting the common good, is to reduce when it is necessary to use self-defense. If there were no police at all, then anyone who robs you without consequence will probably be back, so there’s a stronger reason to use deadly force against them to feel secure. That’s bad, because it seems to allow violence that truly isn’t necessary because no one is providing the good of public security. So, one role of the state is to reduce the number of cases in which the use of deadly force is necessary for our safety. Since most homicides in the United State involve a firearm, one way to reduce the frequency of cases in which deadly force is necessary for self-defense is to reduce the instances of gun crime.

We have attempted to lay the empirical and ethical groundwork necessary to support various interventions, and the recommendations aimed at curbing firearm violence that will be discussed in this next section. Specifically, by discussing the burden of the problem in its various forms (healthcare costs, disproportionate violence towards racial/ethnic minority groups, women, children, vulnerable populations and the lack of research) and the ethics theories public health finds most accessible, we can now turn our attention to well-known, evidence-based recommendations that could be supported by the blended ethics approach: rights-based theories, consequentialism and the common-good approach discussed.

Comprehensive, Universal Background Checks for Firearm Sales

Of the 17 million persons who submitted to a background check to purchase or transfer possession of a firearm in 2010, less than 0.5% were denied approval of purchase ( Federal Bureau of Investigation, 2014 ). At present, a background check is required only when a transfer is made by a licensed retailer, and nearly 40% of firearm transfers in recent years were private party transfers ( Miller et al. , 2017 ). As such, close to one-fourth of individuals who acquired a firearm within the last two years obtained their firearm without a background check ( Miller et al. , 2017 ). Anestis et al. , (2017) and Siegel et al. , (2019) evaluated the relationship between the types of background information required by states prior to firearm purchases and firearm homicide and suicide deaths ( Anestis et al. , 2017 ; Siegel et al. , 2019 ). Firearm homicide deaths appear lower in states checking for restraining orders and fugitive status as opposed to only conducting criminal background checks ( Sen and Panjamapirom, 2012 ). Similarly, suicide involving firearm were lower in states checking for a history of mental illness, fugitive status and misdemeanors ( Sen and Panjamapirom, 2012 ).

Research supports the evidence that comprehensive universal background checks could limit crimes associated with firearms, and enforcement of such laws and policies could prevent firearm violence ( Wintemute, 2019 ; Lee et al. , 2017 ). Comprehensive, universal background check policies that are applicable to all firearm transactions, including private party transfers, sales by firearm dealers and sales at firearm shows are justifiable using a blend of the ethics theories we have previously discussed. With the rights-based approach, one could still honor the right to own a firearm by a competent person while also enforcing the obligation of the firearm vendor to ensure only a qualified individual purchased the firearm. To further reduce gun crime, rather than ensure only the right people own guns, we can just reduce the number of guns owned overall. Consequentialism could be employed to ensure the protection of the most vulnerable such as victims of domestic violence and allowing a firearm vendor to stop a sale to an unqualified individual if they had a history of suspected or proven domestic violence. Also, having universal background checks that go beyond the bare minimum of assessing if a person has a permit, the legally required training, etc., but delving more deeply into a person’s past, such as the inclusion of a red flag ( Honberg, 2020 ), would be promoting the common good approach by creating the conditions for persons to be good and do good while propelling community safety.

Renewable License Before Buying and After Purchase of Firearm and Training Firearm Owners

At present, federal law does not require licensing for firearm owners or purchasers. However, state licensing laws fall into four categories: (1) permits to purchase firearms, (2) licenses to own firearms, (3) firearm safety certificates and (4) registration laws that impose licensing requirements ( Anestis et al. , 2015 ; Giffords Licensing, n.d. ). A study conducted in urban U.S. counties with populations greater than 200,000 indicated that permit-to-purchase laws were associated with 14% reduction in firearm homicides ( Crifasi et al. , 2018 ). In Connecticut, enforcing a mandatory permit-to-purchase law making it illegal to sell a hand firearm to anyone who did not have an eligible certificate to purchase firearms was associated with a reduction in firearm associated homicides ( Rudolph et al. , 2015 ). This also resulted in a significant reduction in the rates of firearm suicide rates in Connecticut ( Crifasi et al. , 2015 ). Conversely, the permit-to-purchase law was repealed in Missouri in 2007, which resulted in an increase of homicides with firearms and firearm suicides ( Crifasi et al. , 2015 ; Webster et al. , 2014 ). Similarly, two large Florida counties indicated that 72% of firearm suicides involved people who were legally permitted to have a firearm ( Swanson et al. , 2016 ). According to the study findings, a majority of those who were eligible to have firearms died from firearm-related suicide, and also had records of previous short-term involuntary holds that were not reportable legal events.

In addition to comprehensive, universal background checks for firearm purchases, licensing with periodic review requires the purchaser to complete an in-person application at a law enforcement agency, which could (1) minimize fraud or inaccuracies and (2) prevent persons at risk of harming themselves or others to purchase firearms ( Crifasi et al. , 2019 ). Subsequent periodic renewal could further reduce crimes and violence associated with firearms by helping law enforcement to confirm that a firearm owner remains eligible to possess firearms. More frequent licensure checks through periodic renewals could also facilitate the removal of firearms from individuals who do not meet renewal rules.

Further, including training on gun safety and shooting with every firearm license request could also be beneficial in reducing gun violence. In Japan, if you are interested in acquiring a gun license, you need to attend a one-day gun training session in addition to mental health evaluation and background check ( Alleman, 2000 ). This training teaches future firearm owners the steps they would need to follow and the responsibilities of owning a gun. The training completes with passing a written test and achieving at least a 95% accuracy during a shooting-range test. Firearm owners need to retake the class and initial exam every three years to continue to have their guns. This training and testing have contributed to the reduction in gun related deaths in Japan. Implementing such requirements could reduce gun misuses. Even though, this is a lengthy process, it could manage and reduce the risks associated with firearm purchases and will support a well-regulated firearm market. While some may argue that other forms of weapons could be used to inflict harm, reduced access to firearms would lead to a significant decrease in the number of firearm-related injuries in the United States.

From an ethics perspective, again, all three theories could be applied to the recommendation for renewable licenses and gun training. From a rights-based perspective, renewable licensure and gun training would still allow for the right to bear arms but would ensure that the right belongs with qualified persons and again would allow the proper state agency to exercise its responsibility to its citizens. Additionally, a temporary removal of firearms or prohibiting firearm purchases by people involuntarily detained in short-term holds might be an opportunity to ensure people’s safety and does so without unduly infringing on the Second Amendment rights. Renewable licenses and gun training create opportunities for law enforcement to step in periodically to ascertain if a licensee remains competent, free from criminal behavior or mental illness, which reduces the harm to the individual and to the community—a tidy application of consequentialism. Again, by creating the conditions for people to be good, we see an exercise of the common good.

Licensing Firearm Dealers and Tracking Firearm Sales

In any firearm transfer or purchase, there are two parties involved: the firearm vendor and the individual purchaser. Federal law states that “it shall be unlawful for any person, except for a licensed importer, licensed manufacturer, or licensed dealer, to engage in the business of importing, manufacturing, or dealing in firearms, or in the course of such business to ship, transport, or receive any firearm in interstate or foreign commerce” (18 U.S.C. 1 922(a)(1)(A)(2007). All firearm sellers must obtain a federal firearm license issued by the Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF). However, ATF does not have the complete authority to inspect firearm dealers for license, revoke firearm license, or take legal actions against sellers providing firearms to criminals ( Vernick and Webster, 2007 ). Depending on individual state laws, typically the firearm purchaser maintains responsibility in obtaining the proper license for each firearm purchase whereas the justice system has the responsibility to enforce laws regulating firearm sales. Firearm manufacturers typically sell their products through licensed distributors and dealers, or a primary market (such as a retail store). Generally, firearms used to conduct a crime (including homicide) or to commit suicide are the product of secondary markets ( Institute of Medicine, 2003 ) such as retail secondhand sales or private citizen transfers/sales. Such secondary firearm transfers are largely unregulated and allow for illegal firearm purchases by persons traditionally prohibited from purchasing in the primary market ( Vernick and Webster, 2007 ; Chesnut et al. , 2017 ).

According to evidence from Irvin et al. (2014) in states that require licensing for firearm dealers and/or allow inspections, the reported rates of homicides were lower ( Irvin et al. , 2014 ). Specifically, after controlling for race, urbanicity, poverty level, sex, age, education level, drug arrest rate, burglary rates and firearm ownership proxy, the states that require licensing for firearm dealers reported ~25% less risk of homicides, and the states that allow inspection reported ~35% less risk of homicides ( Irvin et al. , 2014 ). This protective effect against homicides was stronger in states that require both licensing and inspections compared to states that require either alone. The record keeping of all firearm sales is important as it facilitates police or other authorized inspectors to compare a dealer’s inventory with their records to identify any secondary market transactions or other discrepancies ( Vernick et al. , 2006 ). According to Webster et al. (2006) , a change in firearm sales policy in the firearm store that sold more than half of the firearms recovered from criminals in Milwaukee, resulted in a 96% reduction in the use of recently sold firearms in crime and 44% decrease in the flow of new trafficked firearms in Milwaukee ( Webster et al. , 2006 ).

The licensing of firearm vendors and tracking of firearm sales sits squarely as a typical public health consequentialist argument; in order to protect the community, an individual’s right is only minimally infringed upon. An additional layer, justifiable by consequentialism, includes a national repository of all firearm sales which can be employed to minimize the sale of firearms on the secondary market and dealers could be held accountable for such ‘off-label’ use ( FindLaw Attorney Writers, 2016 ). Enforcing laws, mandating record keeping, retaining the records for a reasonable time and mandating the inspection of dealers could help to control secondary market firearm transfers and minimize firearm-related crimes and injuries.

One could argue from a rights perspective that routine inspections and record keeping are the responsibility of both firearms vendors and law enforcement, and in doing so, still ensure that competent firearm owners can maintain their rights to bear arms. In Hume’s discussion of property rights, he situates his argument in justice; and that actions must be virtuous and the motive virtuous ( Hume, 1978 ). Hume proposes that feelings of benevolence don’t form our motivation to be just. We tend (perhaps rightly) to feel stronger feelings of benevolence to those who deserve praise than to those who have wronged us or who deserve the enmity of humanity. However, justice requires treating the property rights or contracts of one’s enemies, or of a truly loathsome person, as equally binding as the property rights of honest, decent people. Gun violence disproportionately impacts underserved communities, which are same communities impacted by social and economic injustice.

Standardized Policies on Safer Storage for Firearms and Mandatory Education

Results from a cross-sectional study by Johnson and colleagues showed that about 14-30% of parents who have firearms in the home keep them loaded, while about 43% reported an unlocked firearm in the home ( Johnson et al. , 2006 ; Johnson et al. , 2008 ). The risk for unintentional fatalities from firearms can be prevented when all household firearms are locked ( Monuteaux et al. , 2019 ). Negligent storage of a firearm carries various penalties based on the individual state ( RAND, 2018 ). For example, negligent storage in Massachusetts is a felony. Mississippi and Tennessee prohibit reckless or knowingly providing firearms to minors through a misdemeanor charge, whereas Missouri and Kentucky enforce a felony charge. Also, Tennessee makes it a felony for parents to recklessly or knowingly provide firearms to their children ( RAND, 2018 ).

While a competent adult may have a right to bear arms, this right does not extend to minors, even in recreational use. Many states allow for children to participate in hunting. Wisconsin allows for children as young as 12 to purchase a hunting license, and in 2017 then Governor Scott Walker signed into law a no age minimum for a child to participate in a mentored hunt and to carry a firearm in a hunt when accompanied by an adult ( Wisconsin Department of Natural Resources, 2020 ). The minor’s ‘right’ to use a firearm is due in part to the adult taking responsibility for the minor’s safety. As such, some have argued that children need to know how to be safe around firearms as they continue to be one of the most pervasive consumer products in the United States ( Violano et al. , 2018 ).

In addition to locking firearms, parents are also encouraged to store firearms unloaded in a safe locked box or cabinet to prevent children’s access to firearms ( Johnson et al. , 2008 ). It follows then that reducing children and youth’s access to firearm injuries involves complying with safe firearm storage practices ( McGee et al. , 2003 ). In addition to eliminating sources of threat to the child, it is also important for children to be trained on how to safely respond in case they encounter a firearm in an unsupervised environment. Education is one of the best strategies for firearm control, storage and reduction of firearm-related injuries via development of firearm safety trainings and programs ( Jones, 1993 ; Holly et al. , 2019 ). Adults also need firearm safety education and trainings; as such, inclusion of firearm safety skills and trainings in the university-based curriculum and other avenues were adults who use guns are likely to be, could also mitigate firearm safety issues ( Puttagunta et al. , 2016 ; Damari et al. , 2018 ). Peer tutoring could also be utilized to provide training in non-academic and social settings.

Parents have a duty to protect their children and therefore mandating safe firearm storage, education and training for recreational use and periodic review of those who are within the purview of the law. Given that someone in the U. S. gets shot by a toddler a little more frequently than once a week ( Ingraham, 2017 ), others might use a utilitarian argument that limiting a child’s access to firearms minimizes the possibility of accidental discharge or intentional harm to a child or another. Again, the common good approach could be employed to justify mandatory safe storage and education to create the conditions for the flourishing of all.

Firearm and Ammunition Buy-Back Programs

Firearm and ammunition buy-back programs have been implemented in several cities in the United States to reduce the number of firearms in circulation with the ultimate goal of reducing gun violence. The first launch in Baltimore, Maryland was in 1974. The Los Angeles Police Department (LAPD) has conducted a gun buy-back program for nearly eight years to remove more guns off the streets and improve security in communities. Currently there is a plan for a federal gun buy-back program in the United States. The objective of such programs is to reduce gun violence through motivating marginal criminals to sell their firearms to local governments, encourage law-abiding individuals to sell their firearms available for theft by would-be criminals, and to reduce firearm related suicide resulting from easy access to a gun at a time of high emotion ( Barber and Miller, 2014 ).

According to Kuhn et al. (2002) and Callahan et al. (1994) , gun buy-back programs are ineffective in reducing gun violence due to two main facts: 1- the frequently surrendered types of firearms are typically not involved in gun-related violence and 2- the majority of participants in gun buyback programs are typically women and older adults who are not often involved in interpersonal violence ( Kuhn et al. , 2002 ; Callahan et al. , 1994 ). However, as a result of implementation of the ‘‘good for guns’’ program in Worcester, Massachusetts, there has been a decline in firearm related injuries and mortality in Worcester county compared to other counties in Massachusetts ( Tasigiorgos et al. , 2015 ). Even though, there is limited research indicating a direct link between gun buy-back programs and reduction in gun violence in the United States, a gun buy-back program implemented in Australia in combination with other legislations to reduce household ownership of firearms, firearm licenses and licensed shooters was associated with a rapid decline in firearm related deaths in Australia ( Bartos et al. , 2020 ; Ozanne-Smith et al. , 2004 ).

The frequency of disparities in firearm-related violence, injuries and death makes it a central concern for public health. Even though much has been said about firearms and its related injuries, there continues to be an interest towards its use. Some people continue to desire guns due to fear, feeling of protection and safety, recreation and social pressure.

Further progress on reforms can be made through understanding the diversity of firearm owners, and further research is needed on ways to minimize risks while maximizing safety for all. Although studies have provided data on correlation between firearm possession and violence ( Stroebe, 2013 ), further research is needed to evaluate the interventions and policies that could effectively decrease the public health burden of firearm violence. Evidence-based solutions to mitigating firearm violence can be justified using three major public health ethics theories: rights-based theories, consequentialism and common good. The ethical theories discussed in this paper can direct implementation of research, policies, laws and interventions on firearm violence to significantly reduce the burden of firearm violence on individuals, health care systems, vulnerable populations and the society-at-large. We support five major steps to achieve those goals: 1. Universal, comprehensive background checks; 2. Renewable license before and after purchase of firearm; 3. Licensing firearm dealers and tracking firearm sales; 4. Standardized policies on safer storage for firearms and mandatory education; and 5. Firearm buy-back programs. For some of the goals we propose, there might be a substantial risk of non-compliance. However, we hope that through education and sensibilization programs, overtime, these goals are not met with resistance. By acknowledging the proverbial struggle of individual rights and privileges paired against population health, we hope our ethical reasoning can assist policymakers, firearm advocates and public health professionals in coming to shared solutions to eliminate unnecessary, and preventable, injuries and deaths due to firearms.

The conducted research is not related to either human or animal use.

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Gun Violence and Youth/Young Adults

Youths in the United States can be involved with violence as victims, as witnesses/bystanders, or as persons engaging in the violence (David–Ferdon and Simon, 2014; OJJDP, 2014). Violence is the “intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation” (OJJDP, 2014:14). Applying this definition to the scope of this literature review, youth gun violence is when a gun or firearm is present in the process of a youth (ages 10–24) intentionally using force or power to threaten or harm others or themself. Youths are victims of gun violence when they are injured or killed as a consequence of someone (a youth or an adult) intentionally using a gun to threaten or harm them (whether the youth victim was the intended target or not).

This literature review will focus on intentional gun violence involving youths ages 10 to 24 (although the exact age range will depend on the source of information). Gun violence includes homicides (victimization and perpetration), nonfatal injuries, suicides, community violence, and school violence/school shootings. Unintentional gun violence (including accidental injuries or deaths from guns) will not be explored. In addition, the terms gun and firearm will be used interchangeably throughout the review, depending on the terminology in the source of the information.

Scope of the Problem

The scope of the problem of youth gun violence in the United States is reflected by the incidence and prevalence of gun-related homicides, suicides, and nonfatal injuries of youths.

According to the CDC, there were 45,222 firearm-related deaths in the United States in 2020. Of these, 10,197 deaths were of youths between the ages of 0 and 24 (Lee et al., 2022; CDC, 2021). Even youths who are not hurt or killed by guns but who witness gun violence are likely to experience adverse outcomes later in life (Turner et al., 2019; Finkelhor et al., 2015b). Although mass shootings tend to be the center of national news stories, they account for less than half of 1 percent of gun deaths each year (Luca, Malhotra, and Poliquin, 2016).

Data Sources on Gun Violence

There are several different federal sources of data on gun violence-related fatalities, nonfatal injuries, and suicides. The data sources described in the following pages will be used to define the scope of the gun violence issue, particularly as it pertains to youth.

The Centers for Disease Control and Prevention (CDC) Web-based Injury Statistics Query and Reporting System ( WISQARS ) is an online database that provides fatal and nonfatal injury, violent death, and cost-of-injury data in the United States to interested parties. WISQARS provides an interactive online database providing data on intent of injury, mechanism or cause of the injury (such as firearms), geographic location of the injury, demographic information (that is, sex, race/ethnicity, and age of the victim), and other information. Deaths in these data include homicides, suicides, unintentional deaths, and deaths of undetermined intent.

The CDC’s National Violent Deaths Report System ( NVDRS ) is a data source that includes hundreds of data elements on violent deaths (including homicides and suicides) that occur in the United States every year. This data source is part of the WISQARS database. Data on violent deaths are collected from a variety of sources, such as law enforcement, medical examiners and coroners, and death certificates ( NVDRS Fact Sheet, n.d.).

The CDC’s National Vital Statistics System ( NVSS ) provides information on births and deaths in the United States. Information is collected from a variety of sources (such as birth certificates, death certificates, and other federal surveys) at the state and national levels ( NVSS website, n.d.).

The CDC’s National Syndromic Surveillance Program ( NSSP ) is a collaboration among the CDC, federal partners, local and state health departments, and other private sectors to collect, analyze, and share electronic data on patients from emergency departments, urgent care centers, and other health-related settings. The NSSP promotes a community of practice among participants and can provide vital information that can serve as an early warning system for public health concerns (CDC, 2022b).

The Bureau of Justice Statistics (BJS) National Crime Victimization Survey ( NCVS ) is a nationally representative survey of a sample of U.S. households. The survey collects detailed information about crime victimization, such as whether people were the victims of certain types of crime, whether the victimization was reported to police, when and where the crime occurred, and any injuries sustained (BJS, 2022).

The Federal Bureau of Investigation (FBI) Uniform Crime Report ( UCR ) System is a nationwide effort of more than 18,000 law enforcement agencies to generate reliable criminal statistics. The Supplementary Homicide Reports ( SHRs ) dataset is the most detailed of the UCR datasets. It provides specific information about the circumstances of all homicides, including victim and offender demographics (such as age, gender, race, and ethnicity), weapon used, circumstances (such as domestic or gang related), and the date the crime happened (Kaplan, 2023).

For the purpose of this literature review, other sources were used when federal data were not available.

Overall Youth Gun Homicide

In 2020, homicide was the second-leading cause of death for 15- to 24-year-olds (CDC ,  2023). Over time, the rate of firearm homicides for youth has fluctuated. According to BJS, between 1993 and 2010 the firearm homicide victimization rate declined by 51 percent for 18- to 24-year-olds and by 65 percent for 12- to 17-year-olds (Planty and Truman, 2013). However, data from the CDC’s NVSS show that between 2019 and 2020 there was a 38.5 percent increase in firearm homicides of 10- to 24-year-olds (Kegler et al., 2022).

Youth Victims of Gun Homicide

Firearms were the murder weapon in 92.3 percent of youth homicides in 2020 (CDC ,  2023). The following information, using a variety of data sources, provides greater detail on homicides of youth attributable to firearms: 

• With regard to race, of the 5,966 firearm homicides committed against youth, 68.6 percent were carried out against Black youths, 29.4 percent against white youths, and 2.0 percent against American Indians/Alaska Natives or Asians/Pacific Islanders (CDC, 2023).
• Regarding ethnicity, of total firearm homicides committed against youth, 81.9 percent were committed against non-Hispanic youth (CDC, 2023).
• Regarding gender, youth firearm homicide victims are more likely to be male, with 88 percent of firearm homicides committed against males (CDC, 2023). 
• Data from the CDC WISQARS show that in 2019 the firearm mortality rate of youths ages 15 to 24 was more than 10 times as high as of youths ages 10 to 14 (17.2 versus 1.6 per 100,000 respectively) [Bottiani et al., 2021].
• With regard to race, of the 4,693 firearm homicides committed against youths, 72.4 percent were carried out against Black youths, 23.4 percent were carried out against white youths, 1.1 percent against American Indians/Alaska Natives, and 0.7 percent against Asian/Pacific Islanders.
• Regarding ethnicity, of total firearm homicides committed against youths, 84.2 percent were committed against non-Hispanic youths.
• Regarding gender, youth firearm homicide victims were more likely to be male, with 88.0 percent of firearm homicides committed against males.
• Data from the CDC NVSS show that, during 2018–19, 62.5 percent of all firearm homicides of 10- to 19-year-olds were committed in the most populous metropolitan statistical areas in the country (Kegler et al., 2022).

Overall, these trends reflect that youth homicide victims ages 15 to 24 are more likely to be male and Black and to live in highly populous/urban areas (CDC , 2023; Kena and Truman, 2022; Bottiani et al., 2021).

Youths Who Commit Gun Homicides

Based on the UCR SHRs , there were an estimated 5,464 homicides with a firearm committed by known 12- to 24-year-olds in 2020 (Puzzanchera, Chamberlin, and Kang, 2021).

• Of the estimated 5,464 homicides committed by known youths, 66.9 percent of the cases involved a Black individual, 29.3 percent of cases involved a white individual, 1.8 percent were American Indians, Alaska Natives, Asians, or Pacific Islanders, and 1.8 percent of cases involved individuals whose race was unknown (Puzzanchera, Chamberlin, and Kang, 2021). The UCR SHRs demographic data cannot be broken down by ethnicity (Hispanic versus non-Hispanic).
• Males accounted for more than 91.6 percent of the known 12- to 24-year-olds who committed a homicide with a firearm in 2020 (Puzzanchera, Chamberlin, and Kang, 2021).
• The estimated number of firearm-related homicides committed by known youths (ages 12–17) more than quadrupled between 1984 and 1994, from 543 to 2,271. Then, from 1994 to 2001 the rate of firearm-related homicides committed by youths declined. Firearm-related homicides by juveniles increased by 50 percent from 2001 to 2007 but decreased from 2007 to 2014 by 39 percent (OJJDP, 2016). However, since reaching a low rate in 2013, the number of firearm-related homicides committed by known juveniles (ages 17 and under) increased 68 percent through 2019 (Puzzanchera, Hockenberry, and Sickmund, 2022:68).

Overall, these trends reflect that youths (ages 12 to 24 years) who commit the majority of firearm-related homicides are more likely to be Black and male (Puzzanchera, Chamberlin, and Kang, 2021). 

Nonfatal Gun Violence

There is conflicting information about whether the trend in nonfatal firearm-related violence has been increasing or decreasing over time (Kena and Truman, 2022; Truman and Langton, 2015).

Disparities between CDC data—based primarily on reports from U.S. emergency departments—and the BJS NCVS could explain differences between the reported trends. Planty and Truman (2013:11) acknowledge the differences in NCVS and CDC trend data. Their report observed that NCVS is a residential household survey and does not include hidden populations such as those who are homeless or institutionalized (for example, jails or mental health facilities). Further, some of the CDC estimates used to calculate injury trends may be based on small sample sizes and should be interpreted with caution (Bottiani et al., 2021).

Using available data from these sources, the following trends emerge:

• According to CDC WISQARS estimates, there was an increase in the rate of nonfatal firearm gunshot injuries (including self-harm and accidental injuries) for youths ages 15 to 19 from 2012 to 2018 (from 53.4 per 1,000 to 72.6 per 100,000). There also was an increase for youths ages 20 to 24 from 2012 to 2016 (from 94.5 to 141.2 per 100,000). Notably, data for certain years are missing because they were unstable owing to either small sample size or the coefficient of variation of the estimate being below 30 percent (CDC , 2023).
• According to the CDC’s NSSP , from 2018 to 2019, males and females ages 15 to 24 years had higher firearm injury-related emergency department visit rates and saw a significant increase in rates of emergency department visits related to a firearm injury, compared with those in other age groups. These injuries include unintentional, intentional self-directed, assault, legal interventions, terrorism, and injuries of undetermined intent (Zwald et al., 2022).
• Though the rate for 18- to 24-year-olds decreased according to the NCVS, this rate was still the highest compared with all other age groups. For example, from 2014 to 2018, youths ages 18 to 29 represented 19.4 percent of the U.S. population, but they were 27.9 percent of persons committing crimes and 38.9 percent of victims in incidents of nonfatal firearm violence (Kena and Truman, 2022).

Youth Gun Suicide

According to the CDC’s NVSS , suicide was the 10th-leading cause of death in the United States in 2019; however, it was the second-leading cause of death in youths 10 to 24 years old (CDC, 2021).

• According to CDC WISQARS estimates, of the 6,643 youths ages 10 to 24 who died by suicide in 2020, slightly more than half (3,397) were carried out with a firearm (CDC , 2023).
• Of the 3,397 suicides with a firearm by youths 10 to 24 years old in 2020, 78.7 percent were white, 15.7 percent were Black, and 5.6 percent were by American Indians, Alaska Natives, Asians, and Pacific Islanders (CDC , 2023).
• Of total firearm suicides in 2020 of youths ages 10 to 24, 84.7 percent were non-Hispanic (CDC , 2023).
• Males ages 10 to 24 years old (88 percent) were more likely than their female counterparts to die by suicide using a firearm (12 percent) [CDC , 2023]. 

Overall, the numbers suggest that the majority of suicides committed by 10- to 24-year-olds with a firearm are male and white.

Community Gun Violence

While youths can be directly exposed to gun violence—through victimization or perpetration—they also can be indirectly exposed, by witnessing gun violence in their communities (Turner et al., 2019; Listenbee et al., 2012). Youths who witness gun violence experience similar negative psychological and physical harm as youths who have had direct exposure (Turner et al., 2019; Futures Without Violence, 2016). There are various forms of violence that youths may witness in their lifetimes, including assaults, physical abuse, thefts, and shootings. According to the National Survey of Children’s Exposure to Violence (most recently conducted in 2014), about 38 percent of children ages 17 and younger have witnessed violence in the family or the community in their lifetimes (Finkelhor et al., 2015a). Regarding specific exposure to gun violence:  

• About 8 percent of children reported being exposed to a shooting (including hearing gunshots or seeing someone shot) in their lifetimes, with children ages 14 to 17 reporting the highest levels of exposure to a shooting (13 percent). Additionally, boys were more likely than girls to report exposure to shootings (Finkelhor et al., 2015a).
• Regarding youths between the ages of 2 and 17, Black youths and youths living in urban communities had higher rates of witnessing gun violence (21.4 percent and 20.9 percent respectively) and hearing gunshots in public (51.6 percent and 48.3 percent respectively), compared with non-Black and non-urban youths (Bottiani et al., 2021; Turner et al., 2019).
• Youth exposure to shootings decreased between 2008 and 2014, although this change has been minimal (Finkelhor et al., 2014; Finkelhor et al., 2015a).
• Youths are more likely to witness assault in their communities in their lifetimes than to be exposed to a shooting (28 percent, compared with 8 percent, respectively) [Finkelhor et al., 2015a].

Overall, although exposure to gun violence is not as prevalent as other forms of community violence, it still is a potentially traumatic event that many youths will experience in their lifetimes.

School Gun Violence

Fewer than 2 percent of homicides of youths ages 5 to 18 occur on school grounds (CDC, 2021; Planty and Truman, 2013). Although school shootings are rare, most homicides against youth at school were committed with a firearm (Planty and Truman, 2013). Additionally, 95 percent of multiple-victim incidents in schools between 2009 and 2018 were firearm related (Hamlin, 2021).

• About 3 percent of students in grades 9–12 reported carrying a weapon at least 1 day during the previous 30 days on school property in 2019, a decrease from 6 percent in 2009 (Irwin et al., 2021).
• In 2019, 4 percent of students ages 12 to 18 reported having access to a loaded gun without adult permission, either at school or away from school, which was a decrease from 6 percent in 2009 (Irwin et al, 2021; Zhang, Musu–Gillette, and Oudekerk, 2016).
• White male students were more likely than any other demographic to have carried a gun (Irwin et al., 2021; Kann et al., 2016).
• In 2019, 7 percent of high school students reported that they were threatened or injured with a weapon—such as a gun, knife, or club—on school property during the past year (Irwin et al., 2021).

International Comparisons of Youth Gun Violence

According to the United Nations, 54 percent of homicides worldwide in 2017 were carried out using a firearm (UNODC, 2019). In addition, according to a World Health Organization global status report on violence prevention, 43 percent of annual homicides worldwide involve youths ages 10 to 29 (Butchart and Mikton, 2014). Youths are disproportionately affected by homicide regardless of country level of income (Goldstick et al., 2019; Mikton et al., 2016); however, the youth firearm homicide rate in the United States is higher than other high-income countries (e.g., Australia, Canada, the United Kingdom) [Bottiani et al., 2021; Bushman et al., 2016;]. For example, the United States has rates of homicide by firearm 37 times as high as 12 other comparable nations (Goldstick et al., 2019).

Risk Factors for Youth Gun Violence Perpetration

Risk factors are personal traits, characteristics of the environment, or conditions in the family, school, or community that are linked to youths’ likelihood of engaging in delinquency and other problem behaviors (Murray and Farrington 2010) [for more information, see the Model Programs Guide literature review on Risk Factors for Delinquency ]. Several risk factors for firearm violence perpetration have been identified at the individual, peer, family, and community levels (Schmidt et al., 2019). This body of research includes studies of large, nationally representative samples of children and youth (for example, Schleimer et al., 2023; Shetgiri et al., 2016; Simon et al., 2022) and specific, high-risk samples in high-risk neighborhoods (e.g., Carter et al., 2013; Hohl et al., 2017; Rowan et al., 2019). Some risk factors have demonstrated a stronger influence than others, and researchers have found that accumulation of multiple risk factors increases risk for firearm-related violence perpetration, victimization, and suicide (Mmari, Blum, and Teufel–Shone, 2010; Reingle, Jennings, and Maldonado–Molina, 2012; Shetgiri et al., 2016; Williamson, Guerra, and Tynan, 2014).

These risk factors often influence firearm-related outcomes in complex ways and through intricate pathways, which may vary among youths of different ages, backgrounds, races, genders, urbanicity, and experiences (Collings et al., 2023; Culyba et al., 2018; Schleimer et al., 2023; Schmidt et al., 2019; Shetgiri et al., 2016). For example, the Flint Adolescent Study (a longitudinal study of risk and protective factors associated with substance use) found that exposure to violence indirectly increased the risk for carrying a firearm by decreasing youths’ beliefs that they would graduate from high school and continue education after high school (Lee et al., 2020). However, there is little research examining these pathways (Schmidt et al., 2019). Instead, most research tends to examine the direct effects of risk factors on gun-related outcomes.

This section briefly describes risk factors for firearm carrying, firearm violence perpetration and victimization, and firearm suicide among youth. This section pertains to youth firearm violence in general and does not focus on youth who commit mass shootings. This section also does not focus on risk factors related to firearm violence victimization and firearm suicide among youth, as there is limited research on those factors (Knopov et al., 2019; Miller, Azrael, and Hemenway, 2002; Kaufman et al., 2021). The risk factors with the strongest evidence for influencing youth firearm violence appear to be

• Exposure to violence
• Delinquent peers and violent social networks
• Involvement in crime, delinquency, and violence
• Availability of firearms [Beardslee et al., 2021; Goldstick et al., 2019; Lee et al., 2020; Mattson, Sigel, and Mercado, 2020; Oliphant et al., 2019; Schleimer et al., 2023; Simon et al., 2022; Spano and Bolland, 2013; Wamser–Nanney et al., 2019]

Other risk factors are also described here.

Exposure to Violence and Victimization

Exposure to violence refers to direct exposure (personal victimization) or indirect exposure (witnessing or hearing about the victimization of a family member, friend, or neighbor) [Zimmerman and Posick, 2016]. There is a large body of evidence examining the relationship between exposure to violence and subsequent aggressive and violent offending (Farrell and Zimmerman, 2018; Fitton and Fazel, 2020; Hawkins et al., 2000; Wright et al., 2016). Researchers also have identified relationships between exposure to violence and gun-related outcomes (e.g., Beardslee et al., 2021; Carter et al., 2013; Henrich, Brookmeyer, and Shahar 2005; Lee et al., 2020; Oliphant et al., 2019; Pardini et al., 2021; Simon et al., 2022; Teplin et al. 2020).

For example, a study of male youths from the Pathways to Desistence  study (a longitudinal study of individuals who were found guilty of a serious offense at ages of 14–18), who reported shooting or shooting at someone, found that witnessing non–gun violence and being a victim of non–gun violence increased the likelihood of later gun violence perpetration (Rowan et al., 2019). Analysis of data from the Mobile Youth Survey (a longitudinal study of youths ages 10–18 from high-poverty neighborhoods in Mobile, AL) found that youths who had experienced violent victimization were more likely than youths who had not had those experiences to initiate gun carrying when they were older (Spano and Bolland, 2013). Similarly, examination of data from the Flint Youth Injury  study (which involved drug-using youths ages 14–24) found that violence victimization by a partner or a peer, with a firearm or other weapon, predicted initiation of firearm assault behavior (Goldstick et al., 2019).

Studies of large, national samples also find this relationship. Analysis of data from the CDC’s 2017 Youth Risk Behavior Survey ( YRBS ) indicated that gun carrying among males and females was more prevalent among those who had been threatened or injured with a weapon on school property (25.9 percent and 11.2 percent, respectively) than it was among those who had not (5.2 percent and 1.3 percent, respectively) [Simon et al., 2022]. YRBS  data also indicated that students who had experienced dating violence, who had experienced sexual violence, or who missed school because of safety concerns were all more likely to carry a gun compared with students who had not had these experiences (Simon et al., 2022).

Researchers who examine bullying victimization also find relationships with gun- and other weapon-related outcomes. Data from the 2017 YRBS indicated that high school students who were bullied on school property were more likely to carry a gun than students who were not bullied (Pham et al., 2017; Simckes et al., 2017).

History of Violence and Aggression

Violence perpetration is also strongly related to gun violence (Goldstick et al., 2019; Schleimer et al., 2023). For example, analysis of data from the  Flint Youth Injury study found that, among youths who use drugs, those who were aggressive toward their partner or peers were more likely than youths who were not aggressive to initiative firearm assault behavior (Goldstick et al., 2019). Another study found that youths who were more likely to get into serious fights at work or school, more likely to take part in a fight with a group of friends against another group, and more likely to attack someone with the intent to seriously hurt them were also more likely to have carried a handgun in the past 12 months (Schleimer et al., 2023). Similarly, analysis of data from the  Youth Risk Behavior Survey indicates that youths who had been in a physical fight were more likely than youths who had not been in a physical fight to carry a gun (Simon et al., 2022). Finally, a study of more than 1,000 youths in two urban communities in Colorado found that youths who reported engaging in gang fights were five times as likely as those who did not to report having potential access to firearms and that youths who reported perpetrating minor assault were about twice as likely to report having potential access to firearms as youths not reporting this (Mattson, Sigel, and Mercado, 2020).

Access and Availability to Firearms

Part of what enables youths to progress to more deadly forms of violence is their access to firearms, exposure to firearms, and the availability of firearms in their homes and communities (Lizotte et al., 1994; Miller, Azrael, and Hemenway, 2002; Miller, Hemenway, and Azrael, 2007; Oliphant et al., 2019; Williamson, Guerra, and Tynan, 2014). For example, analysis of data from the National Longitudinal Study of Adolescent to Adult Health found that gun availability in the home was associated with aggressive weapon-carrying behavior (such as pulling a gun or knife on someone) for Black youth, but not for white or Latino youth (Shetgiri et al., 2016). Some studies have found that access to guns combined with limited parental supervision is a stronger predictor of gun violence than access to guns alone (e.g., Slovak and Singer, 2001).

Poor Future Orientation and Antisocial Beliefs

Youths’ orientation to the future sometimes is examined in research studies as a factor related to several positive and negative outcomes, including gun violence. Future orientation refers to the degree to which an individual thinks about the future, considers the consequences of their actions, and plans ahead before acting. Many of these studies have found that youths who are more likely to prioritize the present and discount their futures are less likely to consider the serious consequences of gun violence and more likely to encounter opportunities where violence occurs (e.g., Hepburn and Hemenway, 2004; Piquero et al., 2005;3). Some studies have found that poor future orientation is associated with firearm carrying (e.g., Lee et al., 2020) and with engaging in gun violence (e.g., Donovan, 2022; Rowan et al., 2019). Similarly, perceived personal rewards for crime is associated with gun violence. Rowan and colleagues (2019) found that youths who had higher perceived personal rewards to engaging in crime were nearly 50 percent more likely to engage in gun violence compared with youths who had lower perceived personal rewards to engaging in crime.

Substance Use

Tobacco, alcohol, and other drug use has been associated with carrying a firearm among youth in several studies (Vaughn et al., 2012; Carter et al., 2013; Oliphant et al., 2019), and regular heavy drinking has been associated with gun violence among youths who have been adjudicated for a serious offense (Pardini et al., 2021). Similarly, a study conducted in Philadelphia, PA, found that substance use at the individual, family, and neighborhood levels was associated with increased odds of adolescent firearm homicide (Hohl et al., 2017).

Delinquent Peers and Involvement in Crime and Delinquency

Involvement in crime and delinquency and having peers who engage in delinquent and violent behavior are also risk factors for firearm-related outcomes (Beardslee et al., 2021; Oliphant et al., 2019). For example, an examination of more than 17,000 youths ages 12–17 in the National Survey on Drug Use and Health found that youths who sell illicit drugs were more likely than youths who did not to carry a handgun (Vaughn et al., 2012). Analysis of data from more than 1,000 youths from Colorado found that youths who reported having peers who engage in delinquent behavior were six times as likely to report having potential access to firearms as youths who were not, and youths who reported selling drugs were nearly five times as likely to report possessing or carrying a firearm in the past year as youths who did not report selling drugs (Mattson, Sigel, and Mercado, 2020).

Studies of higher-risk populations also have identified these risk factors. Analysis of data from the Flint Youth Injury  study found that among young people ages 14 to 24 who associate with peers who engage in delinquent and law violating behavior were more likely to perpetrate firearm assault than those who do not (Goldstick et al., 2019). Similarly, analysis of a sample of youths ages 13 to 17 in three jurisdictions, who had been arrested for the first time for a low or moderate offense, found that prior non–gun theft and property offending was related to gun carrying, as was peer gun carrying (Beardslee et al., 2021). Finally, analysis of males who were adjudicated for serious offenses (ages 14 to 19) with serious delinquency backgrounds found that current peer gun carrying was related to future gun violence (Pardini et al., 2021). The study by Pardini and colleagues (2021) also found that gang membership was a significant risk factor for youths’ engagement in future gun violence. In fact, many previous studies established the relationship between membership in a gang and the increased risk of gun violence perpetration (Katz et al., 2011; Huebner et al., 2016).

Family Factors

Family factors also have been examined to identify their relationship with gun violence. A study of more than 17,000 youths from the National Survey on Drug Use and Health found that youths who carried handguns were significantly less likely to report a parent being involved in their lives, compared with youths who did not carry handguns (Vaughn et al., 2012). Another study found that boys exposed to poorer parental engagement during childhood were more likely to affiliate with delinquent peers and exhibit externalizing problems during early adolescence, which (in turn) increased their risk of carrying a firearm in later adolescence (Beardslee et al., 2019).

Community Factors

Several community-level factors have been examined with regard to their influence on youth firearm-related outcomes. For example, a study of children’s involvement in firearm assaults and homicides, as documented in pediatric medical charts from a hospital in Georgia, found that gun violence was significantly related to levels of community distress (Tracy et al., 2019). The researchers measured community distress using seven economic indicators:

• Percentage of adults without a high school diploma
• Percentage of housing that was unoccupied
• Percentage of adults not working
• Poverty levels
• Median household income
• Percent change in the number of jobs
• Percent change in the number of business establishments

Another study examining survey data from nearly 25 million adolescents across the United States found that adolescent handgun carrying was most common in the most-rural counties, compared with urban counties (Schleimer et al., 2023). Additionally, although use of violence was associated with handgun carrying in all counties, this association was stronger in urban counties than in rural counties.

Some other factors influencing youth gun carrying are perceived levels of community violence (such as neighborhood conflicts), perceived lack of safety, higher perceived levels of firearm ownership, hearing gunshots regularly in the neighborhood, lack of trust in police effectiveness, and elevated levels of neighborhood social and physical disorder (Oliphant et al., 2019; Swaner et al. 2020). Finally, studies of firearm violence in California and Maryland (that did not examine age-specific data) found that several community-level variables predicted interpersonal firearm violence, including poverty, racial–ethnic geographic segregation and isolation, lack of high school education among men age 65+, and the percentage of adults never married (Goin, Rudolph, and Ahern, 2018; Harfouche, Shields, and Curriero, 2023).

Another community-level risk factor for youth is living in an “ecology of danger”—that is, an environment where social interactions are perceived as threatening, and where individuals are normatively seen as having hostile intent with willingness to inflict harm (Fagan and Wilkinson, 1998; Wilkinson and Fagan, 2001). Youths living in these types of communities are more likely to be influenced by the code of the street, which is a set of informal rules for behavior that govern citizens of disadvantaged urban areas (Allen and Lo, 2012). In the most violent of neighborhoods, 

[A]dolescents presume that their counterparts are armed, and if not, could easily become armed. They also assume that other adolescents are willing to use guns, often at a low threshold of provocation.” [Wilkinson and Fagan, 2001:130]   

The influence of these dangerous social norms predicts youth gun carrying (Allen and Lo, 2012) and youth gun violence (Butts et al., 2015; Stewart and Simons, 2006; Swaner et al. 2020).

Protective Factors Against Youth Gun Violence Perpetration

Resiliency theory indicates that some youths exposed to risk factors do not develop negative, violent behaviors because of the presence and influence of protective factors (Stoddard et al., 2013). Protective factors are the events, opportunities, and experiences in the lives of youth that lessen or buffer against the probability of violence (Resnick, Ireland, and Borowsky, 2004). Protective factors help youths overcome the negative effects of risk factors and are essential in helping compensate for, or protect against, the effects of risk on healthy development (Fergus and Zimmerman, 2005) [for more information, see the Model Programs Guide literature review on Protective Factors Against Delinquency ].

Though there has been less research on protective factors than on risk factors for youth firearm violence perpetration, such as possessing or carrying a firearm (Mattson, Sigel, and Mercado, 2020; Oliphant et al., 2019; Schmidt et al., 2019), some studies have identified some protective factors at the individual, family, and school/community levels.

Family Attachment and Parental Monitoring

There are several ways that families can protect youth against firearm violence perpetration. These include providing emotional support and connection, monitoring and supervision, guidance and advice, economic resources and safety, and positive role models (e.g., Henrich, Brookmeyer, and Shahar, 2005; Luthar and Goldstein, 2004; Oliphant et al., 2019). Analysis of data on more than 17,000 youths in the National Survey on Drug Use and Health found that parental involvement and supervision were associated with a reduced likelihood of handgun carrying. The researchers examined seven measures of parental involvement (e.g., provided help with homework , told youth they were proud of them for something they had done, limited the amount of time youth went out with friends on school nights );   each one was associated with a reduced likelihood of handgun carrying (Vaughn et al., 2012). However, some studies have found that this influence varies by demographic characteristics, such as gender, race, and ethnicity (Shetgiri et al., 2016). Still, other studies have found no influence of attachment to parents on firearm possession or carrying when controlling for other risk factors (Mattson, Sigel, and Mercado, 2020).

Relationships With Supportive Adults

In addition to family, youths can form protective relationships with other adults. A study of more than 1,000 boys who were adjudicated for a serious offense found that those who reported having substantive bonds with at least two supportive adults were at lower risk for engaging in gun violence (Pardini et al., 2021).

Individual Protective Factors

Several individual-level protective factors have been identified that influence youth gun violence perpetration. One study found that among males who had been adjudicated for a serious offense, those who reported higher sensitivity to others’ feelings and a desire to help others, those who endorsed religious beliefs as a source of comfort and support, and those who held personal aspirations for achieving conventional adult goals were less likely to later engage in gun violence than males who did not have empathy, religious beliefs, and prosocial aspirations (Pardini et al., 2021).

Community-Level Protective Factors

Studies are less likely to identify community-level protective factors, when compared with community-level risk factors. For example, a study of more than 1,000 youths in two urban communities in Colorado found that neighborhood attachment was not a significant predictor of potential youth firearm access nor of a youth’s possessing or carrying a firearm in the past year, when controlling for risk factors (Mattson, Sigel, and Mercado, 2020). The authors explain that this may be due to the community’s more “distal influences relative to the more proximal influences of the risk factors,” such as peer delinquency and engaging in violence (2020:14). However, some studies have identified community-level protective factors that influence gun carrying and gun violence, such as community assets (e.g., “Where I live, people recognize me and care about me”), enhancing green space in urban neighborhoods, and restoring blighted, vacant land (Branas et al., 2018; Kondo et al., 2017; Ross et al., 2023; Shepley et al., 2019).

Policy Research on Guns

Federal laws.

There are numerous federal laws that regulate gun purchases made by licensed sellers:

• Prohibiting certain individuals (for example, those convicted of a felony offense) from buying firearms
• Making it a crime to sell or transfer a firearm to someone who is forbidden from possessing one
• Requiring buyers to sign a form stating that they had not been convicted of a felony or were not otherwise disqualified by law from purchasing a gun 
• A person must be at least 18 years old to purchase a long gun from a licensed           gun seller; however, there is no age restriction on a person to possess a long gun     or buy a long gun from a private seller. 
• A person must be at least 21 years old to purchase a handgun from a licensed gun seller but may be only 18 to be transferred a handgun from someone who is not a licensed gun dealer or to possess a handgun (Webster and Wintemute, 2015; Moe et al., 2020)
• The Youth Handgun Safety Act . The act was passed as part of the Violent Crime Control and Law Enforcement Act of 1994 and decreased the legal age of possessing a handgun established by the GCA from 21 to 18 (OJJDP, 1996). 
• The Gun-Free Schools Act . This act also took effect in 1994. It was part of the Improving America's Schools Act and amended part of the Elementary and Secondary Education Act of 1965, requiring schools receiving federal education funds to adopt a policy that required expulsion (for no less than 1 year) for any student who brings a firearm to school (OJJDP, 1996; Stuart–Cassel, Nunez, and Chung, 2022).
• Permit to Purchase. Approximately 13 states have permit-to-purchase (PTP) laws (Gius, 2017), which require individuals to obtain a permit or license (contingent on a background check) before purchasing a handgun, from either licensed businesses or private sellers (Crifasi et al., 2015). PTP laws vary by state; for instance, some states require individuals to appear in person to acquire a permit, while others allow permits to be obtained online or by mail (Webster and Wintemute, 2015). However, these laws wouldn’t directly affect youths under 21—the minimum age set by federal law to purchase a handgun. 
• Background Checks. Under the Brady Act, sales by private gun owners are exempted from the mandatory background check requirement that applies to licensed gun dealers. However, some states have sought to expand the Brady background check requirement (Rudolph et al., 2015). Approximately 17 states and the District of Columbia have adopted stricter background check requirements for private sellers (Rudolph et al., 2015; McClenathan et al., 2018). For example, in Massachusetts, citizens are required by law to report all sales, transfers, inheritances, and losses of firearms to the commonwealth’s Firearms Records Bureau. This law covers private transactions of guns (Braga and Hureau, 2015). 
• Child Access Prevention Laws. Child Access Prevention (CAP) laws are an example of laws specifically focused on preventing youths from accessing guns. CAP laws make it a crime to store firearms in a way that they can be easily accessible to youth (Webster et al., 2004). These polices generally establish requirements for firearm safety locks; in some states, gun owners may be found criminally liable for negligent gun storage (McClenathan et al., 2018; Miller et al., 2022). Between 1980 and 2019, approximately 29 states passed a CAP law (Hamlin, 2021). CAP laws may vary by state on factors such as the requirements to store a firearm or the criminal liability of gun owners, should a youth gain access to a firearm (which can result in fines, imprisonment, or both) [Anderson and Sabia, 2016].

Public Health Perspective on Gun Violence

Researchers, public health officials, and medical experts have suggested that, because of the interrelated individual–familial–community risk factors and the large number of individuals affected, gun violence is a public health issue (IOM and NRC, 2013; Butkus et al., 2014; Byrdsong, Devan and Yamatani, 2015; CDC, 2021; Zwald et al., 2022; Bailey et al., 2022). 

The public health field is concerned with problems that are related to significant levels of morbidity and mortality (for example, viruses, diseases, or other illnesses) in communities and the general public. A public health approach, in general, has three important components: “1) a focus on prevention, 2) a focus on scientific methodology to identify risk and patterns, and 3) multidisciplinary collaboration to address the issue” (IOM and NRC 2013:3).

As laid out by the CDC, a public health approach to violence prevention has four steps:

• “Define and monitor the problem” to understand the “who,” “what,” “when,” “where,” and “how” associated with the violence.
• “Identify risk and protective factors” to understand what factors either protect individuals or put them at risk for experiencing or perpetrating violence.
• “Develop and test prevention strategies” based on findings from research and local data.
• “Assure widespread adoption” that involves implementing effective strategies and assessing whether it addresses the problem of violence. [CDC, 2022]

This approach works to involve different individuals and institutions to address violence and other health problems that affect populations (Hemenway and Miller, 2013; CDC, 2022). Research has found that successful public health efforts are data driven and support those at greatest risk of violence by addressing factors that increase the risk of violence (Webster, 2022).

Public health strategies generally concentrate on the relationships of three elements: 1) the “agent” (or the source of the injury, which in the case of gun violence would be the gun or the person using the gun or both); 2) the “host” (which would be the victim of the gun violence); and 3) the “environment” (which would be the condition under which the violence occurred, including social, physical, or even virtual environments that affect gun policies, norms, and behaviors) [IOM and NRC, 2013].

The public health approach to gun violence prevention recognizes that many public health problems are caused by guns, such as accidents, suicides, intimate-partner violence, and mass shootings (Hemenway and Miller, 2013) and that gun violence may also affect the broader health status of individuals and communities, with studies showing that individuals exposed to gun violence as children had increased likelihood of chronic health issues such as heart disease and diabetes later in life (Byrdsong, Devan, and Yamatani, 2015). Although justice personnel may be primarily responsible for the apprehension, prosecution, and sanctioning of individuals who commit gun violence, a public health approach to combating youth gun violence calls for justice policymakers and practitioners to use a comprehensive, collaborative method that is informed by research from different fields that have successes in reducing and preventing other behavior-related issues (for example, tobacco use and motor vehicle fatalities) [CDC, 2022a; McLean et al., 2019].

An example of a federal initiative influenced by the public health approach is the CDC’s National Centers of Excellence in Youth Violence Prevention. CDC’s Youth Violence Prevention Centers (YVPCs) involve academics partnering with the community to advance both research and practice of youth violence prevention. The YVPCs were first established in 2000, and there were five centers funded for 2021–26 that are conducting research and implementing various strategies to inform local solutions to reduce community rates of youth violence, including evaluating a hospital-initiated, community-integrated, practice-based approach to reducing gun violence among older Black youth; examining changes in community conditions, risk and protective factors, firearm-related hospital admissions, and homicides of youth; and creating toolkits for community and youth-engaged firearm violence prevention (CDC, 2019).

Outcome Evidence

This section focuses on evidence-based practices and programs that were shown to reduce the occurrence of gun violence, including homicides, assaults, and other measures of violent crime. Overall, there is evidence supporting that interventions can reduce violent crime and offending in youth in particular, and gun violence in general; however, there is less evidence supporting reductions specifically in youth gun violence. Following below are examples of interventions from CrimeSolutions and the Model Programs Guide.

Interventions Specifically Focused on Reducing Gun Violence

A meta-analysis by Makarios and Pratt (2012) examined different types of programs under the umbrella of reducing gun violence, including law enforcement campaigns to reduce gun violence, gun laws, and gun buy-back programs. Overall, they found that interventions aimed at  reducing gun violence had small but statistically significant effects on measures of gun crime (though, notably, there was no distinction between rates of youth gun crimes and overall gun crimes).

Based on the results from the meta-analysis, the most promising program strategies were

• Community interventions, such as Operation Ceasefire
• Hot spots policing strategies
• Weapon ban laws
• Stricter probation requirements for juveniles committing crimes with guns, though the authors noted there were limited data on this strategy

The meta-analysis found that enhanced prison terms, waiting periods, and background checks had a small but statistically significant effect on reducing gun violence. No statistically significant relationships were found between reduced gun crimes and prosecutorial strategies such as harsher sentencing, safe storage laws, and gun buy-back programs (that is, these programs were found to have no effect on reducing gun violence) [Makarios and Pratt, 2012].

Focused Deterrence Interventions

Focused deterrence strategies are one type of community-driven intervention that combine enforcement and resources-driven responses (Matei et al., 2022) to work at reducing violent crime (including gun violence).  Focused Deterrence Strategies is a person-based practice consisting of several steps, beginning with selecting a particular crime problem such as youth homicide, convening an interagency working group (for example, law enforcement, social services), and developing a response to targeted persons committing crimes or groups of such individuals that uses a variety of sanctions (“pulling levers”) to stop continued violent behavior (Braga and Weisburd, 2012). Braga and Weisburd’s 2012 meta-analysis revealed that focused deterrence strategies have shown a significant, moderate effect on overall crime reduction.

One example of a focused deterrence intervention was implemented in  Philadelphia . The approach consisted of 1) law enforcement’s directed deterrence message (at “call in” meetings) and follow-through to targeted individuals (“pulling levers”), 2) offers of social services and support, and 3) use of community moral voices to develop and maintain informal social control. Roman and colleagues (2019) found that the strategy resulted in statistically significant reductions in criminal shootings and gang-level shooting violence in treatment areas, compared with the matched comparison areas that did not implement the strategy, at 2 years post implementation. However, individuals under 18 years old were not invited to call-in meetings.

Another example of a focused deterrence-based intervention is Project Safe Neighborhood (PSN). This initiative involves proactive policing, enhanced enforcement, and emphasizes collaboration among numerous stakeholders, such as police, prosecutors, parole officers, community leaders, and academics. The ultimate goal of this approach can vary from place to place, but usually is directed at gang- and gun-related crimes. An evaluation of PSN in  Tampa , FL, by Fox, Allen, and Toth (2021) found that it was related to a statistically significant reduction in violent crime in the treatment group relative to the control group. However, the evaluation found no statistically significant impact on gun crimes. Comparatively, Papachristos, Meares, and Fagan (2007) found that the PSN implemented in  Chicago, IL,  was related to a statistically significant reduction in both gun homicides and in aggravated assaults and batteries in the treatment area, compared with comparison areas. However, there was no statistically significant impact on gang homicides.

One of the more widely known focused deterrence programs is  Operation Ceasefire, which was developed in Boston, MA. It is a problem-solving police strategy that aims to reduce gang violence, illegal gun possession, and gun violence and has been replicated and modified by other communities. Braga and colleagues (Braga et al., 2001; Braga and Pierce, 2005) found statistically significant decreases in youth homicides and gun assaults and recovered new handguns in Operation Ceasefire.

Since its development, Ceasefire has been replicated in cities across the country. For example,  Ceasefire in Oakland, Calif. uses focused-deterrence group violence reduction strategies to reduce or control gun violence. Led by the Oakland Police Department, Oakland Ceasefire includes partnerships with the Mayor’s Office, social service agencies led by the Human Services Department, and community-based leaders and organizations. Braga and colleagues (2019) found that the Oakland Ceasefire group violence-reduction strategies intervention was associated with a statistically significant decline in yearly total shootings in the matched intervention block groups, compared with the matched comparison block groups (note no distinction was made about youth gun crime). Ceasefire also has been implemented in  Detroit, Michigan , where the city uses a data-driven approach to address violent crime by focusing police and community resources on high-risk individuals involved in gun violence and those in their networks. When the targeted individuals are identified, police and community leaders communicate a deterrent message at call-ins and one-on-one meetings as needed and offer an array of services. In an evaluation of the intervention, Circo and colleagues (2020) categorized shooting victims into two age groups: ages 15 to 24 and 25 to 34. However, the study authors found no statistically significant impact on shooting victimizations among individuals ages 15 to 24 and among individuals ages 24 to 34. Though the Detroit Ceasefire call-in meetings resulted in a statistically significant lower likelihood of arrests (for an offense) and arrests for violent offenses for individuals who attended, there were no statistically significant effects on arrests for weapons offenses (though these findings were not broken out by age groups).

Indianapolis Violence Reduction Partnership, a policing program also based on the Ceasefire model, targeted high-risk persons who had repeatedly committed crimes (adults and juveniles) to reduce gun violence in Indianapolis, IN. The initiative’s first pulling-levers notification was held at a male juvenile detention facility and emphasized notifying young, high-risk juveniles of the high likelihood of victimization or incarceration if they were involved in group or gang violence. Further, the initial community outreach component involved going to local middle and high schools to explain the cost of gun violence and to promote legitimate, upcoming summer activities and resources (Corsaro and McGarrell, 2010). The initiative has been found to be related to reduced gun- and non–gun-related homicides across all ages (McGarrell et al., 2006; Corsaro and McGarrell, 2010).

Another focused deterrence intervention that aims to reduce gun violence is  Operation Peacekeeper , based in Stockton, CA, which was designed to reduce gang involvement and violence among youths ages 10 to 18 in an urban area. The program’s pulling-levers approach consisted of an interagency workgroup to link efforts across all the local, county, state, and federal law enforcement agencies; assigning patrol officers to a Gang Street Enforcement Team unit to communicate a credible, clear message about the consequences of gang violence to youths involved in or at risk of becoming involved in gangs; the use of Youth Outreach Workers serving as mentors for youths in neighborhood settings; and other service provisions (Braga, 2008). Evaluation results have found a statistically significant 42 percent decrease in the monthly number of gun homicides in Stockton, compared with pre-intervention trends (however, as with previous studies described above, there was no distinction made about the impact of the program specifically on youth gun crime).

Interventions Using the Public Health Approach

One example of a public health intervention that appears in the criminal justice research literature is a program known as  Cure Violence (Matei et al., 2022). This Chicago–based program employs a public health approach, using trained street violence interrupters and outreach workers, public education campaigns, community mobilization, faith leader (clergy) involvement, and police and prosecutor participation to reduce shootings and killings in the target age group of 16 to 25. The program focuses on changing the behavior and risky activities of a small number of selected members of the community who have a high chance of either being the victim of or perpetrating a shooting (Skogan et al., 2008; Butts et al., 2015). Evaluation results found Cure Violence was associated with statistically significant decreases in shootings, killings, and retaliatory homicides in some (but not all) neighborhoods that implemented the program (Skogan et al., 2008).

Another example is the Safe and Successful Youth Initiative (SSYI) [Massachusetts] , a comprehensive public health approach to serious violence committed by youths that offers a host of services—including case management, outreach, and direct services (for example, subsidized employment, behavioral health)—to young men ages 17 to 24 who are believed to be at “proven risk” for becoming involved in firearm violence. This state-funded, community-based secondary violence prevention program launched in 2011 is now in 13 Massachusetts cities. Petrosino and colleagues (2014) found a statistically significant reduction in monthly city-level violent crime victimization rates for 14- to 24-year-old young men in SSYI treatment cities, compared with the young men in the cities in both comparison groups and over both interruption points. Since the program targets young men at serious risk for becoming involved in firearms violence, homicide and aggravated assault were analyzed separately—as these offenses are the most relevant. Petrosino and colleagues (2014) also found statistically significant reductions in city-level homicide and aggravated assault victimization rates for 14- to 24-year-old young men in SSYI treatment cities, compared with cities in both comparison groups, and over both interruption points.

Hot Spots Policing Interventions

Research has shown that crime tends to be concentrated at microgeographic units such as street segments or clusters of street segments (Weisburd, 2015). In an examination of youth crime in Seattle, WA, Weisburd, Morris, and Groff (2009) found that officially recorded youth crime was strongly concentrated at hot spots. The authors suggested that this implied that efforts to reduce youth crime, including gun crime and violence, could benefit from focused place-based policing efforts (Weisburd, Morris, and Groff, 2009; Gill et al., 2018).  Hot Spots Policing is a place-based practice in which law enforcement agencies expend limited resources in small geographic areas—usually in urban settings, where crime is concentrated and highly predictable (Braga, Papachristos, and Hureau, 2012). Overall, hot spots policing has had mixed evidence. It has been shown to have a statistically significant but small effect on reducing overall crime rates, and on reducing rates of violent, property, public order, and drug offense (Braga et al. 2019); however, the impact on youth gun violence has not been assessed.

Using the youth hot spots identified by Weisburd, Morris, and Groff (2009), Gill and colleagues (2018) implemented a “nonenforcement” approach in these areas, where officers were encouraged to develop interventions focused on increasing supervision and structure for youth; changing environmental features, policies, and rules to facilitate compliance; and/or promoting informal collective efficacy among community stakeholders. The authors did not examine youth gun use or gun crime outcomes and found mixed results on overall youth crime incidents in the youth crime hot spots as a result of the nonenforcement intervention.

One example of a hot spot policing intervention is the  Directed Patrol and Self-Initiated Enforcement in Hot Spots (St. Louis, Missouri) experiment, which examined the impact of hot- spots policing tactics (directed patrol and self-initiated enforcement) on firearm violence. Self-initiated activity was defined as arrest, pedestrian checks, building checks, occupied vehicle checks, unoccupied vehicle checks, foot patrol, and problem solving. Directed patrol involved officers patrolling slowly through the hot spot areas and avoiding self-initiated contact. Rosenfeld and colleagues (2014) found that hot spots treatment areas that received self-initiated enforcement experienced a statistically significant reduction in firearm assault rates, compared with hot spots comparison sites. However, there was no statistically significant difference between the treatment areas that received directed patrol and the comparison sites in firearm assault rates. As with previous studies described above, there was no distinction made about the impact of these programs specifically on youth gun crime.

Gang Reduction Programming

Although these programs are designed to address youth gang violence, as noted earlier in the “Risk Factors for Youth Gun Violence” section, research has shown that delinquent peer associations (such as associating with gang members) are related to perpetrating firearm assault (Goldstick et al., 2019) and that gang membership is one predictor of gun violence (Pardini et al., 2021). Further, evaluations of gang reduction programs have examined youth gun use or violence outcomes. The  Little Village Gang Violence Reduction Project (Comprehensive Gang Model) was a comprehensive, community-wide program designed to reduce serious violence in Chicago’s gang-ridden Little Village neighborhood. The project involved a collaboration of personnel from numerous agencies, including the Chicago Police Department and probation, and four full-time community youth workers who were mainly former gang members from the area. The program focused on implementing the five components of the Comprehensive Gang Model, particularly social intervention, provision of social opportunities, and suppression. Youth subjects were provided with economic and social opportunities for employment and referrals to social interventions, and a suppression component (socialized suppression) was implemented through information gathering, gang member monitoring, and criminal activity arrests. An evaluation by Spergel and colleagues (2003) found that treatment group youths who participated in the Little Village Gang Violence Reduction Project had a greater reduction in serious violent crime arrests (homicide, aggravated battery, aggravated assault, and armed robbery), compared with control group youths, at the program exit. This difference was statistically significant.

The Office of Juvenile Justice and Delinquency Prevention (OJJDP)–funded Gang Reduction Program was a targeted multiyear (2003–08) initiative to reduce crime and violence associated with youth street gangs in a select group of cities throughout the United States. The initiative integrated the Comprehensive Gang Model (also known as the Spergel Model of gang interventions), parts of Project Safe Neighborhoods, and other OJJDP–funded programs to form a comprehensive approach to gang reduction. The  Gang Reduction Program (Los Angeles, California) provided alternative programs for at-risk youths and families; provided social, educational, and behavioral interventions; and implemented programs to reduce gang crime in the target area. Each of the services provided through the initiative fell under prevention, intervention/reentry, or suppression categories. Cahill and colleagues (2008) analyzed the preliminary impact of the program on gang-related crime in Los Angeles and found that calls for shots fired in the Gang Reduction Program target area decreased, compared with the comparison area. The target area reported a reduction of 8.23 calls per month, compared with a reduction of 1.78 per month in the comparison area. This difference was statistically significant.

Overall, there are a variety of interrelated programs and practices that appear to reduce violence and gun violence. There are some limitations to the research, such as the issue of generalizability of the findings to other cities or communities (Matei et al., 2022; Schaefer, Hughes, and Stelzig, 2019) or the inability to rule out the influence of competing and alternative programming or other factors on the crime rate outside of the program being evaluated (Roman et al., 2019; Circo et al., 2020). In addition, only a limited number of programs and practices have examined the specific impact on youth gun violence.

The data available on the incidents of gun violence in the United States show how greatly youths are affected. Available data can describe how many youths are involved in gun violence every year (either perpetrating, witnessing, or being a victim of gun violence). However, the numbers cannot explain why youth gun violence is so prevalent. One issue is the lack of research focused exclusively on the causes, correlates, and consequences specifically of youth gun violence. For instance, although research has examined the risk and protective factors related to youth violence in general, gun violence is usually not specifically focused on, but rather grouped together with other forms of violence, such as school or community violence. Some information is known about the risk factors related to youth gun violence perpetration (for example, the exposure to violence and the access to and availability of firearms are strong predictors of the occurrence of violence). Nevertheless, a great deal about the complexity of youth gun violence still is not known. Specific and well-defined research examining the prevalence and predictors of youth gun violence would help inform future policies and programs designed to reduce gun violence perpetration involving youth.

Some laws and policies that have been enacted at the federal and state levels are intended to reduce youths’ access to guns. But while these laws restrict gun access to those under certain age thresholds (18 in some cases, 21 in others), with few exceptions the laws do not otherwise directly target youth behavior. As more information is gathered and analyzed, more informed policies can be developed to effectively address the issue of youth gun violence. 

Moreover, many specific programs, using different approaches such as public health approaches and hot-spots policing, have been developed to target various forms of community-based violence, including youth gun violence. Several of these programs have been shown to reduce measures of violence; however, few programs have been evaluated to determine the particular impact of specifically youth-centered gun violence. One program that evaluated youth outcomes was Operation Ceasefire in Boston, which was found to statistically significantly decrease youth homicides and gun assaults. Even so, further research is needed in this area.  

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About this Literature Review

Suggested Reference: Development Services Group, Inc. 2023. “Gun Violence and Youth.” Literature Review. Washington, D.C.: U.S. Department of Justice, Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention. https://ojjdp.ojp.gov/model-programs-guide/literature-reviews/gun-violence-and-youth-young-adults

Prepared by Development Services Group, Inc., under Contract Number: 47QRAA20D002V.

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A systematic review of the causes and prevention strategies in reducing gun violence in the United States

Affiliations.

• 1 Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA.
• 2 Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA; University of South Florida, Tampa, FL, USA.
• 3 Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, FL, USA. Electronic address: [email protected].
• PMID: 33071102
• DOI: 10.1016/j.ajem.2020.06.062

Background: Approximately 100 lives are lost each day as a result of gun violence in the United States (US) with civilian mass shootings increasing annually. The gun violence rate in the US is almost 20 times higher than other comparable developed countries and has the most gun ownership per capita of any nation in the world. Understanding the causes and risk factors are paramount in understanding gun violence and reducing its incidence.

Methods: A literature search of all published articles relating to gun violence and mass shootings in the US was conducted using the Medline and PMC databases. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were used in conducting this study. Rayyan statistical software was utilized for analysis. Statistical significant was defined as p < .05.

Results: Of the initial 2304 eligible manuscripts identified, 22 fulfilled our selection criteria. A variety of common causal and contributory factors were identified including but not limited to mental illness, suicidal ideation, intimate partner violence, socioeconomic status, community distress, family life, childhood trauma, current or previous substance abuse, and firearm access.

Conclusion: Gun violence is pervasive and multi-factorial. Interventions aimed at reducing gun violence should be targeted towards the most common risk factors cited in the literature such as access, violent behavioral tendencies due to past exposure or substance abuse, and mental illness including suicidal ideation.

Keywords: Gun violence; Gun violence research funding; Mental illness; Policies; Socio-economic factors.

Copyright © 2020 Elsevier Inc. All rights reserved.

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Conflict of interest statement

Declaration of Competing Interest None.

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Gun Violence: Prediction, Prevention, and Policy

• Gun Violence and Crime

Gun violence is an urgent, complex, and multifaceted problem. It requires evidence-based, multifaceted solutions. Psychology can make important contributions to policies that prevent gun violence. Toward this end, in February 2013 the American Psychological Association commissioned this report by a panel of experts to convey research-based conclusions and recommendations (and to identify gaps in such knowledge) on how to reduce the incidence of gun violence — whether by homicide, suicide, or mass shootings — nationwide.

Following are chapter-by-chapter highlights and short summaries of conclusions and recommendations of the report’s authors. More information and supporting citations can be found within the chapters themselves.

Antecedents to Gun Violence: Developmental Issues

A complex and variable constellation of risk and protective factors makes persons more or less likely to use a firearm against themselves or others. For this reason, there is no single profile that can reliably predict who will use a gun in a violent act. Instead, gun violence is associated with a confluence of individual, family, school, peer, community, and sociocultural risk factors that interact over time during childhood and adolescence. Although many youths desist in aggressive and antisocial behavior during late adolescence, others are disproportionately at risk for becoming involved in or otherwise affected by gun violence. The most consistent and powerful predictor of future violence is a history of violent behavior.  P revention efforts guided by research on developmental risk can reduce the likelihood that firearms will be introduced into community and family conflicts or criminal activity.  Prevention efforts can also reduce the relatively rare occasions when severe mental illness contributes to homicide or the more common circumstances when depression or other mental illness contributes to suicide. Reducing incidents of gun violence arising from criminal misconduct or suicide is an important goal of broader primary and secondary prevention and intervention strategies. Such strategies must also attend to redirecting developmental antecedents and larger sociocultural processes that contribute to gun violence and gun-related deaths.

Antecedents to Gun Violence: Gender and Culture

Any account of gun violence in the United States must be able to explain both why males are perpetrators of the vast majority of gun violence and why the vast majority of males never perpetrate gun violence. Preliminary evidence suggests that changing perceptions among males of social norms about behaviors and characteristics associated with masculinity may reduce the prevalence of intimate partner and sexual violence. Such interventions need to be further tested for their potential to reduce gun violence. The skills and knowledge of psychologists are needed to develop and evaluate programs and settings in schools, workplaces, prisons, neighborhoods, clinics, and other relevant contexts that aim to change gendered expectations for males that emphasize self-sufficiency, toughness, and violence, including gun violence.

What Works: Gun Violence Prediction and Prevention at the Individual Level

Although it is important to recognize that most people suffering from a mental illness are not dangerous, for those persons at risk for violence due to mental illness, suicidal thoughts, or feelings of desperation, mental health treatment can often prevent gun violence. Policies and programs that identify and provide treatment for all persons suffering from a mental illness should be a national priority. Urgent attention must be paid to the current level of access to mental health services in the United States; such access is woefully insufficient. Additionally, it should be noted that behavioral threat assessment is becoming a standard of care for preventing violence in schools, colleges, and the workplace and against government and other public officials. Threat assessment teams gather and analyze information to assess if a person poses a threat of violence or self-harm, and if so, take steps to intervene.

What Works: Gun Violence Prevention at the Community Level

Prevention of violence occurs along a continuum that begins in early childhood with programs to help parents raise emotionally healthy children and ends with efforts to identify and intervene with troubled individuals who are threatening violence. The mental health community must take the lead in advocating for community-based collaborative problem-solving models to address the prevention of gun violence. Such models should blend prevention strategies in an effort to overcome the tendency within many community service systems to operate in silos. There has been some success with community-based programs involving police training in crisis intervention and with community members trained in mental health first aid. These programs need further piloting and study so they can be expanded to additional communities as appropriate. In addition, public health messaging campaigns on safe gun storage are needed. The practice of keeping all firearms appropriately stored and locked must become the only socially acceptable norm.

What Works: Policies to Reduce Gun Violence

The use of a gun greatly increases the odds that violence will lead to a fatality: This problem calls for urgent action. Firearm prohibitions for high-risk groups — domestic violence offenders, persons convicted of violent misdemeanor crimes, and individuals with mental illness who have been adjudicated as being a threat to themselves or to others — have been shown to reduce violence. The licensing of handgun purchasers, background check requirements for all gun sales, and close oversight of retail gun sellers can reduce the diversion of guns to criminals. Reducing the incidence of gun violence will require interventions through multiple systems, including legal, public health, public safety, community, and health. Increasing the availability of data and funding will help inform and evaluate policies designed to reduce gun violence.

Dewey Cornell, PhD, and Nancy G. Guerra, EdD

Gun violence is an important national problem leading to more than 31,000 deaths and 78,000 nonfatal injuries every year. Although the rate of gun homicides in the United States has declined in recent years, U.S. rates remain substantially higher than those of almost every other nation in the world and are at least seven times higher than those of Australia, Canada, France, Germany, India, Italy, Japan, South Korea, Spain, Sweden, the United Kingdom, and many others (see Alpers & Wilson).

Guns are not a necessary or sufficient cause of violence and can be used legally for a variety of sanctioned activities. Still, they are especially lethal weapons that are used in approximately two thirds of the homicides and more than half of all suicides in the United States. Every day in the United States, approximately 30 persons die of homicides and 53 persons die of suicides committed by someone using a gun (Centers for Disease Control and Prevention [CDC], 2013a). Guns also provide individuals with the capacity to carry out multiple-fatality shootings that inflict great trauma and grief on our society, and the public rightly insists on action to make our communities safer.

Gun violence demands special attention. At the federal level, President Barack Obama announced a new “Now Is the Time” plan (White House, 2013) to address firearm violence to better protect children and communities and issued 23 related executive orders to federal agencies. The importance of continued research to address firearm violence is reflected in the 2013 report of the Institute of Medicine (IOM) and the National Research Council (NRC) "Priorities for Research to Reduce the Threat of Firearm-Related Violence. "  This report calls for a public health approach that emphasizes the importance of accurate information on the number and distribution of guns in the United States, including risk factors and motivations for acquisition and use, the association between exposure to media violence and any subsequent perpetration of gun violence, and how new technology can facilitate prevention. The report also outlines a research agenda to facilitate programs and policies that can reduce the occurrence and impact of firearm-related violence in the United States.

Psychology can make an important contribution to policies that prevent gun violence. Rather than debate whether “people” kill people or “guns” kill people, a reasonable approach to facilitate prevention is that “people with guns kill people.” The problem is more complex than simple slogans and requires careful study and analysis of the different psychological factors, behavioral pathways, social circumstances, and cultural factors that lead to gun violence. Whether prevention efforts should focus on guns because they are such a powerful tool for violence, on other factors that might have equal or greater impact, or on some combination of factors should be a scientific question settled by evidence.

Toward this end, the American Psychological Association (APA) commissioned this report, with three goals. First, this report is intended to focus on gun violence, recognizing that knowledge about gun violence must be related to a broader understanding of violence. Second, the report reviews what is known from the best current science on antecedents to gun violence and effective prevention strategies at the individual, community, and national levels. Finally, the report identifies policy directions, gaps in the literature, and suggestions for continued research that can help address unresolved questions about effective strategies to reduce gun violence. For over a decade, research on gun violence has been stifled by legal restrictions, political pressure applied to agencies not to fund research on certain gun-related topics, and a lack of funding. The authors of this report believe the cost of gun violence to our society is too great to allow these barriers to remain in place.

The Role of Mental Health and Mental Illness

An important focus of this report is the role that mental health and mental illness play in why individuals commit firearm-related violence and how this can inform preventive efforts. This focus undoubtedly brings to mind shootings such as those in Newtown, Conn., Aurora, Colo., and Tucson, Ariz. However, it is important to realize that mass fatality incidents of this type, although highly publicized, are extremely rare, accounting for one tenth of 1 percent of all firearm-related homicides in the United States (CDC, 2013a). Moreover, serious mental illness affects a significant percentage of the U.S. population, with prevalence estimates in the general population as high as 5 percent (Substance Abuse and Mental Health Services Administration [SAMHSA], 2012). This is quite significant, given that the term serious mental illness is typically reserved for the most debilitating kinds of mental disorder, such as schizophrenia, bipolar disorder, and the most severe forms of depression, but can include other mental disorders that result in acute functional impairment.

Although many highly publicized shootings have involved persons with serious mental illness, it must be recognized that persons with serious mental illness commit only a small proportion of firearm-related homicides; the problem of gun violence cannot be resolved simply through efforts focused on serious mental illness (Webster & Vernick, 2013a). Furthermore, the overwhelming majority of people with serious mental illness do not engage in violence toward others and should not be stereotyped as dangerous (Sirotich, 2008).

It also is important to recognize that for the small proportion of individuals whose serious mental illness does predispose them to violence, there are significant societal barriers to treatment. Psychiatric hospitalization can be helpful, but treatment can be expensive, and there may not be appropriate follow-up services in the community. Civil commitment laws, which serve to protect individuals from being unreasonably detained or forced into treatment against their will, can also prevent professionals from treating someone who does not recognize his or her need for treatment.

Other kinds of mental disorders that do not rise to the level of serious mental illness also are associated with gun violence and criminal behavior generally. For example, conduct disorder and antisocial personality disorder are associated with increased risk for violence. (This link is not surprising because violent behavior is counted as one of the symptoms that helps qualify someone for the diagnosis.) Nevertheless, there are well-established, scientifically validated mental health treatment programs for individuals with these disorders, such as multisystemic therapy, that can reduce violent recidivism (Henggeler, 2011). Substance abuse is another form of mental disorder that is a risk factor for violence in the general population and also increases the risk for violence among persons with serious mental illness (Van Dorn, Volavka, & Johnson, 2012).

These observations reflect the complexity of relationships among serious mental illness, mental disorders, and violence. In contrast to homicide, suicide accounts for approximately 61 percent of all firearm fatalities in the United States (CDC, 2013a), and more than 90 percent of persons who commit suicide have some combination of depression, symptoms of other mental disorders, and/or substance abuse (Moscicki, 2001). This suggests that mental health and mental illness are especially relevant to understanding and preventing suicide, the leading type of firearm-related death.

Prediction and Prevention

The prediction of an individual’s propensity for violence is a complex and challenging task for mental health professionals, who often are called upon by courts, correctional authorities, schools, and others to assess the risk of an individual’s violence. Mental health professionals are expected to take action to protect potential victims when they judge that their patient or client poses a danger to others. However, decades of research have established that there is only a moderate ability to identify individuals likely to commit serious acts of violence. Much depends on the kind of violence and the time frame for prediction. For example, there are specialized instruments for the assessment of violence risk among sex offenders, civilly committed psychiatric patients, and domestic violence offenders. However, the time frame and focus for these predictions often are broadly concerned with long-term predictions that someone will ever be violent with anyone rather than whether a person will commit a particular act of targeted violence.

Research has moved the field beyond the assessment of “dangerousness” as a simple individual characteristic applicable in all cases to recognize that predictive efforts must consider a range of personal, social, and situational factors that can lead to different forms of violent behavior in different circumstances. Moreover, risk assessment has expanded to include concepts of risk management and interventions aimed at reducing risk.

In making predictions about the risk for mass shootings, there is no consistent psychological profile or set of warning signs that can be used reliably to identify such individuals in the general population. A more promising approach is the strategy of behavioral threat assessment , which is concerned with identifying and intervening with individuals who have communicated threats of violence or engaged in behavior that clearly indicates planning or preparation to commit a violent act. A threat assessment approach recognizes that individuals who threaten targeted violence are usually troubled, depressed, and despondent over their circumstances in life. A threat assessment leads to interventions intended to reduce the risk of violence by taking steps to address the problem that underlies the threatening behavior. Such problems can range from workplace conflicts to schoolyard bullying to serious mental illness. One of the most influential threat assessment models was developed by the U.S. Secret Service (Fein et al., 2002; Vossekuil, Fein, Reddy, Borum, & Modzelski, 2002) and has been adapted for use in schools, colleges, business settings, and the U.S. military.

The limited ability to make accurate predictions of violence has led some to question whether prevention is possible. This is a common misconception, because prevention does not require prediction of a specific individual’s behavior . For example, public health campaigns have reduced problems ranging from lung cancer to motor vehicle accidents by identifying risk factors and promoting safer behaviors even though it is not possible to predict whether a specific individual will develop lung cancer or have a motor vehicle accident (Mozaffarian, Hemenway, & Ludwig, 2013). A substantial body of scientific evidence identifies important developmental, familial, and social risk factors for violence. In addition, an array of rigorously tested psychological and educational interventions facilitate healthy social development and reduce aggressive behavior by teaching social skills and problem-solving strategies. It is important that policymakers and stakeholders recognize the value of prevention.

Prevention measures also should be distinguished from security measures and crisis response plans. Prevention must begin long before a gunman comes into a school or shopping center. Prevention efforts are often conceptualized as taking place on primary, secondary, and tertiary levels:

• Primary prevention (also called universal prevention) consists of efforts to promote healthy development in the general population. An example would be a curriculum to teach all children social skills to resist negative peer influences and resolve conflicts peacefully.
• Secondary prevention (also called selective prevention) involves assistance for individuals who are at increased risk for violence. Mentoring programs and conflict-mediation services are examples of such assistance.
• Tertiary prevention (also called indicated prevention) consists of intensive services for individuals who have engaged in some degree of aggressive behavior and could benefit from efforts to prevent a recurrence or escalation of aggression. Programs to rehabilitate juvenile offenders are examples.

Throughout this report, we discuss evidence-based prevention programs relevant to the issue of firearm-related violence.

Research can help us understand and prevent gun violence. The psychological research summarized in this report can inform public policy and prevention efforts designed to promote public safety and reduce violence. Gun violence is not a simple, discrete category of crime; it shares characteristics with other forms of violence, and it can be a product of an array of cultural, social, psychological, and situational factors. Nevertheless, there is valuable psychological knowledge that can be used to make our communities safer.

Robert Kinscherff, PhD, JD; Nancy G. Guerra, EdD; and Ariel A. Williamson, MA

Youth gun violence is often sensationalized and misunderstood by the general public, in part because of increasingly public acts of violence and related media coverage (Snyder & Sickmund, 2006; Williams, Tuthill, & Lio, 2008). In truth, only a small number of juvenile offenders commit the majority of violent juvenile crimes in the United States (Williams et al., 2008). Most juvenile offenders commit “nonperson” offenses, usually in terms of property and technical (parole) violations (Sickmund, Sladky, Kang, & Puzzanchera, 2011). For example, in 2010, the majority of juvenile offenses were nonperson offenses such as property offenses (27.2 percent), drug offenses (8.4 percent), public order offenses (10.7 percent), technical violations (14.4 percent), and status offenses (4.6 percent) — that is, crimes defined by minor (under age 18) status, such as alcohol consumption, truancy, and running away from home (Sickmund et al., 2011). Additionally, young adults between the ages of 18 and 34 are the most likely to commit violent crimes like homicide and to do so using a gun, compared with individuals under 18 (Cooper & Smith, 2011).

A subgroup of youth is particularly vulnerable to violence and victimization. Minority males constitute a disproportionate number of youths arrested and adjudicated, with 60 percent of all arrested youths identifying as part of a racial/ethnic minority group (Sickmund et al., 2011). Males also outnumber females in arrest rates for every area except status offenses and technical violations. Urban African American males are at substantially greater risk for involvement in gun-related homicides as perpetrators and as victims (CDC, 2013a; Spano, Pridemore, & Bolland, 2012). However, the majority of the infrequent but highly publicized shootings with multiple fatalities, such as those at Sandy Hook Elementary School or the Aurora, Colo., movie theater, have been committed by young White males.

This presents a picture of a small number of youths and young adults who are at an increased risk for involvement in gun violence. In the United States, these youths are somewhat more likely to be males of color growing up in urban areas. But it also is important to understand that most young males of all races and ethnicities — and most people in general — are not involved in serious violence and do not carry or use guns inappropriately.

How did this small subset of youths and young adults come to be involved in serious gun violence? Is there a “cradle-to-prison” pipeline, particularly for youths of color living in poverty and in disadvantaged urban areas, that triggers a cascade of events that increase the likelihood of gun violence (Children’s Defense Fund, 2009)? A developmental perspective on antecedents to youth gun violence can help us design more effective prevention programs and strategies.

This chapter describes the biological and environmental risk factors that begin early in development and continue into adolescence and young adulthood. Developmental studies that link children’s aggressive behavior to more serious involvement in the criminal justice system suggest the accumulation and interaction of many risks in multiple contexts (Dodge, Greenberg, Malone, & Conduct Problems Prevention Research Group, 2008; Dodge & Pettit, 2003). There is no single biological predisposition, individual trait, or life experience that accounts for the development and continuity of violent behavior or the use of guns. Rather, violence is associated with a confluence of individual, family, school, peer, community, and sociocultural risk factors that interact over time during childhood and adolescence (Brennan, Hall, Bor, Najman, & Williams, 2003; Dodge & Pettit, 2003). Risk for gun violence involves similar risk processes, although the complexity and variability of individuals means there is no meaningful profile that allows reliable prediction of who will eventually engage in gun violence. Nevertheless, developmental factors beginning in utero may increase the risk of aggressive behavior and lead to gun violence — especially when guns are readily available and part of an aggressive or delinquent peer culture.

Early-Onset Aggression

Early onset of aggressive behavior significantly increases risk for later antisocial behavior problems. The most consistent and powerful predictor of future violence is a history of violent behavior, and risk increases with earlier and more frequent incidents. Longitudinal work has shown that having a first arrest between 7 and 11 years of age is associated with patterns of long-term adult offending (Loeber, 1982). Children who are highly aggressive throughout childhood and continue to have serious conduct problems during adolescence have been identified as “life-course persistent” (LCP) youths (Moffitt, 1993). Examining longitudinal data from a large birth cohort in New Zealand, Moffitt (1993) created a taxonomy of antisocial behavior that differentiates LCP youths from an “adolescence-limited” subgroup. The latter subgroup characterizes those who engage in antisocial behaviors during adolescence and usually desist by adulthood. By contrast, LCP youths display more severe early aggression in childhood and develop a pattern of chronic violence during adolescence and into adulthood.

Both biological and environmental risks during prenatal development, infancy, and early childhood contribute to the development of early-onset aggression and the LCP developmental trajectory (Brennan et al., 2003; Dodge & Pettit, 2003; Moffitt, 2005). Pre- and postnatal risks associated with early-onset aggression include maternal substance abuse during pregnancy, high levels of prenatal stress, low birth weight, birth complications and injuries (especially those involving anoxia), malnutrition, and exposure to environmental toxins like lead paint (Brennan et al., 2003; Dodge & Pettit, 2003). According to Moffitt (1993), these early developmental risks disrupt neural development and are associated with neuropsychological deficits, particularly in executive functioning and verbal abilities.

Along with neuropsychological deficits, poor behavioral control and a difficult temperament are associated with the development of early-onset aggression (Dodge & Pettit, 2003; Moffitt, 1993). Children with difficult temperaments are typically irritable, difficult to soothe, and highly reactive. These patterns of behavior often trigger negative and ineffective reactions from parents and caregivers that can escalate into early aggressive behavior (Dodge & Pettit, 2003; Wachs, 2006). Family influences, such as familial stress and negative parent–child interactions, can interact with a child’s individual characteristics, leading to increased aggressive behavior during childhood.

Family Influences

Highly aggressive children who engage in serious acts of violence during later childhood and adolescence also are exposed to continued environmental risks throughout development (Dodge et al., 2008). The family context has been found to be quite influential in the development and continuity of antisocial behavior. Particularly for early-onset aggressive youths raised in families that are under a high degree of environmental stress, aggressive child behavior and negative parenting practices interact to amplify early-onset aggression. Examples of family risk factors include low parent–child synchrony and warmth, poor or disrupted attachment, harsh or inconsistent discipline (overly strict or permissive), poor parental monitoring, the modeling of antisocial behavior, pro-violent attitudes and criminal justice involvement, and coercive parent–child interaction patterns (Dodge & Pettit, 2003; Farrington, Jolliffe, Loeber, Stouthamer-Loeber, & Kalb, 2001; Hill, Howel, Hawkins, & Battin-Pearson, 1999; Patterson, Forgatch, & DeGarmo, 2010).

Coercive parent–child interactions have been associated with the emergence of aggressive behavior problems in children (Patterson et al., 2010). In these interactions, children learn to use coercive behaviors such as temper tantrums to escape parental discipline. When parents acquiesce to these negative behaviors, they inadvertently reward children for coercive behaviors, reinforcing the idea that aggression or violence is adaptive and can be used instrumentally to achieve goals. These interaction patterns tend to escalate in their severity (e.g., from whining, to temper tantrums, to hitting, etc.) and frequency, leading to increased aggression and noncompliance (Patterson et al., 2010). Such behaviors also generalize across contexts to children’s interactions with others outside the home, including with teachers, other adults, and peers. Indeed, prevention research has shown that intervening with at-risk families to improve parenting skills can disrupt the pathway from early-onset aggressive behavior to delinquency in adolescence (Patterson et al., 2010).

Other family risk factors for youths with early predispositions to aggression may be especially relevant to increased risk for gun violence. For instance, research has shown that many families with children own firearms and do not keep them safely stored at home (Johnson, Miller, Vriniotis, Azrael, & Hemenway, 2006). Although keeping firearms at home is not a direct cause of youth gun violence, the rates of suicides, homicides, and unintentional firearm fatalities are higher for 5–14-year-olds who live in states or regions in which rates of gun ownership are more prevalent (Miller, Azrael, & Hemenway, 2002). Poor parental monitoring and supervision, which are more general risk factors for involvement in aggression and violent behaviors (Dodge et al., 2008), may be especially salient in risk for gun violence. For example, impulsive or aggressive children who are often unsupervised and live in a home with access to guns may be at risk.

The family also is an important context for socialization and the development of normative beliefs or perceptions about appropriate social behavior that become increasingly stable during early development and are predictive of later behavior over time (Huesmann & Guerra, 1997). These beliefs shape an individual’s social-cognitive understanding about whether and under what circumstances threatened or actual violence is justified. Children who develop beliefs that aggression is a desirable and effective way to interact with others are more likely to use coercion and violence instrumentally to achieve goals or solve problems (Huesmann & Guerra, 1997). Antisocial attitudes and social-cognitive distortions (e.g., problems in generating nonviolent solutions, misperceiving hostile/aggressive intent by others, justifying acts of violence that would be criminal) can also increase risk for violence (Borum & Verhaagen, 2006; Dodge & Pettit, 2003).

Families can play a role in establishing and maintaining normative beliefs about violence and gun usage. For example, pro-violence attitudes and the criminality of parents and siblings during childhood have been found to predict adolescent gang membership and delinquency (Farrington et al., 2001; Hill et al., 1999). Youths from families that encourage the use of guns for solving problems also may be exposed to such attitudes in other contexts (in communities, with peers, and in the media) and may perceive firearms to be an appropriate means to solve problems and protect themselves.

School and Peer Influences

The school setting is another important context for child socialization. Children who enter school with high levels of aggressive behavior, cognitive or neurobiological deficits, and poor emotional regulation may have difficulty adjusting to the school setting and getting along with peers (Dodge et al., 2008; Dodge & Pettit, 2003). Highly aggressive children who have learned to use aggression instrumentally at home will likely use such behavior with teachers, increasing the chances that they will have poor academic experiences and low school engagement (Patterson et al., 2010). Academic failure, low school interest, truancy, and school dropout are all correlated with increased risk for problem behavior and delinquency, including aggression and violence (Dodge & Pettit, 2003). This risk is strongest when poor academic achievement begins in elementary school and contributes to school underachievement and the onset of adolescent problem behaviors, such as substance use and drug trafficking, truancy, unsafe sexual activity, youth violence, and gang involvement (Dodge et al., 2008; Guerra & Bradshaw, 2008).

Involvement in these risk behaviors also is facilitated by affiliation with deviant peers, particularly during adolescence (Dodge et al., 2008). Research has shown that children who are aggressive, victimized, and academically marginalized from the school setting may suffer high levels of peer rejection that amplify preexisting aggressive behaviors (Dodge et al., 2008; Dodge & Pettit, 2003). Longitudinal work indicates that experiences of academic failure, school marginalization, and peer rejection interact to produce affiliations with similarly rejected, deviant, and/or gang-involved peers. Friendships between deviant peers provide youths with “training” in antisocial behaviors that reinforce and exacerbate preexisting aggressive tendencies (Dishion, Véronneau, & Meyers, 2010; Dodge et al., 2008). Peer deviancy training is a primary mechanism in the trajectory from overt, highly aggressive behaviors during childhood to more covert processes during adolescence, such as lying, stealing, substance use, and weapon carrying (Dishion et al., 2010; Patterson et al., 2010).

The larger school context also can interact with youths’ experiences of academic failure, peer rejection, and deviant peer affiliations to influence the continuity of antisocial behavior. Poorly funded schools located in low-income neighborhoods have fewer resources to address the behavioral, academic, mental health, and medical needs of their students. In addition, these schools tend to have stricter policies toward discipline, are less clinically informed about problem behaviors, and have stronger zero tolerance policies that result in more expulsions and suspensions (Edelman, 2007). This contextual factor is important, as youths who are attending and engaged in school are less likely to engage in delinquent or violent behavior, whereas marginalized and rejected youths, particularly in impoverished schools, are at increased risk for aggression and violence at school and in their communities. Schools that provide safe environments that protect students from bullying or criminal victimization support student engagement, reduce incidents of student conflict that could result in volatile or violent behavior, and diminish risks that students will bring weapons to school.

Although few homicides (< 2 percent) and suicides occur at school or during transportation to and from school (Roberts, Zhang, & Truman, 2012) and widely publicized mass school shootings are rare, research indicates that a small number of students do carry guns or other weapons. In 2011, 5.1 percent of high school students in Grades 9–12 reported carrying a gun in the 30 days prior to the survey, and 5.4 percent of students had carried a weapon (gun, knife, or club) on school grounds at least once in the 30 days prior to the survey (Eaton et al., 2012). Studies show that youths who carry guns are more likely to report involvement in multiple problem behaviors, to be affiliated with a gang, to overestimate how many of their peers carry guns, and to have a high need for interpersonal safety. For instance, student reports of involvement in and exposure to risk behaviors at school such as physical fighting, being threatened, using substances, or selling drugs on school grounds have been positively correlated with an increased likelihood of carrying weapons to school (Furlong, Bates, & Smith, 2001).

In another study of high school students, 5.5 percent of urban high school students reported that they carried a gun in the year prior to the study, but students estimated that 32.6 percent of peers in their neighborhoods carried guns, a substantial overestimation of the actual gun-carrying rates. Lawful, supervised gun carrying by juveniles is not the concern of this line of research; however, when unsupervised youths carry guns in high-violence neighborhoods, they may be more likely to use guns to protect themselves and resolve altercations. Gun-carrying youths in this study had higher rates of substance use, violence exposure, gang affiliation, and peer victimization (Hemenway, Vriniotis, Johnson, Miller, & Azrael, 2011). Additionally, many gun-carrying youths had lower levels of perceived interpersonal safety (Hemenway et al., 2011). Research has also revealed that deviant peer group affiliations during specific periods of adolescent development may increase the risk for gun violence. For example, research findings have shown that gang membership in early adolescence is significantly associated with increased gun carrying over time. This changes somewhat in late adolescence and young adulthood, when gun carrying is linked more to involvement in drug dealing and having peers who illegally own guns (Lizotte, Krohn, Howell, Tobin, & Howard, 2000).

Communities Matter

The community context is an additional source of risk for the development and continuity of antisocial behavior. Living in extremely disadvantaged, underresourced communities with high levels of crime and violence creates serious obstacles to healthy development. Recent estimates show that currently in the United States, 16.4 million children live in poverty and 7.4 million of those live in extreme poverty (i.e., an annual income of less than half of the federal poverty level; Children’s Defense Fund, 2012). One in four children under 5 years of age is poor during the formative years of brain development. In addition, 22 percent of children who have lived in poverty do not graduate from high school, compared with 6 percent of children who have never been poor (Children’s Defense Fund, 2012). For families and youths, living in poverty is associated with high levels of familial stress, poor child nutrition, elevated risks of injury, and limited access to adequate health care (Adler & Steward, 2010; Patterson et al., 2010). Ethnic minority youth in the United States are overrepresented in economically struggling communities. These environmental adversities can, in turn, compromise children’s health status and functioning in other environments and increase the risk for involvement in violent behaviors, contributing significantly to ethnic and cultural variations in the rates of violence (Borum & Verhaagen, 2006).

In a community context, the degree to which children have access to adequate positive resources (e.g., in terms of health, finances, nutrition, education, peers, and recreation), have prosocial and connected relationships with others, and feel safe in their environment can significantly affect their risk for involvement in violent behaviors. Aggressive children and adolescents who are living in neighborhoods with high levels of community violence, drug and firearm trafficking, gang presence, and inadequate housing may have increased exposure to violence and opportunities for involvement in deviant behavior. Compared with communities that have better resources, disenfranchised and impoverished communities may also lack social, recreational, and vocational opportunities that contribute to positive youth development. Youths with high levels of preexisting aggressive behavior and emerging involvement with deviant or gang-involved peers may be especially at risk for increased violent behavior and subsequent criminal justice involvement when exposed to impoverished and high-crime communities.

Exposure to violence in one’s community, a low sense of community safety, unsupervised access to guns, and involvement in risky community behaviors such as drug dealing all contribute to youths’ involvement in gun carrying and gun violence. Decreased community perceptions of neighborhood safety and higher levels of social (e.g., loitering, public substance use, street fighting, prostitution, etc.) and physical (e.g., graffiti, gang signs, and discarded needles, cigarettes, and beer bottles) neighborhood disorder have been associated with increased firearm carrying among youths (Molnar, Miller, Azrael, & Buka, 2004). A study of African American youths living in poverty found that those who had been exposed to violence prior to carrying a gun were 2.5 times more likely than nonexposed youths to begin carrying a gun at the next time point, even when controlling for gang involvement (Spano et al., 2012). This study also indicated that after exposure to violence, youths were more likely to start carrying guns in their communities (Spano et al., 2012).

Studies have shown that apart from characteristics like conduct problems and prior delinquency, youths who are involved in gang fighting and selling drugs are also more likely to use a gun to threaten or harm others (e.g., Butters, Sheptycki, Brochu, & Erikson, 2011). Involvement in drug dealing in one’s community appears to be particularly risky for gun carrying during later adolescence and early adulthood, possibly due to an increased need for self-protection (Lizotte et al., 2000). Taken together, these studies show that firearm possession may be due to interactions between the need for self-protection in violent communities and increased involvement in delinquent behaviors.

Sociocultural Context: Exposure to Violent Media

Child and adolescent exposure to violent media, a more distal, sociocultural influence on behavior, is also important when considering developmental risks for gun violence. Decades of experimental, cross-sectional, and longitudinal research have documented that exposure to violent media, in movies and television, is associated with increased aggressive behaviors, aggressive thoughts and feelings, increased physiological arousal, and decreased prosocial behaviors (e.g., Anderson et al., 2003; Anderson & Bushman, 2001; Huesmann, 2010; Huesmann, Moise-Titus, Podolski, & Eron, 2003). In light of ongoing advances in technology, research has been expanded to include violent content in video games, music, social media, and the Internet (Anderson et al., 2010; IOM & NRC, 2013).

Findings on associations between violent media exposure and aggressive behavior outcomes have held across differences in culture, gender, age, socioeconomic status, and intellect (e.g., Anderson et al., 2010; Huesmann et al., 2003). Social-cognitive theory on violent media exposure suggests that these images are part of children’s socialization experiences, similar to violence exposure in interpersonal and community contexts (Huesmann, 2010). The viewing of violent images can serve to desensitize children to violence and normalize violent behavior, particularly when children have previously developed beliefs that aggression and violence are an acceptable means of achieving goals or resolving conflicts.

It is important to note that the link between violent media exposure and subsequent violent behaviors does not demonstrate a direct causal effect but instead shows how some children may be more susceptible to this risk factor than others. For instance, Huesmann et al. (2003) found that identification with aggressive characters on television and the perception that television violence was real were robust predictors of later aggression over time. Additionally, there is no established link between violent media exposure and firearm usage in particular. However, given the substantial proportion of media that includes interactions around firearms (e.g., in video games, movies, and television shows), the IOM and NRC (2013) recently identified a crucial need to examine specific associations between exposure to violent media and use of firearms. Exposure to violent media, especially for youths with preexisting aggressive tendencies and poor parental monitoring, may be an important contextual factor that amplifies risk for violent behavior and gun use.

Summary and Conclusions

The relatively small number of youths most likely to persist in serious acts of aggression (including increased risk of gun violence) have often experienced the following:

• Early childhood onset of persistent rule-breaking and aggression
• Socialization into criminal attitudes and behaviors by parents and caretakers who themselves are involved in criminal activities
• Exposure in childhood to multiple adverse experiences in their families and communities
• Social dislocation and reduced opportunities due to school failure or underachievement
• Persisting affiliation with deviant peers or gangs engaged in delinquent/criminal misconduct and with attitudes and beliefs that support possession and use of guns
• Broad exposure to sociocultural influences such as mass media violence and depictions of gun violence as an effective means of achieving goals or status

Most youths — even those with chronic and violent delinquent misconduct — desist in aggressive and antisocial behavior during late adolescence, and no single risk factor is sufficient to generate persisting violent behavior. Still, many are disproportionately at risk for becoming perpetrators or victims of gun violence. Homicide remains the second leading cause of death for teens and young adults between the ages of 15 and 24. In 2010, there were 2,711 infant, child, and adolescent victims of firearm deaths. In that year, 84 percent of homicide victims between the ages of 10 and 19 were killed with a firearm, and 40 percent of youths who committed suicide between the ages 15 and 19 did so with a gun (CDC, 2013a). 1

There is no one developmental trajectory that specifically leads to gun violence. However, prevention efforts guided by research on developmental risk can reduce the likelihood that firearms will be introduced into community and family conflicts or criminal activity. Prevention efforts can also reduce the relatively rare occasions when severe mental illness contributes to homicide or the more common circumstances when depression or other mental illness contributes to suicide.

Reducing incidents of gun violence arising from criminal misconduct or suicide is an important goal of broader primary and secondary prevention and intervention strategies. Such strategies must also attend to redirecting developmental antecedents and larger sociocultural processes that contribute to gun violence and gun-related deaths.

1 The 2010 data shown here are available online .

Eric Mankowski, PhD

Any account of gun violence in the United States must consider both why males are the perpetrators of the vast majority of gun violence and why the vast majority of males never perpetrate gun violence. An account that explains both phenomena focuses, in part, on how boys and men learn to demonstrate and achieve manhood through violence, as well as the differences in opportunities to demonstrate manhood among diverse groups of males. Although evidence exists for human biological and social-environmental systems interacting and contributing to aggressive and violent behavior, this review focuses on the sociocultural evidence that explains males’ higher rates of gun violence.

Reducing the propensity for some males to engage in violence will involve both social and cultural change. Hence, this section reviews existing research on the relationships between sex, gender (i.e., masculinity), and the perpetration and victimization of gun violence in the United States. The intersection of gender, race/ethnicity, and economic disadvantage is also considered in explaining the rates of gun violence across diverse communities. Finally, the relationships between masculinity, gender socialization, and gun violence are analyzed to identify gender-related risk factors for gun violence that can be targeted for prevention strategies and social policy.

Sex Differences in Gun Violence

Prevalence and Risk Men represent more than 90 percent of the perpetrators of homicide in the United States and are also the victims of the large majority (78 percent) of that violence (Bureau of Justice Statistics, 2008; Federal Bureau of Investigation [FBI], 2007). Homicide by gun is the leading cause of death among Black youth, the second leading cause of death among all male youth, and the second or third leading cause of death among female youth (depending on the specific age group) (e.g., Miniño, 2010; Webster, Whitehill, Vernick, & Curriero, 2012). In addition, roughly four times as many youths visit hospitals for gun-induced wounds as are killed each year (CDC, 2013a).

Even more common than homicide, suicide is another leading cause of death in the United States, and most suicides are completed with a firearm. Males complete the large majority of suicides; depending on the age group, roughly four to six times as many males as females kill themselves with firearms (CDC, 2013a). Among youth, suicide ranks especially high as a cause of death. It is the third leading cause of death of 15–24-year-olds and the sixth leading cause of death for 5–14-year-olds. However, the rate of suicide and firearm suicide gradually increases over the lifespan. In addition to gender and age differences in prevalence, sizable differences also exist among ethnic groups. Firearm suicide generally is at least twice as high among Whites than among Blacks and other racial groups from 1980 to 2010 (CDC, 2013a), and White males over the age of 65 have rates that far exceed all other major groups.

Perpetrator–Victim Relationship and Location The prevalence of gun violence strongly depends not only on the sex of the offender but also on the offender’s relationship to the victim and the location of the violence (Sorenson, 2006). Both men and women are more likely to be killed with firearms by someone they know than by a stranger. Specifically, men are most likely to be killed in a public place by an acquaintance, whereas women are most likely to be killed in the home by a current or former spouse or dating partner (i.e., “intimate partner”). Women compared with men are especially likely to be killed by a firearm used by an intimate partner.

Women are killed by current or former intimate partners four to five times more often than men (Campbell, Glass, Sharps, Laughon, & Bloom, 2007), including by firearm. These sex differences in victimization do not appear to hold in the limited data available on same-sex intimate partner homicide; it is more common for men to kill their male partners than for women to kill their female partners (Campbell et al., 2007). Notably, these sex differences in gun violence, as a function of the type of perpetrator–victim relationships, are also found in nonfatal gun violence when emergency room visits are examined (Wiebe, 2003).

A disproportionate number of gun homicides occur in urban areas. Conversely, a disproportionate number of firearm suicides occur in rural (compared with urban) areas (Branas, Nance, Elliott, Richmond, & Schwab, 2004). Although they are highly publicized, less than 2 percent of the homicides of children occur in schools (Borum, Cornell, Modzeleski, & Jimerson, 2010; CDC, 2008, 2013b). There are even fewer “random” or “mass” school shootings in which multiple victims are killed at the same time.

Gun Access and Possession A person must own or obtain a gun to be able to commit gun violence. Research shows that there are sex differences in access to and carrying a gun. Males are roughly two to four times as likely as females to have access to a gun in the home or to possess a gun (Swahn, Hamming, & Ikeda, 2002; Vaughn et al., 2012). In turn, gun carrying is a key risk factor for gun violence perpetration and victimization. For example, gun carrying is associated with dating violence victimization among adolescents, with boys more likely to be victimized than girls (Yan, Howard, Beck, Shattuck, & Hallmark-Kerr, 2010).

Conclusions based on sex differences in access to guns should be drawn with some caution, given that there also appear to be sex differences in the reporting of guns in the home. Men report more guns in the home than do women from the same household (e.g., Ludwig, Cook, & Smith, 1998; Sorenson & Cook, 2008), a sex difference that appears to stem specifically from the substantially higher level of contact with and experience in handling and using guns among boys than girls in the same household (Cook & Sorenson, 2006). Nonetheless, the presence of guns in the home remains predictive of gun violence.

Gender and Gun Violence

Robust sex and race differences in firearm violence have been established. Examined next is how the socialization of men as well as differences in living conditions and opportunities among diverse groups of boys and men help explain why these differences occur.

Making Gender Visible in the Problem of Gun Violence Gender remains largely invisible in research and media accounts of gun violence. In particular, gender is not used to explain the problem of “school shootings,” despite the fact that almost every shooting is perpetrated by a young male. Newspaper headlines and articles describe “school shooters,” “violent adolescents,” and so forth, but rarely call attention to the fact that nearly all such incidents are perpetrated by boys and young men. Studies of risk factors for school shootings may refer accurately to the perpetrators generally as “boys” but largely fail to analyze gender (e.g., Verlinden, Hersen, & Thomas, 2000).

The large sex differences in gun violence should not be overlooked simply because the vast majority of boys and men do not perpetrate gun violence or excused as “boys will be boys.” The size of sex differences in the prevalence of gun violence differs substantially within regions of the United States (Kaplan & Geling, 1998) and across countries (e.g., Ahn, Park, Ha, Choi, & Hong, 2012), which further suggests that gender differences in sociocultural environments are needed to explain sex differences in gun violence.

Masculinity, Power, and Guns Status as a “man” is achieved by the display of stereotypically masculine characteristics, without which one’s manhood is contested. Although the particular characteristics defining manhood and the markers of them can vary across subcultural contexts (Connell, 1995), masculinity has, historically, generally been defined by aggressive and risk-taking behavior, emotional restrictiveness (particularly the vulnerable emotions of fear and sadness, and excepting anger), heterosexuality, and successful competition (Brannon, 1976; Kimmel, 1994; O’Neil, 1981). Such normative characteristics of traditional masculinity are in turn directly related to numerous factors that are associated with gun violence. For example, risk taking is associated with adolescent males’ possession of and access to guns (Vittes & Sorenson, 2006).

Social expectations and norms, supported by social and organizational systems and practices, privilege boys who reject or avoid in themselves anything stereotypically feminine, act tough and aggressive, suppress emotions (other than anger), distance themselves emotionally and physically from other men, and strive competitively for power. Men of color, poor men, gay men, and men from other marginalized groups differ substantially in their access to opportunities to fulfill these manhood ideals and expectations in socially accepted ways. For example, men with less formal educational and economic opportunity, who in the United States are disproportionately Black and Latino, cannot fulfill expectations to be successful breadwinners in socially acceptable ways (e.g., paid, legal employment) as easily as White men, and gay men have less ability to demonstrate normative heterosexual masculinity where they cannot legally marry or have children.

At the same time, higher levels of some forms of violence victimization and perpetration (including suicide) are found among these disadvantaged groups. For example, gay youth are more likely than heterosexual males to commit suicide, and African American male youth are disproportionately the victims of gun violence. Such structural discrimination can be seen reflected in implicit cognitive biases against these group members. Virtual simulations of high-threat incidents, such as those used to train police officers, reliably demonstrate a “shooter bias” in which actors are more likely to shoot Black male targets than those from other race-gender groups (i.e., Black women, White men, and White women) (Plant, Goplen, & Kunstman, 2011).

Even to the extent that it is achieved, manhood status is theorized as precarious, needing to be protected and defended through aggression and violence, including gun violence, in order to avoid victimization from (mostly) male peers (Connell, 1995). Paradoxically, as in all competition, the more convincingly manhood is achieved, the more vulnerable it becomes to challenges or threats and thus requires further defending, often with increasing levels and displays of toughness and violence. The dynamic of these expectations of manhood and their enforcement is like a tight box (Kivel, 1998). Boys and men are either trapped inside this box or, in violating the expectations by stepping out of the box, risk being targeted by threats, bullying, and other forms of violence.

Adherence to stereotypic masculinity, in turn, is commonly associated with stress and conflict, poor health, poor coping and relationship quality, and violence (Courtenay 2000; Hong, 2000). Men’s gender role stress and conflict are directly associated with various forms of interpersonal aggression and violence, including the perpetration of intimate partner violence and suicide (Feder, Levant, & Dean, 2010; Moore & Stuart, 2005; O’Neil, 2008). Men with more restricted emotionality and more restricted affection with other men are more likely to be aggressive, coercive, or violent (O’Neil, 2008). These dimensions of masculinity also are related to a number of other harmful behaviors that are, in turn, associated directly with gun violence and other forms of aggression (see O’Neil, 2008, for a review). For example, the effect of alcohol consumption on intimate partner violence is greater among men than women (Moore, Elkins, McNulty, Kivisto, & Handsel, 2011), and alcohol consumption may be associated with lethal male-to-male violence at least partly because it is associated with carrying a gun (Phillips, Matusko, & Tomasovic, 2007).

In addition, accumulating research evidence indicates a relationship between gender and many of the factors that are associated with suicide (e.g., substance abuse, unemployment; Payne, Swami, & Stanistreet, 2008). Beliefs in traditional masculinity are related to suicidal thoughts, although differently across age cohorts (Hunt, Sweeting, Keoghan, & Platt, 2006). Men’s historic role as economic providers in heterosexual families typically ends with their retirement from the workforce. Suicide rates, including firearm suicide, increase dramatically at precisely this point in the life course (i.e., age 65 and older), whereas they decrease among women this age. The increase in suicide rates among White men at age 65 and older does not occur among Black men, who as a group have much higher levels of unemployment throughout their lives and consequently may not experience the same sense of loss of meaning or entitlement. Male firearm suicide also increases dramatically in adolescence and early adulthood, precisely the years during which young men’s sense of manhood is developing.

Beliefs about gender and sexual orientation also help explain sex differences in fatal hate crimes involving guns. Key themes in male gender role expectations are anti-femininity (Brannon, 1976) and homophobia (Kimmel, 1994). Boys are expected to rid themselves of stereotypically feminine characteristics (e.g., “you throw like a girl,” “big boys don’t cry”). Gun violence against lesbian, gay, bisexual, and transgendered persons can be understood in this context. One explanation of these hate crimes is that they are perpetrated to demonstrate heterosexual masculinity to male peer group members. These homicides, compared with violent crimes in which the victim is (or is perceived to be) heterosexual, often are especially brutal and are more commonly perpetrated by groups of men rather than individual men or women. However, such homicides appear to be perpetrated less often using firearms, which suggests motives beyond a desire to kill — for example, expressing intense hatred or transferring negative affect directly onto the victim (Gruenwald, 2012).

Male role expectations for achievement of success and power, combined with restricted emotionality, may have dangerous consequences, particularly for boys who suffer major losses and need help. A majority of the males who have completed homicides at schools had trouble coping with a recent major loss. Many had also experienced bullying or other harassment (Vossekuil et al., 2002). Such characteristics cannot and should not be used to develop risk profiles of attackers because school shootings are such rare events, and so many men who share these same characteristics never will perpetrate gun violence. However, when male gender and characteristics associated with male gender are highly common among attackers, it is responsible to ask how male gender contributes to school shootings and other forms of gun violence.

In their case studies of male-perpetrated homicide-suicides at schools, Kalish and Kimmel (2010) speculated that a sense of “aggrieved entitlement” may be common among the shooters. In this view, the young men see suicide and revenge as appropriate, even expected, responses for men to perceived or actual victimization. Related findings emerged from a similar analysis of all “random” school shootings (those with multiple, nontargeted victims) from 1982 to 2001 (Kimmel & Mahler, 2003). With a small number of exceptions, the vast majority were committed by White boys (26 of 28) in suburban or rural (not urban) areas (27 of 28). Many of these boys also had experienced homophobic bullying.

Masculinity and Beliefs About Guns Sex differences in beliefs about guns may begin at an early age as a function of parental socialization and attitudes. Fathers, particularly White fathers, are more permissive than mothers of their children, particularly sons, playing with toy guns (Cheng et al., 2003). Through the socialization of gender, boys and men may come to believe that displaying a gun will enhance their masculine power. Carrying a weapon is, in fact, instrumental in fulfilling male gender role expectations. Estimates of a person’s physical size and muscularity are greater when they display a gun (or large knife) than other similarly sized and shaped objects (e.g., drill, saw), even when the person is only described and not visible. This perception persists despite no apparent correlation between actual gun ownership and size or muscularity (Fessler, Holbrook, & Snyder, 2012). Guns symbolically represent some key elements of hegemonic masculinity — power, hardness, force, aggressiveness, coldness (Connell, 1995; Stroud, 2012).

Implications for Prevention and Policy

Sex Differences in Attitudes Toward Gun Policies Policies and laws addressing the manufacture, purchase, and storage of guns have been advocated in response to the prevalence of gun violence. Perhaps reflecting their differential access to firearms and differential perpetration and victimization rates, men and women hold different attitudes about such gun control policies. Females are generally much more favorable toward gun restriction and control policies (e.g., Vittes, Sorenson, & Gilbert, 2003).

Prevention Programs Addressing Gender The foregoing analysis of the link between gender and gun violence suggests the potential value of addressing gender in efforts to define the problem of gun violence and develop preventive responses. Preliminary evidence suggests that correcting and changing perceptions among men of social norms regarding beliefs about behaviors and characteristics that are associated with stereotypic masculinity may reduce the prevalence of intimate partner and sexual violence (Fabiano, Perkins, Berkowitz, Linkenbach, & Stark, 2003; Neighbors et al., 2010). However, the effect of such interventions in specifically reducing gun violence remains to be tested. The skills and knowledge of psychologists are needed to develop and evaluate programs and settings in schools, workplaces, prisons, neighborhoods, clinics, and other relevant contexts that aim to change gendered expectations for males that emphasize self-sufficiency, toughness, and violence, including gun violence.

Robert Kinscherff, PhD, JD; Arthur C. Evans Jr., PhD; Marisa R. Randazzo, PhD; and Dewey Cornell, PhD

A natural starting point for the prevention of gun violence is to identify individuals who are at risk for violence and in need of assistance. Efforts focused on at-risk individuals are considered secondary prevention because they are distinguished from primary or universal prevention efforts that address the general population. Secondary prevention strategies for gun violence can include such actions as providing prompt mental health treatment for an acutely depressed and suicidal person or conducting a threat assessment of a person who has threatened gun violence against a spouse or work supervisor.

To be effective, strategies to prevent gun violence should be tailored to different kinds of violence. One example is the distinction between acts of impulsive violence (i.e., violence carried out in the heat of the moment, such as an argument that escalates into an assault) and acts of targeted or predatory violence (i.e., acts of violence that are planned in advance of the attack and directed toward an identified target). The incidents of mass casualty gun violence that have garnered worldwide media attention, such as the shootings at Sandy Hook Elementary School in Newtown, Conn., at a movie theater Aurora, Colo., at the Fort Hood military base, and at a political rally in a shopping center in Tucson, Ariz., are all examples of targeted or predatory violence. Distinguishing between impulsive violence, targeted/predatory violence, and other types of violence is important because they are associated with different risk factors and require different prevention strategies.

Predicting and Preventing Impulsive Gun Violence

Research on impulsive violence has enabled scientists to develop moderately accurate predictive models that can identify individuals who are more likely than other persons to engage in this form of violence. These models cannot determine with certainty whether a particular person will engage in violence — just whether a person is at greater likelihood of doing so. This approach is known as a violence risk assessment or clinical assessment of dangerousness . A violence risk assessment is conducted by a licensed mental health professional who has specific training in this area. The process generally involves comparing the person in question with known base rates for those of the same age/gender who have committed impulsive violence and then determining whether the person in question has individual risk factors that would increase that person’s likelihood of engaging in impulsive violence. In addition, the process involves examining individual protective factors that would decrease the person’s overall likelihood of engaging in impulsive violence. Research that has identified risk and protective factors for impulsive violence is limited in that more research has been conducted on men than women and on incarcerated or institutionalized individuals than on those in the general population. Nevertheless, this approach can be effective for determining someone’s relative likelihood of engaging in impulsive violence.

Some risk factors for impulsive violence are static — for example, race and age — and cannot be changed. But those factors that are dynamic — for example, unmet mental health needs for conditions linked with violence to self (such as depression) or others (such as paranoia), lack of mental health care, abuse of alcohol — are more amenable to intervention and treatment that can reduce the risk for gun violence. Secondary prevention strategies to prevent impulsive gun violence can include having a trained psychologist or other mental health professional treat the person’s acute mental health needs or substance abuse needs. There must be a vigorous and coordinated response to persons whose histories include acts of violence, threatened or actual use of weapons, and substance abuse, particularly if they have access to a gun. This response should include a violence risk assessment by well-trained professionals and referral for any indicated mental health treatment, counseling and mediation services, or other forms of intervention that can reduce the risk of violence.

Youths and young adults who are experiencing an emerging psychosis should be referred for prompt assessment by mental health professionals with sufficient clinical expertise with psychotic disorders to craft a clinical intervention plan that includes risk management. In some cases, secondary prevention measures may include a court-ordered emergency psychiatric hospitalization where a person can receive a psychiatric evaluation and begin treatment. Criteria for allowing such involuntary evaluations vary by state but typically can occur only when someone is experiencing symptoms of a serious mental illness and, as a result, potentially poses a significant danger to self or others. There is an urgent need to improve the effectiveness of emergency commitment procedures because of concerns that they do not provide sufficient services and follow-up care.

Predicting and Preventing Targeted or Predatory Gun Violence

Acts of targeted or predatory violence directed at multiple victims, including crimes sometimes referred to as rampage shootings and mass shootings, 2 occur far less often in the United States than do acts of impulsive violence (although targeted violence garners far more media attention). Acts of targeted violence have not been subject to study that has developed statistical models like those used for estimating a person’s likelihood of impulsive violence. Although it seems appealing to develop checklists of warning signs to construct a profile of individuals who commit these kinds of crimes, this effort, sometimes described as psychological profiling, has not been successful. Research has not identified an effective or useful psychological profile of those who would engage in multiple casualty gun violence. Moreover, efforts to use a checklist profile to identify these individuals fail in part because the characteristics used in these profiles are too general to be of practical value; such characteristics are also shared by many nonviolent individuals.

Because of the limitations of a profiling approach, practitioners have developed the behavioral threat assessment model as an alternative means of identifying individuals who are threatening, planning, or preparing to commit targeted violence. Behavioral threat assessment also emphasizes the need for interventions to prevent violence or harm when a threat has been identified, so it represents a more comprehensive approach to violence prevention. The behavioral threat assessment model is an empirically based approach that was developed largely by the U.S. Secret Service to evaluate threats to the president and other public figures and has since been adapted by the U.S. Secret Service and U.S. Department of Education (Fein et al., 2002; Vossekuil et al., 2002) and others (Cornell, Allen, & Fan, 2012) for use in schools, colleges and universities, workplaces, and the U.S. military. Threat assessment teams are typically multidisciplinary teams that are trained to identify potentially threatening persons and situations. They gather and analyze additional information, make an informed assessment of whether the person is on a pathway to violence — that is, determine whether the person poses a threat of interpersonal violence or self-harm — and if so, take steps to intervene, address any underlying problem or treatment need, and reduce the risk for violence.

Behavioral threat assessment is seen as the emerging standard of care for preventing targeted violence in schools, colleges, and workplaces, as well as against government officials and other public figures. The behavioral threat assessment approach is the model currently used by the U.S. Secret Service to prevent violence to the U.S. president and other public officials, by the U.S. Capitol Police to prevent violence to members of Congress, by the U.S. State Department to prevent violence to dignitaries visiting the United States, and by the U.S. Marshals Service to prevent violence to federal judges (see Fein & Vossekuil, 1998). The behavioral threat assessment model also is recommended in two American national standards: one for higher education institutions (which recommends that all colleges and universities operate behavioral threat assessment teams; see ASME-Innovative Technologies Institute, 2010) and one for workplaces (which recommend s similar teams to prevent workplace violence; see ASIS International and Society for Human Resource Management, 2011). In addition, a comprehensive review conducted by a U.S. Department of Defense (2010) task force following the Fort Hood shooting concluded that threat assessment teams or threat management units (i.e., teams trained in behavioral threat assessment and management procedures) are the most effective tool currently available to prevent workplace violence or insider threats like the attack at Fort Hood.

Empirical research on acts of targeted violence has shown that many of those attacks were carried out by individuals motivated by personal problems who were at a point of desperation. In their troubled state of mind, these individuals saw no viable solution to their problems and could envision no future. The behavioral threat assessment model is used not only to determine whether a person is planning a violent attack but also to identify personal or situational problems that could be addressed to alleviate desperation and restore hope. In many cases, this includes referring the person to mental health services and other sources of support. In some of these cases, psychiatric hospitalization may be needed to address despondence and suicidality. Nonpsychiatric resources also can help alleviate the individual’s problems or concerns. Resources such as conflict resolution, credit counseling, job placement assistance, academic accommodations, veterans’ services, pastoral counseling, and disability services all can help address personal problems and reduce desperation. When the underlying personal problems are alleviated, people who may have posed a threat of violence to others no longer see violence as their best or only option.

Predicting and Preventing Violence by Those With Acute Mental Illness

When treating a person with acute or severe mental illness, mental health professionals may encounter situations in which they need to determine whether their patient (or client) is at risk for violence. Typically, they would conduct a violence risk assessment if the clinician’s concern is about risk for impulsive violence, as discussed previously. Clinicians also can conduct — or work with a team to help conduct — a threat assessment if their concern involves targeted violence. The available research suggests that mental health professionals should be concerned when a person with acute mental illness makes an explicit threat to harm someone or is troubled by delusions or hallucinations that encourage violence, but even in these situations, violence is far from certain. Although neither a violence risk assessment nor a threat assessment can yield a precise prediction of someone’s likelihood of violence, it can identify high-risk situations and guide efforts to reduce risk. It is important to emphasize that prevention does not require prediction; interventions to reduce risk can be beneficial even if it is not possible to determine who would or would not have committed a violent act.

When their patients (or clients) pose a risk of violence to others, mental health professionals have a legal and ethical obligation to take appropriate action to protect potential victims of violence. This obligation is not easily carried out for several reasons. First, mental health professionals have only a modest ability to predict violence, even when assisted by research-validated instruments. Mental health professionals who are concerned that a patient is at high risk for violence may be unable to convince their patient to accept hospitalization or some other change in treatment. They can seek involuntary hospitalization or treatment, but civil commitment laws (that vary from state to state) generally require convincing evidence that a person is imminently dangerous to self or others. There is considerable debate about the need to reform civil commitment laws in a manner that both protects individual liberties and provides necessary protection for society.

There is no guarantee that voluntary or involuntary treatment of a potentially dangerous individual will be effective in reducing violence risk, especially when the risk for violence does not arise from a mental illness but instead from intense desperation resulting from highly emotionally distressing circumstances or from antisocial orientation and proclivities for criminal misconduct. When individuals with prior histories of violence are released from treatment facilities, they typically need continued treatment and monitoring for potential violence until they stabilize in community settings. Jurisdictions vary widely in the resources available to achieve stability in the community and in the legal ability to impose monitoring or clinical care on persons who decline voluntary services.

Furthermore, if unable to obtain civil commitment to a protective setting, mental health professionals must consider other protective actions permitted in their jurisdictions, which may include warning potential victims that they are in danger or alerting local law enforcement, family members, employers, or others. Whether their particular jurisdiction mandates a response to “warn or protect” potential victims or leaves this decision to the discretion of the clinician, mental health professionals are often reluctant to take such actions because they are concerned that doing so might damage the therapeutic relationship with their patient and drive patients from treatment or otherwise render effective treatment impossible.

Another post-hospitalization strategy is to prohibit persons with mental illness from acquiring a firearm. The Gun Control Act of 1968 prohibited persons from purchasing a firearm if they had been involuntarily committed to a psychiatric inpatient unit. The Brady Handgun Violence Act (1994), known as the Brady Law, began the process of background checks to identify individuals who might attempt to purchase a firearm despite prohibitions. There is some evidence that rates of gun violence are reduced when these procedures are adequately implemented, but research, consistent implementation, and refinement of these procedures are needed (Webster & Vernick, 2013a).

Predicting and Preventing Gun-Based Suicide

Suicide accounts for approximately 61 percent of all firearm fatalities in the United States — 19,393 of the 31,672 firearm deaths reported by the CDC for 2010 (Murphy, Xu, & Kochanek, 2013). When there is concern that a person may be suicidal, mental health professionals can conduct suicide screenings and should rely on structured assessment tools to assess that person’s risk to self. Behavioral threat assessment also may be indicated in such situations if the potentially suicidal individual may also pose a threat to others.

More than half of suicides are accomplished by firearms and most commonly with a firearm from the household (Miller, Azrael, Hepburn, Hemenway, & Lippmann, 2006). More than 90 percent of persons who commit suicide had some combination of symptoms of depression, symptoms of other mental disorders, and/or substance abuse (Moscicki, 2001). Ironically, although depression is the condition most closely associated with attempted or completed suicide, it is also less likely than schizophrenia or other disorders to prompt an involuntary civil commitment or other legal triggers that can prevent some persons with mental illness from possessing firearms. As in behavioral threat assessment, suicide risk may be reduced through identifying and providing support in solving the problems that are driving a person to consider suicide. In many cases the person may need a combination of psychological treatment and psychiatric medication.

Tragic shootings like the ones at Sandy Hook Elementary School and the movie theater in Aurora, Colo., spark intense debate as to whether specific gun control policies would significantly diminish the number of mass shooting incidents. This debate includes whether or how to restrict access to firearms, especially with regard to persons with some mental illnesses. Another line of debate concerns whether to limit access to certain types of firearms (e.g., reducing access to high-capacity magazines). Empirical evidence documents the efficacy of some firearms restrictions, but because the restrictions often are not well implemented and have serious limitations, it is difficult to conduct the kind of rigorous research needed to fairly evaluate their potential for reducing gun violence.

The often-debated Brady Law (1994) does not consistently prevent persons with mental illness from acquiring a firearm. The prohibition applies only to persons with involuntary commitments and omits both persons with voluntary admissions and those with no history of inpatient hospitalization. The law does not prevent a person with a history of involuntary commitment from obtaining a previously owned firearm or one possessed by a friend or relative. Additional problems with implementing the Brady Law include incomplete records of involuntary commitments, background checks limited to purchases from licensed gun dealers, and exceptions from background checks for firearms purchased during gun shows.

Despite these limitations and gaps, there is some scientific evidence that background checks reduce the rate of violent gun crimes by persons whose mental health records disqualify them from legally obtaining a firearm. A study of one state (Connecticut) found that the risk of violent criminal offending among persons with a history of involuntary psychiatric commitment declined significantly after the state began reporting these individuals to the National Instant Criminal Background Check System (Swanson et al., 2013). This study supports the value of additional research to investigate strategies for limiting access to firearms by persons with serious mental illness.

In contrast, access to appropriate mental health treatment can work to reduce violence at the individual level. For example, one major finding of the MacArthur Risk Assessment study (Monahan et al., 2001) was that getting continued mental health treatment in the community after release from a psychiatric hospitalization reduced the number of violent acts by those who had been hospitalized. In other studies, outpatient mental health services, including mandated services, have been effective in preventing or reducing violent and harmful behavior (e.g., New York State Office of Mental Health, 2005; N.Y. Mental Hygiene Law [Kendra’s Law], 1999; O’Keefe, Potenza, & Mueser, 1997; Swanson et al., 2000).

There is abundant scientific research demonstrating the effectiveness of treatment for persons with severe mental illness such as schizophrenia and bipolar disorder. However, there are social, economic, and legal barriers to treatment. First, there is a persistent social stigma associated with mental illness that deters individuals from seeking treatment for themselves or for family members. Public education to increase understanding of and support for persons with serious mental illness and to encourage access to treatment is needed.

Second, mental health treatment, especially inpatient hospitalization, is expensive, and persons with mental illness often cannot access this level of care or afford it. Commercial insurers often have limitations on hospital care or do not cover intensive services that are alternatives to inpatient admission. Public sector facilities such as community mental health centers and state-operated psychiatric hospitals have experienced many years of shrinking government support; demand for their services exceeds their capacity. Many mental health providers limit their services to the most acute cases and cannot extend services after the immediate crisis has resolved.

Third, there are complex legal barriers to the provision of mental health services when an individual does not desire treatment or does not believe he or she is in need of treatment. A severe mental illness can impair an individual’s understanding of his or her condition and need for treatment, but a person with mental illness may make a rational decision to refuse treatment that he or she understandably regards as ineffective, aversive, or undesirable for some reason (e.g., psychiatric medications can produce unpleasant side effects and hospitalization can be a stressful experience).

When an individual refuses to seek treatment, it may be difficult to determine whether this decision is rational or irrational. To protect individual liberties, laws throughout the United States permit involuntary treatment only under stringent conditions, such as when an individual is determined to be imminently dangerous to self or others due to a mental illness. People who refuse treatment but are not judged to be imminently dangerous (a difficult and ambiguous standard) fall into a “gray zone” (Evans, 2013). Some individuals with serious mental illness pose a danger to self or others that is not imminent, and often it is not possible to monitor them adequately or determine precisely when they become dangerous and should be hospitalized on an involuntary basis. In other situations, the primary risk posed by the individual does not arise from mental illness but from his or her willingness to engage in criminal misconduct for personal gain.

Furthermore, when a person is committed to a psychiatric hospital on an involuntary basis, treatment is limited in scope. Once the person is no longer regarded as imminently dangerous (the criteria differ across states), he or she must be released from treatment even if not fully recovered; that person may be vulnerable to relapse into a dangerous state. In some cases of mass shootings, persons who committed the shooting were known to have a serious mental illness, but authorities could not require treatment when it was needed. In other cases, authorities were not aware of an individual’s mental illness before the attempted or actual mass shooting incident.

A related problem is that the onset or recurrence of serious mental illness can be difficult to detect. Symptoms of mental illness may emerge slowly, often in late adolescence or early adulthood, and may not be readily apparent to family members and friends. A person hearing voices or experiencing paranoid delusions may hide these symptoms and simply seem preoccupied or distressed but not seriously ill. A person who has been treated successfully for a serious mental illness may experience a relapse that is not immediately recognized. There is a great need for public education about the onset of serious mental illness, recognition of the symptoms of mental illness, and increased emphasis on the importance of seeking prompt treatment.

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2 The FBI (n.d.) defines mass murder as incidents that occur in one location (or in closely related locations during a single attack) and that result in four or more casualties. Mass murder shootings are much less common than other types of gun homicides. They are also not a new phenomenon. Historically, most mass murder shootings occurred within families or in criminal activities such as gang activity and robberies. Rampage killings is a term used to describe some mass murders that involve attacks on victims in unprotected settings (such as schools and colleges, workplaces, places of worship) and public places (such as theaters, malls, restaurants, public gatherings). However, these shootings are often planned well in advance and carried out in a methodical manner, so the term rampage is a misnomer.

Ellen Scrivner, PhD, ABPP; W. Douglas Tynan, PhD, ABPP; and Dewey Cornell, PhD

Prevention of violence occurs along a continuum that begins in early childhood with programs to help parents raise healthy children and ends with efforts to identify and intervene with troubled individuals who threaten violence. A comprehensive community approach recognizes that no single program is sufficient and there are many opportunities for effective prevention. Discussion of effective prevention from a community perspective should include identification of the community being examined. Within the larger community, many stakeholders are affected by gun violence that results in a homicide, suicide, or mass shooting.

Such stakeholders include community and public safety officials, schools, workplaces, neighborhoods, mental health and public health systems, and faith-based groups. When it comes to perpetrating gun violence, however, a common thread that exists across community groups is the recognition that someone, or possibly several people, may have heard something about an individual’s thoughts and/or plans to use a gun. Where do they go with that information? How do they report it so that innocent people are not targeted or labeled unfairly — and how can their information initiate a comprehensive and effective crisis response that prevents harm to the individual of concern and the community?

To date, there is little research to help frame a comprehensive and effective prevention strategy for gun violence at the community level. One of the most authoritative reviews of the body of gun violence research comes from the National Research Council of the National Academy of Sciences (see Wellford, Pepper, & Petrie, 2004). In reviewing a range of criminal justice initiatives designed to reduce gun violence, such as gun courts, enhanced sentencing, and problem-based policing, Wellford et al. concluded that problem-oriented policing, also known as place-based initiatives or target policing, holds promise, particularly when applied to “hot spots” — areas in the community that have high crime rates. They included studies on programs such as the Boston Gun Project (see Kennedy, Braga, & Piehl, 2001), more commonly known as Operation Ceasefire, in their review and concluded that although many of these programs may have reduced youth homicides, there is only modest evidence to suggest that they effectively lowered rates of crime and violence, given the confounding factors that influence those rates and are difficult to control. In other words, the variability in the roles of police, prosecutors, and the community creates complex interactions that can confound the levels of intervention and affect sustainability.

Wellford et al.’s (2004) conclusions were supported by the findings of the 2011 Firearms and Violence Research Working Group (National Institute of Justice, 2011), which also questioned whether rigorous evaluations are possible given the reliability and validity of the data. Wellford et al. advocated for continued research and development of models that include collaboration between police and community partners and for examination of different evaluation methodologies.

There are varied prevention models that address community issues. When it comes to exploring models that specifically address preventing the recent episodes of gun violence that have captured the nation’s attention, however, the inevitable conclusion is that there is a need to develop a new model that would bring community stakeholders together in a collaborative, problem-solving mode, with a goal of preventing individuals from engaging in gun violence, whether directed at others or self-inflicted. This model would go beyond a single activity and would blend several strategies as building blocks to form a workable systemic approach. It would require that community service systems break their tendencies to operate in silos and take advantage of the different skill sets already available in the community — for example:

• Police are trained in crisis intervention skills with a primary focus on responding to special populations such as those with mental illness.
• Community members are trained in skilled interventions such as Emotional CPR  and Mental Health First Aid — consumer-based initiatives that use neighbor-to-neighbor approaches that direct people in need of care to appropriate mental health treatment.
• School resource officers are trained to show a proactive presence in schools.

Each group may provide a solution to a piece of the problem, but there is nothing connecting the broad range of activities to the type of collaborative system needed to implement a comprehensive, community-based strategy to prevent gun violence. From a policy and practice perspective, no one skill set or one agency can provide the complete answer when it comes to developing a prevention methodology. However, some models developed through the community policing reform movement may be relevant because they are generally acknowledged to have been useful in reducing violence against women and domestic violence and in responding to children exposed to violence. These community policing models involve collaborative problem solving as a way to safeguard the community as opposed to relying only on arrest procedures. Moreover, they engage the community in organized joint efforts to produce public safety (Peak, 2013).

Another initiative, Project Safe Neighborhoods ( PSN ), is also relevant. PSN, a nationwide program that began in 2001 and was designed specifically to reduce gun violence, has some similarity to the community policing model. PSN involved the 94 U.S. attorneys in cities across the country in a prominent leadership role, ensured flexibility across jurisdictions, and required cross-agency buy-in, though there seems to have been less formalized involvement with mental health services. Nevertheless, it used a problem-solving approach that was aimed at getting guns off the streets, and the results of varied outcome assessments demonstrate that it was successful in reducing gun violence, particularly when the initiatives were tailored to the gun violence needs of specific communities (McGarrell et al., 2009).

A common approach used by PSN involved engaging the community to establish appropriate stakeholder partnerships, formulating strategic planning on the basis of identification and measurement of the community problem, training those involved in PSN, providing outreach through nationwide public service announcements, and ensuring accountability through various reporting mechanisms. The PSN problem-solving steps, with some adaptations, could provide a useful strategy for initiating collaborative problem solving with relevant community stakeholders in the interest of reducing gun violence and victimization through prevention.

The models discussed here illustrate how community engagement and collaboration helped break new ground in response to identified criminal justice problems, but they could be strengthened considerably by incorporating the involvement of professional psychology. The need for collaboration was again highlighted at a Critical Issues in Policing meeting (Police Executive Research Forum, 2012) as part of a discussion on connecting agency silos by building bridges across systems. Because police and mental health workers often respond to the same people, there is a need for collaboration on the best way to do this without compromising their roles. This emphasis takes the discussion beyond the student/school focus and expands it to include the use of crisis intervention teams (CIT) and community advocacy groups as additional resources for achieving the goal of preventing violence in the community.

The CIT model was another result of community policing reform that brought police and mental health services together to provide a more effective response to the needs of special populations, particularly mental health-related cases. Developed in Memphis in 1988 but now deployed in many communities across the country, the CIT model trains CIT officers to deescalate situations involving people in crises and to use jail diversion options, if available, rather than arrests. Although research on the effectiveness of CITs is generally limited to outcome studies in select cities, the model continues to gain prominence. In fact, the National Alliance on Mental Illness ( NAMI ) has established a NAMI CIT Center and is promoting the expansion of CIT nationwide. Studies by Borum (2000), Steadman, Deane, Borum, and Morrissey (2000), and Teller, Munetz, Gil, and Ritter (2006) have illustrated that high-risk encounters between individuals with mental illness and police can be substantially improved through CIT training, particularly when there are options such as drop-off centers, use of diversion techniques, and collaborations between law enforcement, mental health, and family members. Each plays a significant role in ensuring that city or county jails do not become de facto institutions for those in mental health crises.

Crisis intervention teams were also a major focus of a 2010 policy summit (International Association of Chiefs of Police [IACP], 2012). The summit, hosted by SAMHSA, the Bureau of Justice Assistance, and IACP, produced a 23-item action agenda. Although the summit focused on decriminalizing the response to persons with mental illness and was not directed specifically at dealing with people who perpetrate gun violence, some of their recommendations did apply. The central theme of the agenda encouraged law enforcement and mental health service systems to engage in mutually respectful working relationships, collaborate across partner agencies, and establish local multidisciplinary advisory groups. These partnerships would develop policy, protocols, and guidelines for informing law enforcement encounters with persons with mental illness who are in crisis, including a protocol that would enable agencies to share essential information about those individuals and whether the nature of the crisis could provoke violent behavior. They further recommended that these types of protocols be established and maintained by the multidisciplinary advisory group and that training be provided in the community to sensitize community members to signs of potential danger and how to intervene in a systematic way.

A Police Foundation (2013) roundtable on gun violence and mental health reported that some police departments have reached out to communities and offered safe storage of firearms when community members have concern about a family member’s access to firearms in the home. As a service to the community, the police would offer to keep guns secured in accessible community locations until the threat has subsided and the community member requests the return. The police would also confer with mental health practitioners regarding a designated family or community member on an as-needed basis. This strategy is consistent with a community threat assessment approach in which law enforcement authorities engage proactively with the community to reduce the risk of violence when an individual poses a risk.

Gun Violence in Schools

Gun violence in schools has been a national concern for more than two decades. Although school shootings are highly traumatic events and have brought school safety to the forefront of public attention, schools are very safe environments compared with other community settings (Borum et al., 2010). Less than 2 percent of homicides of school-aged children occur in schools. Over a 20-year period, there have been approximately 16 shooting deaths in U.S. schools each year (Fox & Burstein, 2010), compared with approximately 32,000 shooting deaths annually in the nation as a whole (Hoyert & Xu, 2012).

The Gun-Free Schools Act of 1994 made federal education funding contingent upon states requiring schools to expel for at least one year any student found with a firearm at school. This mandate strengthened the emerging philosophy of zero tolerance as a school disciplinary policy. According to the APA Zero Tolerance Task Force (2008), this policy was predicated on faulty assumptions that removing disobedient students would motivate them to improve their behavior, deter misbehavior by other students, and generate safer school conditions. The task force found no scientific evidence to support these assumptions and, on the contrary, concluded that the practice of school suspension had negative effects on students and a disproportionately negative impact on students of color and students with disabilities.

After the 1999 shooting at Columbine High School, both the FBI (O’Toole, 2000) and the U.S. Secret Service (Vossekuil et al., 2002) conducted studies of school shootings and concluded that schools should not rely on student profiling or checklists of warning signs to identify potentially violent students. They cautioned that school shootings were statistically too rare to predict with accuracy and that the characteristics associated with student shooters lacked specificity, which means that numerous nonviolent students would be misidentified as dangerous. Both law enforcement agencies recommended that schools adopt a behavioral threat assessment approach, which, as noted earlier, involves assessment of students who threaten violence or engage in threatening behavior and then individualized interventions to resolve any problem or conflict that underlies the threat. One of the promising features of threat assessment is that it provides schools with a policy alternative to zero tolerance. Many schools across the nation have adopted threat assessment practices. Controlled studies of the "Virginia Student Threat Assessment Guidelines" have shown that school-based threat assessment teams are able to resolve student threats safely and efficiently and to reduce school suspension rates (Cornell et al., 2012; Cornell, Gregory, & Fan, 2011; Cornell, Sheras, Gregory, & Fan, 2009).

The Role of Health and Mental Health Providers in Gun Violence Prevention

The health care system is an important point of contact for families regarding the issue of gun safety. Physicians’ counseling of individuals and families about firearm safety has in some cases proven to be an effective prevention measure and is consistent with other health counseling about safety. According to the 2012 policy statement of the American Academy of Pediatrics (AAP):

The AAP supports the education of physicians and other professionals interested in understanding the effects of firearms and how to reduce the morbidity and mortality associated with their use. HHS should establish a program to support gun safety training and counseling programs among physicians and other medical professionals. The program should also provide medical and community resources for families exposed to violence.

The AAP’s Bright Futures practice guide urges pediatricians to counsel parents who possess guns that storing guns safely and preventing access to guns reduce injury by as much as 70 percent and that the presence of a gun in the home increases the risk for suicide among adolescents. A randomized controlled trial indicates that health care provider counseling, when linked with the distribution of cable locks, has been demonstrated to increase safer home storage of firearms (Barkin et al., 2008). The removal of guns or the restriction of access should be reinforced for children and adolescents with mood disorders, substance abuse (including alcohol), or a history of suicide attempts (Grossman et al., 2005). Research is needed to identify the best ways to avoid unintended consequences while achieving intended outcomes.

In recent years, legal and legislative challenges have emerged that test the ability of physicians and other medical professionals to provide guidance on firearms. For example, in 2011 the state of Florida enacted the Firearm Owners’ Privacy Act, which prevented physicians from providing such counsel under threat of financial penalty and potential loss of licensure. The law has been permanently blocked from implementation by a U.S. district court. Similar policies have been introduced in six other states: Alabama, Minnesota, North Carolina, Oklahoma, Tennessee, and West Virginia. The fundamental right of all health and mental health care providers to provide counseling to individuals and families must be protected to mitigate risk of injury to people where they live, work, and play.

It is apparent that long before the events at Sandy Hook Elementary School, many public health and public safety practitioners were seeking strategies to improve responses to violence in their communities and have experienced some success through problem-solving projects such as PSN and CIT. Yet there is still a need to rigorously evaluate and improve these efforts. In the meantime, basic safety precautions must be emphasized to parents by professionals in health, education, and mental health.

Public health messaging campaigns around safe storage of firearms are needed. The practice of keeping firearms stored and locked must be encouraged, and the habit of keeping loaded, unlocked weapons available should be recognized as dangerous and rendered socially unacceptable. To keep children and families safe, good safety habits have to become the only socially acceptable norm.

Susan B. Sorenson, PhD, and Daniel W. Webster, ScD, MPH

The use of a gun greatly increases the odds that violence will result in a fatality. In 2010, the most recent year for which data are available, an estimated 17.1 percent of the interpersonal assaults with a gunshot wound resulted in a homicide, and 80.7 percent of the suicide attempts in which a gun was used resulted in death (CDC, 2013a). By contrast, the most common methods of assault (hands, fists, and feet) and suicide attempt (ingesting pills) in 2010 resulted in death in only 0.009 percent and 2.5 percent of the incidents, respectively (CDC, 2013a). 3

As shown in Figure 1, in the past 30 years, the percentage of deaths caused by gunfire has stabilized to about 68 percent for homicides and, as drug overdoses have increased, dropped to 50 percent for suicide. There are more gun suicides than gun homicides in the United States. In 2010, 61.2 percent (19,392) of the 31,672 gun deaths in the United States were suicides (CDC, 2013a).

Figure 1. Deaths Attributed to Firearms, 1981–2010

Note: Data are from the Web-Based Injury Statistics Query and Reporting System (WISQARS™), Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 2013. Retrieved from http://www.cdc.gov/injury/wisqars/fatal.html.

Much of the public concern about guns and gun violence focuses on interpersonal violence, and public policy mirrors this emphasis. Although there is no standard way to enumerate each discrete gun law, most U.S. gun laws focus on the user of the gun. Relatively few focus on the design, manufacture, distribution, advertising, or sale of firearms (Teret & Wintemute, 1993). Fewer yet address ammunition.

The focus herein is on the lifespan of guns — from design and manufacture to use — and the policies that could address the misuse of guns. It is critical to understand how policies create conditions that affect access to and use of guns. Because they constitute the largest portion of guns used in homicides (FBI, 2012a), handguns are the focus of most laws. Despite the substantial human and economic costs of gun violence in the United States and the ongoing debate about the effectiveness of gun regulations, scientifically rigorous evaluations are not available for many of these policies (Wellford et al., 2004). The dearth of such research on gun policies is due, in part, to the lack of government funding on this topic because of the political influences of the gun lobby (e.g., Kellermann & Rivara, 2013).

Design and Manufacture

The type of handguns manufactured in the United States has changed. Pistols overtook revolvers in manufacturing in the mid-1980s. In addition, the most widely sold pistol went from a .22 caliber in 1985 to a 9 mm or larger (e.g., .45 caliber pistols) by 1994 (Wintemute, 1996), with smaller, more concealable pistols favored by permit holders as well as criminals. This shift has been described as increasing the lethality of handguns, although, according to our review, no research has examined whether the change in weapon design has led to an increased risk of death. Such research may not be feasible given that the aforementioned weapons — that is, small, concealable pistols — still likely constitute a small portion of the estimated 283 million guns in civilian hands in the United States (Hepburn, Miller, Azrael, & Hemenway, 2007). The disproportionate appearance of such pistols among guns that were traced by law enforcement following their use in a crime has been attributed to the ease with which smaller guns can be concealed and their low price point (Koper, 2007; Wright, Wintemute, & Webster, 2010).

Ammunition, by contrast, is directly related to lethality. Hollow-point bullets are used by hunters because, in part, they are considered a more humane way to kill. The physics of hollow-point bullets are such that, upon impact, they will tumble inside the animal and take it down. Some bullets have been designed to be frangible, that is, to break apart upon impact and thus cause substantial internal damage. By contrast, the physics of full metal jacket bullets are such that, unless they hit a bone, they are likely to continue on a straight trajectory and pass through the animal, leaving it wounded and wandering. Hollow-point bullets are used by law enforcement to reduce over-penetration (i.e., when a bullet passes through its intended target and, thus, risks striking others).

Some design features would substantially reduce gun violence. One of the most promising ideas is that of “smart guns” that can be fired only by an authorized user. For example, young people, who are prohibited due to their age from legally purchasing a firearm, typically use a gun from their own home to commit suicide (Johnson, Barber, Azrael, Clark, & Hemenway, 2010; Wright, Wintemute, & Claire, 2008) and to carry out a school shooting (CDC, 2003). If personalized to an authorized adult in the home, the gun could not be operated by the adolescent or others in the home, thus rendering it of little use to the potential suicide victim or school shooter. During the Clinton administration, the federal government made a modest investment in the research and development of personalized firearms. There also was considerable private investment in technologies that would prevent unauthorized users from being able to fire weapons. Efforts to create these “smart guns” have resulted in multiple patent applications. Armatix GmbH, a German company, has designed and produced a personalized pistol that is being sold in several Western European nations and has been approved for importation to the United States. Although the cost of this new personalized gun is very high, it is believed that personalized guns can be produced at a cost that would be affordable by many (Teret & Merritt, 2013).

The assault weapons ban (the Violent Crime Control and Law Enforcement Act), enacted for a 10-year period beginning in 1994, provided a good opportunity to assess the effectiveness of restricting the manufacturing, sale, and possession of a certain class of weapons. “Assault weapons,” however, are difficult to conceal and are used rarely in most street crime or domestic violence. Assault weapons are commonly used in mass shootings in which ammunition capacity can determine the number of victims killed or wounded. Because multiple bullets are not an issue in suicide, one would not expect changes in such deaths either. Perhaps not surprisingly, an effect of the ban could not be detected on total gun-related homicides (Koper, 2013; Koper & Roth, 2001).

Unfortunately, prior research on the effects of the federal assault weapons ban did not focus on the law’s effects on mass shootings or the number of persons shot in such shootings. Assault weapons or guns with large-capacity ammunition feeding devices account for half of the weapons used in mass shootings such as at Sandy Hook Elementary School (see Follman & Aronson , 2013). Mass shootings with these types of weapons result in about 1.5 times as many fatalities as those committed with other types of firearms (Roth & Koper, 1997).

Distribution

The distribution of guns is largely the responsibility of a network of middlemen between gun manufacturers and gun dealers. When a gun is recovered following its use (or suspected use) in a crime, law enforcement routinely requests that the gun be traced — that is, the serial number is reported to the manufacturer, who then contacts the distributor and/or dealer who, in turn, reviews records to determine the original purchaser of a specific weapon. The number of gun traces is such that the manufacturers get many calls about their guns each day. One researcher estimated that Smith and Wesson, with about 10 percent of market share, received a call every seven to eight minutes about one of their guns (Kairys, 2008). Thus, one could reasonably expect that manufacturers would have some knowledge of which distributors sell guns that are disproportionately used in crime, and distributors would, in turn, know which retailers disproportionately sell guns used in crime.

Following in the footsteps of cities and states that had successfully sued the tobacco industry under state consumer protection and antitrust laws for costs the public incurred in caring for smokers, beginning in the late 1990s cities and states began to file claims against firearm manufacturers in an attempt to recover the costs of gun violence they incurred. In response, in 2005, Congress enacted and President George W. Bush signed the Protection of Lawful Commerce in Arms Act, which prohibits civil liability lawsuits against “manufacturers, distributors, dealers, or importers of firearms or ammunition for damages, injunctive or other relief resulting from the misuse of their products by others” ( 15 U.S.C. §§ 7901-7903 ). Thus, the option of using litigation, a long-standing and sometimes controversial tool by which to address entrenched public health problems (e.g., Lytton, 2004), was severely restricted.

Advertising

Advertisements for guns have largely disappeared from classified ads in newspapers. By contrast, advertising in magazines, specifically gun magazines, is strong (Saylor, Vittes, & Sorenson, 2004). Such advertising is subject to the same Federal Trade Commission (FTC) regulations as other consumer products. In 1996, several organizations filed a complaint with the FTC after documenting multiple cases of what they asserted to be false and misleading claims about home protection (for specific examples, see Vernick, Teret, & Webster, 1997). As of November 1, 2013, the FTC had not ruled on the complaint. However, the firearm industry changed its practices such that by 2002, self-protection was an infrequent theme in advertisements for guns (Saylor et al., 2004). To our knowledge, current advertising has not been studied. New issues relevant to the advertising of guns include online advertisements by private sellers who are not obligated to verify that purchasers have passed a background check, online ads from prohibited purchasers seeking to buy firearms, the marketing of military-style weapons to civilians, and the marketing of firearms to underage youth (for examples and more information, see Kessler & Trumble, 2013; Mayors Against Illegal Guns, 2013; McIntire, 2013; Violence Policy Center, 2011).

Sales and Purchases

Gun sales have been increasing in the United States. The FBI reported a substantial jump in background checks (a proxy for gun sales) in the days following the Sandy Hook Elementary School shootings. In fact, of the 10 days with the most requests for background checks since the FBI started monitoring such information, 7 of them were within 8 days of Sandy Hook (FBI, 2013). Guns can be purchased from federally licensed firearm dealers or private, unlicensed sellers in a variety of settings, including gun shows, flea markets, and the Internet.

Responsible sales practices (for examples, see Mayors Against Illegal Guns, n.d.) rely heavily on the integrity of the seller. And usually that responsibility is well placed: Over half (57 percent) of the guns traced (i.e., submitted by law enforcement, usually in association with a crime, to determine the original purchaser of the weapon) were originally sold by only 1.2 percent of federally licensed firearm dealers (Bureau of Alcohol, Tobacco and Firearms [ATF], 2000). However, there are problems. Sometimes a person who is prohibited from purchasing a gun engages someone else, who is not so prohibited, to purchase a gun for him or her. The person doing the buying is called a “straw purchaser.” Straw purchase attempts are not uncommon; in a random sample of 1,601 licensed dealers and pawnbrokers in 43 states, two thirds reported experiencing straw purchase attempts (Wintemute, 2013b).

Two studies tested the integrity of licensed firearm dealers by calling the dealers and asking whether they could purchase a handgun on behalf of someone else (in the studies, a boyfriend or girlfriend), a straw purchase transaction that is illegal. In the study of a sample of gun dealers listed in telephone directories of the 20 largest U.S. cities, the majority of gun dealers indicated a willingness to sell a handgun under the illegal straw purchase scenario (Sorenson & Vittes, 2003). In a similar study of licensed gun dealers in California, a state with relatively strong regulation and oversight of licensed gun dealers, one in five dealers expressed a willingness to make the illegal sale (Wintemute, 2010). Programs such as the ATF and National Sports Shooting Council’s “Don’t Lie for the Other Guy,” which provides posters and educational materials to display in gun stores as well as tips for gun dealers on how to identify and respond to straw purchase attempts, have not been evaluated.

It is important to be able to identify high-risk dealers because, in 2012, the ATF had insufficient resources to monitor federally licensed gun dealers (Horwitz, 2012); there were 134,997 unlicensed gun dealers in April 2013 (ATF, 2013). Some states have recognized the limited capacity of the ATF and the weaknesses of federal laws regulating gun dealers and enacted their own laws requiring the licensing, regulation, and oversight of gun dealers (Vernick, Webster, & Bulzacchelli, 2006) and, when enforced, these laws appear to reduce the diversion of guns to criminals shortly after a retail sale (Webster, Vernick, & Bulzacchelli, 2009). Undercover stings and lawsuits against gun dealers who facilitate illegal straw sales have also been shown to reduce the diversion of guns to criminals (Webster, Bulzacchelli, Zeoli, & Vernick, 2006; Webster & Vernick, 2013b).

To help ensure that guns are not sold to those who are prohibited from purchasing them, the National Instant Criminal Background Check System ([NICS], part of the Brady Law) was developed so that the status of a potential purchaser could be checked immediately by a federally licensed firearm dealer. Prohibited purchasers include, but are not limited to, convicted felons, persons dishonorably discharged from the military, those under a domestic violence restraining order, and, in the language of the federal law, persons who have been adjudicated as mentally defective or have been committed to any mental institution (see 18 U.S.C. § 922(g) (1)-(9) and (n)). About 0.6% of sales have been denied on the basis of these criteria since NICS was established in 1998 (FBI, 2012b).

A substantial portion of firearm sales and transfers, however, is not required to go through a federally licensed dealer or a background check requirement; this includes, in most U.S. states, private party sales including those that are advertised on the Internet and those that take place at gun shows where licensed gun dealers who could process background checks are steps away. Some evidence suggests that state policies regulating private handgun sales reduce the diversion of guns to criminals (Vittes, Vernick, & Webster, 2013; Webster et al., 2009; Webster, Vernick, McGinty, & Alcorn, 2013).

The ability to check the background of a potential purchaser nearly instantly means that in many states, someone who is not a prohibited purchaser can purchase a gun within a matter of minutes. Ten states and the District of Columbia have a waiting period (sometimes referred to as a “cooling-off” period) for handguns ranging from 3 (Florida and Iowa) to 14 (Hawaii) days (Law Center to Prevent Gun Violence, 2012). The efficacy of waiting periods has received little direct research attention.

With the exception of misdemeanor domestic violence assault, federal law and laws in most states prohibit firearm possession of those convicted of a crime only if the convictions are for felony offenses in adult courts. Research has shown that misdemeanants who were legally able to purchase handguns committed crimes involving violence following those purchases at a rate 2–10 times higher than that of handgun purchasers with no prior convictions (Wintemute, Drake, Beaumont, & Wright, 1998). Wintemute and colleagues (Wintemute, Wright, Drake, & Beaumont, 2001) examined the impact of a California law that expanded firearm prohibitions to include persons convicted of misdemeanor crimes of violence. In their study of legal handgun purchasers with criminal histories of misdemeanor violence before and after the law, denial of handgun purchases due to a prior misdemeanor conviction was associated with a significantly lower rate of subsequent violent offending.

Persons who are legally determined to be a danger to others or to themselves as a result of mental illness are prohibited by federal law from purchasing and possessing firearms. A significant impediment to successful implementation of this law is that the firearm disqualifications due to mental illness often are not reported to the FBI’s background check system. As mentioned earlier, in 2007 Connecticut began reporting these disqualifications to the background check system. In a ground-breaking study, Swanson and colleagues (2013) studied the effects of this policy change on individuals who would most likely be affected — that is, those who were legally prohibited from possessing firearms due solely to the danger posed by their mental illnesses. They found that the rate of violent crime offending was about half as high among those whose mental illness disqualification was reported to the background system compared with those whose mental illness disqualification was not reported.

Federal law allows an individual to buy several guns, even hundreds, at once; the only requirement is that a multiple-purchase form be completed (18 U.S.C. § 923(g)(3)(A)(2009)). Large bulk purchases have been linked to gun trafficking (Koper, 2005). Policies such as one-handgun-a-month have rarely been enacted. Evaluations of these laws document mixed findings (Webster et al., 2009, 2013;Weil & Knox, 1996).

The United States was one of the signers of the Geneva Convention, which prohibits the use of hollow-point bullets in war (the goal being to wound but not kill wartime enemies), but hollow-point bullets are available to civilians in the United States. A hunting license is not a prerequisite for the purchase of hollow-point bullets in the United States. California passed a law requiring a thumbprint for ammunition purchases; the law was ruled “unconstitutionally vague” by a Superior Court judge in 2011, but some municipalities (e.g., Los Angeles, Sacramento) have similar local ordinances in effect.

In 2004, a national survey found that 20 percent of the U.S. adult population reported they own one or more long-guns (shotguns or rifles), and 16 percent reported they own a handgun (Hepburn et al., 2007). Self-protection was the primary reason for owning a gun. Most people who have a gun have multiple guns, and half of gun owners reported owning four or more guns. In fact, 4 percent of the population is estimated to own 65 percent of the guns in the nation.

Nationally representative studies suggest that the mental health of gun owners is similar to that of individuals who do not own guns (Miller, Barber, Azrael, Hemenway, & Molnar, 2009; Sorenson & Vittes, 2008). However, gun owners are more likely to binge drink and drink and drive (Wintemute, 2011).

In perhaps the methodologically strongest study to date to examine handgun ownership and mortality, Wintemute and colleagues found a strong association between the purchase of a handgun and suicide: “In the first year after the purchase of a handgun, suicide was the leading cause of death among handgun purchasers, accounting for 24.5 percent of all deaths” (Wintemute, Parham, Beaumont, Wright, & Drake, 1999). The risk of suicide remained elevated (nearly twofold and sevenfold, respectively, for male and female handgun purchasers) at the end of the 6-year study period. Men’s handgun purchase was associated with a reduced risk of becoming a homicide victim (0.69); women’s handgun purchase, by contrast, was associated with a 55 percent increase in risk of becoming a homicide victim. A waiting period may reduce immediate risk but appears not to eliminate short- or long-term risk for suicide.

Risk can extend to others in the home. Efforts to educate children about guns (largely to stay away from them), when tested with field experiments, indicate they are generally ineffective (e.g., Hardy, 2002). Child Access Prevention (CAP) laws focus on the responsibilities of adults; adults are held criminally liable for unsafe storage of firearms around children. CAP laws have been associated with modest decreases in unintentional shootings of children and the suicides of adolescents (Webster & Starnes, 2000; Webster, Vernick, Zeoli, & Manganello, 2004).

Most gun-related laws focus on the user of the gun (e.g., increased penalties for using a gun in the commission of a crime). Some research suggests that having been threatened with a gun, as well as the perpetrator’s having access to a gun and using a gun during the fatal incident, is associated with increased risk of women becoming victims of intimate partner homicide (Campbell et al., 2003). Regarding sales, note that persons with a domestic violence misdemeanor or under a domestic violence restraining order are prohibited by federal law from purchasing and possessing a firearm and ammunition. Research to date indicates that firearm restrictions for persons subject to such laws have reduced intimate partner homicides by 6 percent to 19 percent (Vigdor & Mercy, 2006; Zeoli & Webster, 2010).

As with initial discussions about motor vehicle safety, which focused on what was then referred to as the “nut behind the wheel,” current discussions about gun users sometimes involve terms such as “good guys” and “bad guys.” Although intuitively appealing, such categories seem to assume a static label and do not take into account the fact that “good guys” can become “bad guys” and “bad guys” can become “good guys.” One way an armed “good guy” can become a “bad guy” is to use a gun in a moment of temporary despondence or rage (Bandeira, 2013; Wintemute, 2013a).

Research on near-miss suicide attempts among young adults indicates that impulsivity is of concern. About one fourth of those whose suicide attempt was so severe they most likely would have died reported first thinking about suicide five minutes before attempting it (Simon et al., 2001). Although an estimated 90 percent of those who attempt suicide go on to die of something else (i.e., they do not subsequently kill themselves; for a review, see Bostwick & Pankratz, 2000), for those who use a gun, as noted in opening paragraph of this chapter, there generally is not a second chance.

Given the complexity of the issue, a multifaceted approach will be needed to reduce firearm-related violence (see, for example, Chapman & Alpers, 2013). Not all ideas that on the surface seem to be useful actually are. For example, gun buyback programs may raise awareness of guns and gun violence in a community but have not been shown to reduce mortality (Makarios & Pratt, 2012). Such data can inform policy. President Obama’s January 2013 executive orders about gun violence include directing the CDC to research the causes and prevention of gun violence. The federal government has since announced several funding opportunities for research related to gun violence. And the recent Institute of Medicine and National Research Council (2013) report called for lifting access restrictions on gun-related administrative data (e.g., data related to dealers’ compliance with firearm sales laws, gun trace data) that could be used to identify potential intervention and prevention points and strategies. So perhaps more data will be available to inform and evaluate policies designed to reduce gun violence.

The focus of this section has largely been on mortality. The scope of the problem is far greater, however. For every person who dies of a gunshot wound, there are an estimated 2.25 people who are hospitalized or receive emergency medical treatment for a nonfatal gunshot wound (Gotsch, Annest, Mercy, & Ryan, 2001). And guns are used in the street and in the home to intimidate and coerce (e.g., Sorenson & Wiebe, 2004; Truman, 2011).

Single policies implemented by themselves have been shown to reduce certain forms of gun violence in the United States. Adequate implementation and enforcement as well as addressing multiple intervention points simultaneously may improve the efficacy of these laws even more. After motor vehicle safety efforts expanded to include the vehicle, roadways, and other intervention points (vs. a focus on individual behavior), motor vehicle deaths dropped precipitously and continue to decline (CDC, 1999, 2013a). A multifaceted approach to reducing gun violence will serve the nation well.

3 The 2010 data used to calculate current rates shown here are available at http://www.cdc.gov/injury/wisqars/ .

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APA Panel of Experts

Dewey Cornell, PhD Clinical Psychologist and Professor of Education Curry School of Education University of Virginia

Arthur C. Evans Jr., PhD Commissioner Department of Behavioral Health and Intellectual disAbility Services Philadelphia, Pa.   Nancy G. Guerra, EdD (Coordinating Editor) Professor of Psychology Associate Provost for International Programs Director, Institute for Global Studies University of Delaware   Robert Kinscherff, PhD, JD Associate Vice President for Community Engagement Massachusetts School of Professional Psychology Senior Associate National Center for Mental Health and Juvenile Justice   Eric Mankowski, PhD Professor of Psychology Department of Psychology Portland State University

Marisa R. Randazzo, PhD Managing Partner SIGMA Threat Management Associates Alexandria, Va.   Ellen Scrivner, PhD, ABPP Executive Fellow Police Foundation Washington, D.C.   Susan B. Sorenson, PhD Professor of Social Policy / Health & Societies Senior Fellow in Public Health University of Pennsylvania

W. Douglas Tynan, PhD, ABPP Professor of Pediatrics Jefferson Medical College Thomas Jefferson University   Daniel W. Webster, ScD, MPH Professor and Director Center for Gun Policy and Research Johns Hopkins Bloomberg School of Public Health

We are grateful to the following individuals for their thoughtful reviews and comments on drafts of this report:   Louise A. Douce, PhD Special Assistant, Office of Student Life Adjunct Faculty, Department of Psychology The Ohio State University   Joel A. Dvoskin, PhD, ABPP Department of Psychiatry University of Arizona   Ellen G. Garrison, PhD Senior Policy Advisor American Psychological Association   Melissa Strompolis, MA Doctoral Candidate University of North Carolina at Charlotte   Mathilde Pelaprat, PsyD , provided writing and research assistance on Chapter 2.

Rhea Farberman, APR Executive Director Public and Member Communications American Psychological Association

Editorial and Design Services Deborah C. Farrell, Editor │ Elizabeth F. Woodcock, Designer

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Youth Exposure to Endemic Community Gun Violence: A Systematic Review

• Systematic Review
• Published: 02 February 2022
• Volume 7 , pages 383–417, ( 2022 )

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• Pilar Bancalari   ORCID: orcid.org/0000-0002-2808-6550 1 ,
• Marni Sommer 1 &
• Sonali Rajan 2 , 3  

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Community gun violence persists as a daily reality for many youth in low-income urban communities. While most gun violence research has focused on the direct victims of firearm homicide, exploration into the broader public health repercussions of community gun violence on youth has lagged. This systematic review aimed to synthesize and critically assess the state of evidence on indirect exposure to community gun violence among low-income urban youth in the U.S. PubMed, Web of Science, ProQuest, and SCOPUS were searched for peer-reviewed articles exploring the scope, risk factors, and impacts of community gun violence exposure on this population. Of the 143 studies identified and screened, 13 studies were ultimately included. The broad themes emerging include (1) a lack of consensus regarding the range of experiences that constitute community gun violence, (2) exposure to violence involving a firearm as distinct from that with other weapons, (3) a need to conceptualize multiple dimensions of gun violence exposure, (4) differential impacts of exposure to community gun violence across developmental stages, and (5) how indirect gun violence exposure uniquely contributes to cycles of community violence. Future research must move toward a consistent typology, multidimensional conceptualization, and developmental- and context-specific examination of community gun violence exposure.

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The authors would like to extend their thanks to John Usseglio from the Augustus C. Long Health Sciences Library at Columbia University Irving Medical Center for his consultation in developing a rigorous search strategy for this review.

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Bancalari, P., Sommer, M. & Rajan, S. Youth Exposure to Endemic Community Gun Violence: A Systematic Review. Adolescent Res Rev 7 , 383–417 (2022). https://doi.org/10.1007/s40894-022-00178-5

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Firearms and Violence: A Critical Review (2005)

Chapter: executive summary, executive summary.

T here is hardly a more contentious issue in American politics than the ownership of guns and various proposals for gun control. Each year tens of thousands of people are injured and killed by firearms; each year firearms are used to defend against and deter an unknown number of acts of violence; and each year firearms are widely used for recreational purposes. For public authorities to make reasonable policies on these matters, they must take into account conflicting constitutional claims and divided public opinion as well as facts about the relationship between guns and violence. And in doing so they must try to strike what they regard as a reasonable balance between the costs and the benefits of private gun ownership.

Adequate data and research are essential to judge both the effects of firearms on violence and the effects of different violence control policies. Those judgments are key to many important policy questions, among them: Should regulations restrict who may possess and carry a firearm? Should regulations differ for different types of firearms? Should purchases be delayed and, if so, for how long and under what circumstances? Should restrictions be placed on the number or types of firearms that can be purchased? Should safety locks be required? While there is a large body of empirical research on firearms and violence, there is little consensus on even the basic facts about these important policy issues.

Given the importance of these issues and the continued controversy surrounding the debate on firearms, the Committee to Improve Research Information and Data on Firearms was charged with providing an assessment of the strengths and limitations of the existing research and data on gun violence

and identifying important gaps in knowledge; describing new methods to put research findings and data together to support the design and implementation of improved prevention, intervention, and control strategies for reducing gun-related crime, suicide, and accidental fatalities; and utilizing existing data and research on firearms and firearm violence to develop models of illegal firearms markets. The charge also called for examining the complex ways in which firearm violence may become embedded in community life and considering whether firearm-related homicide and suicide have become accepted as ways of resolving problems, especially among youth. However, there is a lack of empirical research to address these two issues.

MAJOR CONCLUSIONS

Empirical research on firearms and violence has resulted in important findings that can inform policy decisions. In particular, a wealth of descriptive information exists about the prevalence of firearm-related injuries and deaths, about firearms markets, and about the relationships between rates of gun ownership and violence. Research has found, for example, that higher rates of household firearms ownership are associated with higher rates of gun suicide, that illegal diversions from legitimate commerce are important sources of crime guns and guns used in suicide, that firearms are used defensively many times per day, and that some types of targeted police interventions may effectively lower gun crime and violence. This information is a vital starting point for any constructive dialogue about how to address the problem of firearms and violence.

While much has been learned, much remains to be done, and this report necessarily focuses on the important unknowns in this field of study. The committee found that answers to some of the most pressing questions cannot be addressed with existing data and research methods, however well designed. For example, despite a large body of research, the committee found no credible evidence that the passage of right-to-carry laws decreases or increases violent crime, and there is almost no empirical evidence that the more than 80 prevention programs focused on gun-related violence have had any effect on children’s behavior, knowledge, attitudes, or beliefs about firearms. The committee found that the data available on these questions are too weak to support unambiguous conclusions or strong policy statements.

Drawing causal inferences is always complicated and, in the behavioral and social sciences, fraught with uncertainty. Some of the problems that the committee identifies are common to all social science research. In the case of firearms research, however, the committee found that even in areas in which the data are potentially useful, the complex methodological prob-

lems inherent in unraveling causal relationships between firearms policy and violence have not been fully considered or adequately addressed.

Nevertheless, many of the shortcomings described in this report stem from the lack of reliable data itself rather than the weakness of methods. In some instances—firearms violence prevention, for example—there are no data at all. Even the best methods cannot overcome inadequate data and, because the lack of relevant data colors much of the literature in this field, it also colors the committee’s assessment of that literature.

DATA RECOMMENDATIONS

If policy makers are to have a solid empirical and research base for decisions about firearms and violence, the federal government needs to support a systematic program of data collection and research that specifically addresses that issue. Adverse outcomes associated with firearms, although large in absolute numbers, are statistically rare events and therefore are not observed with great frequency, if at all, in many ongoing national probability samples (i.e., on crime victimization or health outcomes). The existing data on gun ownership, so necessary in the committee’s view to answering policy questions about firearms and violence, are limited primarily to a few questions in the General Social Survey. There are virtually no ongoing, systematic data series on firearms markets. Aggregate data on injury and ownership can only demonstrate associations of varying strength between firearms and adverse outcomes of interest. Without improvements in this situation, the substantive questions in the field about the role of guns in suicide, homicide and other crimes, and accidental injury are likely to continue to be debated on the basis of conflicting empirical findings.

Emerging Data Systems on Violent Events

The committee reinforces recommendations made by past National Research Council committees and others to support the development and maintenance of the National Violent Death Reporting System and the National Incident-Based Reporting System. These data systems are designed to provide information that characterizes violent events. No single system will provide data that can answer all policy questions, but the necessary first step is to collect accurate and reliable information to describe the basic facts about violent injuries and deaths. The committee is encouraged by the efforts of the Harvard School of Public Health’s Injury Control Research Center pilot data collection program and the recent seed money provided to implement a Violent Death Reporting System at the Centers for Disease Control and Prevention.

Ownership Data

The inadequacy of data on gun ownership and use is among the most critical barriers to better understanding of gun violence. Such data will not by themselves solve all methodological problems. However, its almost complete absence from the literature makes it extremely difficult to understand the complex personality, social, and circumstantial factors that intervene between a firearm and its use. Also difficult to understand is the effect, if any, of programs designed to reduce the likelihood that a firearm will cause unjustified harm, or to investigate the effectiveness of firearm use in self-defense. We realize that many people have deeply held concerns about expanding the government’s knowledge of who owns guns and what type of guns they own. We also recognize the argument that some people may refuse to supply such information in any system, especially those who are most likely to use guns illegally. The committee recommends a research effort to determine whether or not these kinds of data can be accurately collected with minimal risk to legitimate privacy concerns.

A starting point is to assess the potential of ongoing surveys. For example, efforts should be undertaken to assess whether tracing a larger fraction of guns used in crimes, regularly including questions on gun access and use in surveys and longitudinal studies (as is done in data from the ongoing, yearly Monitoring the Future survey), or enhancing existing items pertaining to gun ownership in ongoing national surveys may provide useful research data. To do this, researchers need access to the data. The committee recommends that appropriate access be given to data maintained by regulatory and law enforcement agencies, including the trace data maintained by the Bureau of Alcohol, Tobacco, and Firearms; registration data maintained by the Federal Bureau of Investigation and state agencies; and manufacturing and sales data for research purposes.

In addition, researchers need appropriate access to the panel data from the Monitoring the Future survey. These data may or may not be useful for understanding firearms markets and the role of firearms in crime and violence. However, without access to these systems, researchers are unable to assess their potential for providing insight into some of the most important firearms policy and research questions. Concerns about security and privacy must be addressed in the granting of greater access to these data, and the systems will need to be continually improved to make them more useful for research. Nevertheless, there is a long-established tradition of making sensitive data available with appropriate safeguards to researchers.

Methodological Approaches

Difficult methodological issues exist regarding how different data sets might be used to credibly answer the complex causal questions of interest.

The committee recommends that a methodological research program be established to address these problems. The design for data collection and analysis should be selected in light of particular research questions. For example, how, if at all, could improvements in current data, such as firearms trace data, be used in studies of the effects of policy interventions on firearms markets or any other policy issue? What would the desired improvements contribute to research on policy interventions for reducing firearms violence? Linking the research and data questions will help define the data that are needed. We recommend that the results of such research be regularly reported in the scientific literature and in forums accessible to investigators.

RESEARCH RECOMMENDATIONS

Firearms, criminal violence, and suicide.

Despite the richness of descriptive information on the associations between firearms and violence at the aggregate level, explaining a violent death is a difficult business. Personal temperament, the availability of weapons, human motivation, law enforcement policies, and accidental circumstances all play a role in leading one person but not another to inflict serious violence or commit suicide.

Because of current data limitations, researchers have relied primarily on two different methodologies. First, some studies have used case-control methods, which match a sample of cases, namely victims of homicide or suicide, to a sample of controls with similar characteristics but who were not affected by violence. Second, some “ecological” studies compare homicide or suicide rates in large geographic areas, such as counties, states, or countries, using existing measures of ownership.

Case-control studies show that violence is positively associated with firearms ownership, but they have not determined whether these associations reflect causal mechanisms. Two main problems hinder inference on these questions. First and foremost, these studies fail to address the primary inferential problems that arise because ownership is not a random decision. For example, suicidal persons may, in the absence of a firearm, use other means of committing suicide. Homicide victims may possess firearms precisely because they are likely to be victimized. Second, reporting errors regarding firearms ownership may systemically bias the results of estimated associations between ownership and violence.

Ecological studies currently provide contradictory evidence on violence and firearms ownership. For example, in the United States, suicide appears to be positively associated with rates of firearms ownership, but homicide is not. In contrast, in comparisons among countries, the association between

rates of suicide and gun ownership is nonexistent or very weak but there is a substantial association between gun ownership and homicide. These cross-country comparisons reflect the fact that the suicide rate in the United States ranks toward the middle of industrialized countries, whereas the U.S. homicide rate is much higher than in all other developed countries.

The committee cannot determine whether these associations demonstrate causal relationships. There are three key problems. First, as noted above, these studies do not adequately address the problem of self-selection. Second, these studies must rely on proxy measures of ownership that are certain to create biases of unknown magnitude and direction. Third, because the ecological correlations are at a higher geographic level of aggregation, there is no way of knowing whether the homicides or suicides occurred in the same areas in which the firearms are owned.

In summary, the committee concludes that existing research studies and data include a wealth of descriptive information on homicide, suicide, and firearms, but, because of the limitations of existing data and methods, do not credibly demonstrate a causal relationship between the ownership of firearms and the causes or prevention of criminal violence or suicide. The issue of substitution (of the means of committing homicide or suicide) has been almost entirely ignored in the literature. What sort of data and what sort of studies and improved models would be needed in order to advance understanding of the association between firearms and suicide? Although some knowledge may be gained from further ecological studies, the most important priority appears to the committee to be individual-level studies of the association between gun ownership and violence. Currently, no national surveys on ownership designed to examine the relationship exist. The committee recommends support of further individual-level studies of the link between firearms and both lethal and nonlethal suicidal behavior.

Deterrence and Defense

Although a large body of research has focused on the effects of firearms on injury, crime, and suicide, far less attention has been devoted to understanding the defensive and deterrent effects of firearms. Firearms are used by the public to defend against crime. Ultimately, it is an empirical question whether defensive gun use and concealed weapons laws generate net social benefits or net social costs.

Defensive Gun Use

Over the past decade, a number of researchers have conducted studies to measure the prevalence of defensive gun use in the population. However, disagreement over the definition of defensive gun use and uncertainty over the

accuracy of survey responses to sensitive questions and the methods of data collection have resulted in estimated prevalence rates that differ by a factor of 20 or more. These differences in the estimated prevalence rates indicate either that each survey is measuring something different or that some or most of them are in error. Accurate measurement on the extent of defensive gun use is the first step for beginning serious dialogue on the efficacy of defensive gun use at preventing injury and crime.

For such measurement, the committee recommends that a research program be established to (1) clearly define and understand what is being measured, (2) understand inaccurate response in the national gun use surveys, and (3) apply known methods or develop new methods to reduce reporting errors to the extent possible. A substantial research literature on reporting errors in other contexts, as well as well-established survey sampling methods, can and should be brought to bear to evaluate these response problems.

Right-to-Carry Laws

A total of 34 states have laws that allow qualified adults to carry concealed handguns. Right-to-carry laws are not without controversy: some people believe that they deter crimes against individuals; others argue that they have no such effect or that they may even increase the level of firearms violence. This public debate has stimulated the production of a large body of statistical evidence on whether right-to-carry laws reduce or increase crimes against individuals.

However, although all of the studies use the same basic conceptual model and data, the empirical findings are contradictory and in the committee’s view highly fragile. Some studies find that right-to-carry laws reduce violent crime, others find that the effects are negligible, and still others find that such laws increase violent crime. The committee concludes that it is not possible to reach any scientifically supported conclusion because of (a) the sensitivity of the empirical results to seemingly minor changes in model specification, (b) a lack of robustness of the results to the inclusion of more recent years of data (during which there were many more law changes than in the earlier period), and (c) the statistical imprecision of the results. The evidence to date does not adequately indicate either the sign or the magnitude of a causal link between the passage of right-to-carry laws and crime rates. Furthermore, this uncertainty is not likely to be resolved with the existing data and methods. If further headway is to be made, in the committee’s judgment, new analytical approaches and data are needed. (One committee member has dissented from this view with respect to the effects of these laws on homicide rates; see Appendix A .)

Interventions to Reduce Violence and Suicide

Even if it were to be shown that firearms are a cause of lethal violence, the development of successful programs to reduce such violence would remain a complex undertaking, because such interventions would have to address factors other than the use of a gun. Three chapters in this report focus specifically on what is known about various interventions aimed at reducing firearms violence by restricting access, or implementing prevention programs, or implementing criminal justice interventions. These chapters focus largely on what is known about the effects of different interventions on criminal violence. Although suicide prevention rarely has been the basis for public support of the passage of specific gun laws, such laws could have unintended effects on suicide rates or unintended by-products. Thus, in addition to the recommendations related to firearms and crime below, the committee also recommends further studies of the link between firearms policy and suicide.

Restricting Access

Firearms are bought and sold in markets, both formal and informal. To some observers this suggests that one method for reducing the burden of firearm injuries is to intervene in these markets so as to make it more expensive, inconvenient, or legally risky to obtain firearms for criminal use or suicide. Market-based interventions intended to reduce access to guns by criminals and other unqualified persons include taxes on weapons and ammunition, tough regulation of federal firearm licensees, limits on the number of firearms that can be purchased in a given time period, gun bans, gun buy-backs, and enforcement of laws against illegal gun buyers or sellers.

Because of the pervasiveness of guns and the variety of legal and illegal means of acquiring them, it is difficult to keep firearms from people barred by law from possessing them. The key question is substitution. In the absence of the pathways currently used for gun acquisition, could individuals have obtained alternative weapons with which they could have wrought equivalent harm? Substitution can occur in many dimensions: offenders can obtain different guns, they can get them from different places, and they can get them at different times.

Arguments for and against a market-based approach are now largely based on speculation, not on evidence from research. It is simply not known whether it is actually possible to shut down illegal pipelines of guns to criminals nor the costs of doing so. Answering these questions is essential to knowing whether access restrictions are a possible public policy. The committee has not attempted to identify specific interventions, research strategies, or data that might be suited to studying market interventions, substitu-

tion, and firearms violence. Rather, the committee recommends that work be started to think carefully about possible research and data designs to address these issues.

Prevention Programs and Technology

Firearm violence prevention programs are disseminated widely in U.S. public school systems to children ages 5 to 18, and safety technologies have been suggested as an alternative means to prevent firearm injuries. The actual effects of a particular prevention program on violence and injury, however, have been little studied and are difficult to predict. For children, firearm violence education programs may result in increases in the very behaviors they are designed to prevent, by enhancing the allure of guns for young children and by establishing a false norm of gun-carrying for adolescents. Likewise, even if perfectly reliable, technology that serves to reduce injury among some groups may lead to increased deviance or risk among others.

The committee found little scientific basis for understanding the effects of different prevention programs on the rates of firearm injuries. Generally, there has been scant funding for evaluation of these programs. For the few that have been evaluated, there is little empirical evidence of positive effects on children’s knowledge, attitudes, beliefs, or behaviors. Likewise, the extent to which different technologies affect injuries remains unknown. Often, the literature is entirely speculative. In other cases, for example the empirical evaluations of child access prevention (CAP) laws, the empirical literature reveals conflicting estimates that are difficult to reconcile.

In light of the lack of evidence, the committee recommends that firearm violence prevention programs should be based on general prevention theory, that government programs should incorporate evaluation into implementation efforts, and that a sustained body of empirical research be developed to study the effects of different safety technologies on violence and crime.

Criminal Justice Interventions

Policing and sentencing interventions have had recent broad bipartisan support and are a major focus of current efforts to reduce firearms violence. These policies generally do not affect the ability of law-abiding citizens to keep guns for recreation or self-defense, and they have the potential to reduce gun violence by deterring or incapacitating violent offenders. Descriptive accounts suggest that some of these policies may have had dramatic crime-reducing effects: homicide rates fell dramatically after the implementation of Boston’s targeted policing program, Operation Ceasefire, and Richmond’s sentencing enhancement program, Project Exile.

Despite these apparent associations between crime and policing policy, however, the available research evidence on the effects of policing and sentencing enhancements on firearm crime is limited and mixed. Some sentencing enhancement policies appear to have modest crime-reducing effects, while the effects of others appear to be negligible. The limited evidence on Project Exile suggests that it has had almost no effect on homicide. Several city-based quasi-random interventions provide favorable evidence on the effectiveness of targeted place-based gun and crime suppression patrols, but this evidence is both application-specific and difficult to disentangle. Evidence on Operation Ceasefire, perhaps the most frequently cited of all targeted policing efforts to reduce firearms violence, is limited by the fact that it is a single case at a specific time and location. Scientific support for the effectiveness of the Boston Gun Project and most other similar types of targeted policing programs is still evolving.

The lack of research on these potentially important kinds of policies is an important shortcoming in the body of knowledge on firearms injury interventions. These programs are widely viewed as effective, but in fact knowledge of whether and how they reduce crime is limited. Without a stronger research base, policy makers considering adoption of similar programs in other settings must make decisions without knowing the true benefits and costs of these policing and sentencing interventions.

The committee recommends that a sustained, systematic research program be conducted to assess the effect of targeted policing and sentencing aimed at firearms offenders. Additional insights may be gained from using observational data from different applications, especially if combined with more thoughtful behavioral models of policing and crime. City-level studies on the effect of sentencing enhancement policies need to engage more rigorous methods, such as pooled time-series cross-sectional studies that allow the detection of short-term impacts while controlling for variation in violence levels across different areas as well as different times. Another important means of assessing the impact of these types of targeted policing and sentencing interventions would be to conduct randomized experiments to disentangle the effects of the various levers, as well as to more generally assess the effectiveness of these targeted policing programs.

For years proposals for gun control and the ownership of firearms have been among the most contentious issues in American politics. For public authorities to make reasonable decisions on these matters, they must take into account facts about the relationship between guns and violence as well as conflicting constitutional claims and divided public opinion. In performing these tasks, legislators need adequate data and research to judge both the effects of firearms on violence and the effects of different violence control policies.

Readers of the research literature on firearms may sometimes find themselves unable to distinguish scholarship from advocacy. Given the importance of this issue, there is a pressing need for a clear and unbiased assessment of the existing portfolio of data and research. Firearms and Violence uses conventional standards of science to examine three major themes - firearms and violence, the quality of research, and the quality of data available. The book assesses the strengths and limitations of current databases, examining current research studies on firearm use and the efforts to reduce unjustified firearm use and suggests ways in which they can be improved.

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1. Where there are more guns there is more homicide (literature review )

Our review of the academic literature found that a broad array of evidence indicates that gun availability is a risk factor for homicide, both in the United States and across high-income countries.  Case-control studies, ecological time-series and cross-sectional studies indicate that in homes, cities, states and regions in the U.S., where there are more guns, both men and women are at a higher risk for homicide, particularly firearm homicide.

Hepburn, Lisa; Hemenway, David .  Firearm availability and homicide: A review of the literature.  Aggression and Violent Behavior: A Review Journal .  2004; 9:417-40.

2. Across high-income nations, more guns = more homicide

We analyzed the relationship between homicide and gun availability using data from 26 developed countries from the early 1990s.  We found that across developed countries, where guns are more available, there are more homicides.  These results often hold even when the United States is excluded.

Hemenway, David; Miller, Matthew .  Firearm availability and homicide rates across 26 high income countries.  Journal of Trauma .  2000; 49:985-88.

3. Across states, more guns = more homicide

Using a validated proxy for firearm ownership, we analyzed the relationship between firearm availability and homicide across 50 states over a ten-year period (1988-1997).

After controlling for poverty and urbanization, for every age group, people in states with many guns have elevated rates of homicide, particularly firearm homicide.

Miller, Matthew; Azrael, Deborah; Hemenway, David .  Household firearm ownership levels and homicide rates across U.S. regions and states, 1988-1997.   American Journal of Public Health .  2002; 92:1988-1993.

4. Across states, more guns = more homicide (2)

Using survey data on rates of household gun ownership, we examined the association between gun availability and homicide across states, 2001-2003.  We found that states with higher levels of household gun ownership had higher rates of firearm homicide and overall homicide.  This relationship held for both genders and all age groups, after accounting for rates of aggravated assault, robbery, unemployment, urbanization, alcohol consumption, and resource deprivation (e.g., poverty).  There was no association between gun prevalence and non-firearm homicide.

Miller, Matthew; Azrael, Deborah; Hemenway, David.   State-level homicide victimization rates in the U.S. in relation to survey measures of household firearm ownership, 2001-2003 .  Social Science and Medicine .  2007; 64:656-64.

5. A summary of the evidence on guns and violent death

This book chapter summarizes the scientific literature on the relationship between gun prevalence (levels of household gun ownership) and suicide, homicide and unintentional firearm death and concludes that where there are higher levels of gun ownership, there are more gun suicides and more total suicides, more gun homicides and more total homicides, and more accidental gun deaths.

This is the first chapter in the book and provides and up-to-date and readable summary of the literature on the relationship between guns and death.  It also adds to the literature by using the National Violent Death Reporting System data to show where (home or away) the shootings occurred.  Suicides for all age groups and homicides for children and aging adults most often occurred in their own home.

Miller M, Azrael D, Hemenway D .  Firearms and violence death in the United States.  In: Webster DW, Vernick JS, eds.  Reducing Gun Violence in America .  Baltimore MD: Johns Hopkins University Press, 2013.

6. More guns = more homicides of police

This article examines homicide rates of Law Enforcement Officers (LEOs) from 1996 to 2010.  Differences in rates of homicides of LEOs across states are best explained not by differences in crime, but by differences in household gun ownership.  In high gun states, LEOs are 3 times more likely to be murdered than LEOs working in low-gun states.

This article was cited by President Obama in a speech to a police association.  This article will hopefully bring police further into the camp of those pushing for sensible gun laws.

Swedler DI, Simmons MM, Dominici F, Hemenway D .  Firearm prevalence and homicides of law enforcement officers in the United States.  American Journal of Public Health .  2015; 105:2042-48.

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Model programs guide literature review: gun violence and youth.

This literature review focuses on intentional gun violence committed by youths ages 10-24, which includes homicides (both victimization and perpetration), nonfatal injuries, suicides, community violence, and school violence/school shootings.

Unintentional gun violence, such as accidental injuries or deaths by guns was not included in the literature review. The information presented from the literature review addresses the scope of the problem of youth as victims and perpetrators of gun violence in the Untied States, risk and protective factors for youth gun violence, policy research on guns, public health perspective on gun violence, and evidence- based practices and programs found to significantly reduce the occurrence of gun violence. In this regard, the literature review found evidence that interventions can reduce violent crime by juveniles and gun violence in general; however, there is less evidence that supports reductions in juvenile gun violence. The most promising program strategies found in the literature are community interventions such as Operation Ceasefire, "hot spots" policing strategies, weapon ban laws, and strict probation requirements for juvenile gun offenders. The meta-analysis found that enhanced prison terms, waiting periods, and background checks had little impact on reducing gun violence. No significant relationships were found between reduced gun crimes and prosecutorial strategies such as harsher sentencing, safe storage laws, and gun buy-back programs. Another issue identified in the literature review was the lack of research that focused on the causes, correlates, and consequences of youth gun violence. Specific and well-defined research on the prevalence and predictors of youth violence would inform future policies and programs designed to reduce youth gun violence. Approximately 120 references

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