Psychosocial Impacts of Non-Fatal Firearm Injuries on Youth: Findings from a Qualitative Study

Abstract

Most adolescents and young adult victims of firearm violence survive, yet the mental and behavioral health outcomes associated with these incidents remain understudied. Given the potential for recurrent violence victimization and long-term psychosocial sequela after being shot, understanding the experiences of firearm injury survivors is a critical area for development. We conducted a qualitative study to explore the development of attitudes, describe psychosocial consequences, and contextualize behavioral and social outcomes among young, gunshot wounded (GSW) patients from a Level 1 trauma center in southeast Texas. A retrospective chart review and prospective recruitment of GSW patients aged 15 to 29 years old was conducted between January 2019 and February 2023. A semi-structured, individual interview was conducted via Zoom with 11 participants (8 interpersonal assault survivors and 3 survivors of unintentional/accidental self-shootings). Most participants were shot 1 to 2 years prior to the interview. Themes included: (1) post-traumatic stress symptoms persisted, marked by flashbacks, paranoia, distrust, and anxiety. This led to sleep loss, marijuana use, and loss of enjoyment in activities; (2) loneliness and social isolation were directly related to the injuries and common among young adults who incurred body image alterations; and (3) fervor for firearm ownership, carriage, and gun use increased post-injury. Healthcare systems and the larger community have important roles to play in promoting mental healing and enhancing societal safety through research and practice.

Keywords

gun violence mental health trauma survivorship young adults

Highlight

● The number of non-fatal firearm injuries far outnumbers firearm fatalities, yet we know very little about the psychological, social, and behavioral health outcomes among survivors. This qualitative inquiry provides context for the increased risk of violent re-injury among young adult gunshot wound survivors and highlights their complex psychological experiences related to post-trauma, body image, and loneliness. Implications for healing and prevention are examined across individual, healthcare, and community contexts.

Background

Firearm violence is the leading cause of death among adolescents and young adults in the United States.¹ Among youth ages 15 to 29 in 2022, the death rate due to firearm-related injuries of all types (homicide, suicide, unintentional, undetermined) was 21.91 per 100 000 people, or 14,581 deaths.² Despite these alarming fatality rates, 71% of all wounded victims survive,³ and surprisingly little is known about the long-term mental, behavioral, and social health effects of gunshot wound (GSW) survivors. Evidence supports poor long-term health and social outcomes among GSW survivors. For example, approximately 37% of assault-related survivors, including those due to GSW, require repeat emergency medical treatment due to violent re-injury within 2 years.⁴ GSW survivors are at significantly greater risk for a subsequent firearm-related hospitalization, death, and firearm or violence-related arrest, compared to patients who are hospitalized for noninjury reasons.⁵ Furthermore, high cumulative exposure to gun violence, especially as a GSW survivor, is associated with both aggression and depression, which further increases risk for perpetrating interpersonal violence and suicidal ideation.^6,7 Less is known about contexts which may explain the linkages between GSW survivorship and subsequent health risks.

One of the most well-established consequences of a GSW injury is Post-traumatic Stress Disorder (PTSD).⁸ About 49% to 60% of all GSW patients are diagnosed with PTSD within 1 year,⁹ but this is likely underestimated due to challenges in patient follow-up. The impact of PTSD and prolonged, chronic PTSD, can be particularly devastating in the formative years of adolescence and young adulthood (ie, 15-29 years old).^8,10 This age group is marked by developing and establishing social networks, increasing independence, mobility, and multiple life transitions, all of which can be altered due to impaired psychosocial development associated with PTSD. PTSD is defined as a disorder resulting after a real or perceived life-threatening experience, marked by flashbacks, avoidance of activities, and chronic physiological disturbances (eg, inability to sleep, difficulty concentrating, guilt). Symptoms may lead to deleterious coping behaviors, such as increased substance and alcohol use.^11,12 This can impair cognitive judgment and increase outward behaviors, including aggression toward others. Increased understanding of psychosocial development and perceived experiences among GSW youth can inform prevention and treatment efforts. The purpose of the current study is to explore and contextualize psychological, behavioral, and social outcomes in young GSW survivors.

Methods

We conducted a qualitative study of young adult GSW patients after they had been discharged from a Level 1 trauma center in southeast Texas. The study was approved by the first author’s Institutional Review Board. Eligible individuals were 15 to 29 years old at the time of injury and English speaking. Incarcerated individuals and minors involved with state child welfare entities were excluded. All eligible participants were contacted, regardless of race, ethnicity, sex, gender, and other documented demographical characteristics noted in their patient health records.

Recruitment

The study began in August 2022. We screened participants through a retrospective chart review of GSW patients who were treated from January 2019 through August 2022, at which point patients were identified prospectively until February 2023. Prospective patients were identified at the trauma center by an injury prevention specialist and consented by phone by the primary investigator, a nurse scientist with research experience in firearm injury prevention (AD).^13
-18 A co-investigator (AW) and research assistant also consented patients into the study. Eligible, retrospective patients were contacted initially by mail or email, then by a maximum of 3 phone calls at least 1 day apart.

Participants signed and emailed consent forms to the study team, and a subsequent date was arranged to conduct a personal interview by Zoom platform. All participants were mailed a loadable debit card for $50 and a firearm safety lockbox after the interview. Participants were contacted afterwards by a research assistant to verify receipt of the incentives and to clarify any ambiguous interview comments.

Data Collection

We used a semi-structured interview guide to elicit descriptions about post-injury mental and behavioral sequelae, firearm ownership, and attitudes toward firearm use (see Appendix). The guide was developed by 2 nurse scientists (AD and IA), a medical student (AW), a qualitative violence prevention scholar (LW), and faculty with expertise in rehabilitation and disparities (MP). Interview questions were driven by Social Cognitive Theory, which infers that behaviors are influenced by environmental factors (social and physical) and cognition (e.g., attitudes).¹⁹ We adapted several questions from previous, trauma-focused qualitative work by LW and MP.^20,21 A nurse scientist and trained research assistant conducted the interviews. Participants had not previously met the nurse scientist in a clinical capacity. All interview transcriptions were outsourced to a professional transcription company. We stored and analyzed interviews and field notes using NVIVO, version 13. Each interview was coded by 2 of 4 co-investigators independently (AD, IA, AW, LD), then discussed for consensus and meaning. Senior faculty (LW, MP, JT, and JL) were consulted for conceptual feedback throughout the codebook development, thematic interpretations, and manuscript development.

Analysis

We used a classic, grounded theory research paradigm, whereby codes were assigned to demarcate concepts in the interview text, then compared to text in subsequent interviews, then relabeled if necessary to describe new concepts.²² The codebook was refined continuously throughout the data collection process (i.e., constant comparison), with some codes being defined a priori, based on concepts that we wanted to explore, and some that emerged as the interviews were analyzed. We began with 68 codes, refined and reduced the codes to 43, and created 16 subcodes. Related codes were grouped together to form categories (axial coding), and themes were developed as the relationships solidified between codes, and within and between categories. Trustworthiness was established through consensus between coders throughout the coding process, peer checking with senior researchers, and support from existing literature. The traditional definition of saturation was clarified by using criteria of conceptual depth, particularly through rich and detailed descriptions.²³ Data were analyzed concurrently with interpretation to assess conceptual depth. Authors adhered to the Consolidated criteria for reporting qualitative research (COREQ) checklist for qualitative studies.²⁴

Results

A total of 139 names were retrieved from medical records, which fit the age criteria (15-29 years at hospital admission), years of interest (January 2019-February 2023), and criteria for hospital admission (gunshot wound). Eight names were removed due to the patient being deceased, incarcerated, or having a restricted medical chart. Of the final 131 names, the study recruited 11 participants (8%). The remaining eligible participants were not consented due to incorrect contact information or no response to phone calls (n = 95, 73%), patient or parent declining participation (n = 15, 11%) or agreeing to participate initially but being unable to reach for the interview (n = 10, 8%). Of the final 11 participants who were included in the study, 9 participants were male, the median age was 23, and the median time elapsed since injury was 1.5 years. The group was racially and ethnically diverse (4 Black, 4 Hispanic White, 3 Non-Hispanic White participants). See Table 1 for participant characteristics. Despite our low sample size, the racial/ethnic composition of our sample represented the diversity within southeast Texas, and our ratio of female to male participants matched the national firearm-related injury statistics by sex.²⁵ The interviews lasted approximately 1 hour.

Table 1.

Participant Characteristics.

Participant	Current age	Sex	Race	Cause	Time elapsed since GSW injury
1	19	M	Black, NH	Assault	1 year, 5 months
2	20	M	White, NH	Undetermined^a	1 year, 6 months
3	23	M	Black, NH	Assault	1 year, 8 months
4	26	M	White, NH	Accidental	1 year, 6 months
5	25	F	White, Hispanic	Accidental^a	2 years, 7 months
6	28	F	White, Hispanic	Assault	1 year, 9 months
7	25	M	Black, NH	Assault	1 year, 4 months
8	23	M	Black, NH	Accidental	4 years, 3 months
9	26	M	White, Hispanic	Assault	0 year, 1 month
10	18	M	White, Hispanic	Accidental	2 years, 2 months
11	23	M	White, NH	Assault	1 year, 1 month

NH = non-Hispanic.

Qualitative patient accounts describe assaults in both cases.

Case Characteristics

Six shootings were coded as assaults and 5 as undetermined or unintentional (“accidental”); however, 2 of these undetermined/accidental participants (P2, P5) described being intentionally shot by other people. We thus analyzed these 2 cases as interpersonal assaults and counted a total of 8 (73%) assault, 3 (27%) accidental self-shootings (ie, unintentional shootings), and no cases of self-harm. Of the original 131 eligible cases in our recruitment pool, 77 (56%) patients were assault survivors, 22 (17%) were shot by accident, 28 (21%) undetermined, 3 (2%) intentional self-harm, and 1 (<1%) legal intervention. Although the distribution of cases by intent in our sample did not represent the case distribution in the recruitment pool, the 21% of undetermined cases in the recruitment pool, if determined, would likely contribute to the assault category, followed by accidental shootings.²⁶ We did not expect to interview many, if any, participant cases of intentional self-harm, given the lethality of firearm use.²⁷

We kept the accidental, self-inflicted shooting incidents in the study for contrast. Of the assault cases, 3 were perpetrated by previous friends or a former lover; these shootings occurred at a party, in an apartment building, and in a parking lot. Two separate assault cases were robbery attempts to take money and, in 1 scenario, the victim’s car as well. Two were random acts of community violence—walking home from a bar and setting up for a community event. The final assault case was committed by an unknown perpetrator who was provoked by the participant’s friend while the friend was selling a small personal item to the perpetrator. The 3 accidental shootings were fired by the participants themselves. All 3 participants reported having the firearm for self-protection; however, 2 participants accidentally shot themselves while handling the firearm in their respective bedrooms. The third accidental shooting occurred as the participant was showing the firearm to a coworker at a social function; the participant reported that a faulty mechanism caused it to fire unintentionally, and both the participant and coworker were shot. The length of hospital stays, which typically indicates injury severity, was under 6 days in all cases except for 2 participants who were injured in the face (9- and 38-day hospital days).

Three themes developed from our research: (1) post-traumatic stress symptoms were prevalent, including flashbacks, paranoia, distrust of people, and anxiety, (2) participants experienced social isolation and loneliness, especially among those with body image concerns, and (3) among assault survivors, fervent desire to own, use, and carry firearms increased post-injury.

Theme 1: Post-Traumatic Stress Symptoms After Injury were Prevalent, Including Flashbacks, Paranoia, Distrust of People, and Anxiety

All participants who survived interpersonal firearm attacks often thought about the incident and described increased feelings of paranoia and distrust of other people. Consistent descriptions indicated a pervasive sense of unease that were episodic and triggered by loud noises or environments that resembled the place where they were shot. Flashbacks were common, accompanied by anxious thoughts and paranoia that “somebody’s out to kill me” (P7). Flashbacks were triggered by loud noises and seeing the shooting location. Anxiety (i.e., worry or fear about an uncertain outcome) was often described in the same context as following instinct and needing to stay at home behind locked doors or carrying a firearm on them when outside of the house. Although we did not clinically diagnose our participants with PTSD, these symptoms were consistent with the disorder (Table 2).

Table 2.

Illustrative Quotes, Theme 1—Post-traumatic stress symptoms were prevalent.

Since that day, with somebody playin’ around with a firearm around me, I don’t really take that lightly now. It brings back flashbacks. (P8)

They all make fun of me. I’m just like, “Ah!” jumpin’ around when I see somebody out of the corner of my eye. I did end up in the emergency room. I was lying on the bed, and I don’t know what happened. I guess I just had a panic attack or anxiety attack, and I was just freakin’ out and I had the chills. (P6)

I’m more on the edge now. I’m paranoid ‘cause I see him around town here and there. I’m always paranoid, especially ‘cause I got my kid and my wife is pregnant.. . .I wake up dreaming. I dream a lot about it. (P2)

I would start askin’ my girlfirend, “Where’s my gun? Where’s my gun?”(P7)

I’m nervous. You know what I mean? If somethin’ makes me feel uneasy, you know what I mean? I was feelin’ uneasy that night, and I didn’t follow my gut. Didn’t follow my gut. Stay inside, lock the doors, keep everything safe. I didn’t follow that. Now if my gut tells me something, I listen. (P9)

I carry every time I walk out the front door. Before, I took it sometimes. I thought I was paranoid; now I’m extremely paranoid. (P11)

I know that I’ll never be her again because I am honestly scared of people. (P5)

Subtheme 1.1 Behavioral changes included sleep loss, marijuana use, and loss of enjoyment in activities

Hydrocodone. It didn’t do anything for my pain. It just gave me really bad nightmares. I threw that shit away. . .I stopped going to get the refills because alcohol and weed works better. When I tell you, I took a hit, smoked it with my friend. Holy shit, I didn’t feel any back or leg pain. I was walking around without my cane! (P11)

I used to smoke marijuana very heavy before the incident. When the incident happened, I just stopped smoking. . .I probably—I started smokin’ again two or three months ago. (P7)

The psychiatrist did try to prescribe me a happy pill. I did not like the way that made me feel. . ..Yeah, it just it’s almost like it’s killing your inner emotions. (P9)

I used to like going to a shooting range and all that stuff all the time, and now I went the other day—or I went a few months ago—and I didn’t enjoy it at all, I shot maybe three or four times and all that. I wouldn’t say it’s like PTSD, but it’s not enjoyable at all anymore. (P4)

I wouldn’t drop the motorcycle, but havin’—messin’ with your balance, with your toes bein’ weak like that, there’s really nothin’ that you can really push to—you really can’t push as hard as you want to against it. Yeah, it did affect me with that. (P8)

GSW survivors of accidental self-shootings (P4, P8, P10) described symptoms of PTSD but for different reasons. They expressed being wary of situations where firearms were present, including flashbacks when another person was handling a gun. Their distrust appeared to stem from concern about an accidental gun firing, as opposed to a distrust of people. P8 states that “since that day, with somebody playin’ around with a firearm around me, I don’t really take that lightly now. It brings back flashbacks.” P4 also experienced flashbacks and unease at shooting ranges because of the audible shots and handling of firearms in that setting.

Subtheme 1. 1: Behavioral Changes Included Sleep Loss, Marijuana Use, and Loss of Enjoyment in Activities.

Survivors of GSW assaults reported that their symptoms led to altered patterns of sleep, predominantly insomnia. One participant tried to alleviate her anxiety and sleep dysregulation by taking a relative’s anti-anxiety medications, while another participant was not able to rest at night until he checked the door “three or four times just to keep my paranoia and my anxiety down. I gotta make sure this door’s locked five times tonight” (P9).

Many survivors of GSW assaults repeatedly referred to marijuana as their substance of choice for pain and anxiety. One participant stated that he stopped getting refills on prescribed pain medication because “alcohol and weed works better” (P11). It was also preferred to stronger opiates like hydrocodone and Vicodin (hydrocodone plus acetaminophen) because of the undesired effects of those substances (e.g., causing nightmares, feeling sick). Participant 9 described the effects of prescribed medicine as mentally numbing, “It’s almost like it’s killing your inner emotions. You’re not havin’ these emotions for nothin’. We are human. You are meant to be sad, and you’re meant to go through things.”

Participant 5 stated that she was shocked that an anti-anxiety drug was not prescribed at discharge; this participant and another participant obtained Xanax from relatives and friends. She then used marijuana instead to “take [her] mind off it for a little bit.” Seven of the 11 participants reported using marijuana after the injury; all were GSW assault survivors. An eighth participant sold marijuana but did not admit nor deny using it. Some participants used marijuana as a form of escapism, while others reported pain relief.

Participants also reported that post-traumatic stress symptoms led to avoidance of other people and settings that they used to enjoy. Participant 5 described “not being the life of the party anymore” and not going to places with large groups of people or loud music. She would “rather be home where [she] knows it’s safe” (P5).

While avoidance of settings was also due to prolonged physical and functional impairment, this was primarily the case with survivors of accidental self-shootings. For example, P4 stated that he frequently attended the gym and was very active before the injury but realized the gravity of his situation when he went from being physically active to “not being able to even open a can of toothpaste. . . that was the biggest deal for me.” Other accidental self-shooting survivors described impairments to balance and use of extremities.

Theme 2: Loneliness and Social Isolation were Described, Especially Among Assault Survivors Who Experienced Body Image Concerns

Loneliness and related feelings were described in various contexts: feeling abandoned by the police because the perpetrators were not arrested and then continuing to feel that no one else was listening to the participant’s experience (P5), or that hospital clinicians were not including participant views in their own treatment, even talking about the participants in front of them or otherwise using insensitive communication (P4, P5, P11). After being discharged from the hospital, some participants felt that friends and family continued normally with their lives after the participants’ wounds had physically healed but that the physical healings masked their loneliness and sense of fragility. One GSW assault survivor stated that he “sits and cries because [he’s] all by himself” (P9). Participant 5 stated that friends and relatives do not understand being the victim of interpersonal gun violence: “They don’t even own firearms, so they wouldn’t even understand where I even begin to come from about the situation. Of course, they have their sympathy and their empathy, like, ‘Oh. Damn. So bad that you got shot and you had to go through that.’ They don’t know what it’s actually like.”

Notably, body image was a major concern for participants who incurred facial scarring, swelling, or other physical requirements to rehabilitate. These outcomes were reported by GSW assault survivors. One participant wore a urinary catheter as a result of the injury. The catheter that connected to a bag on the participant’s leg was a source of frustration and exhaustion because the bag frequently spilled. Facial alterations seemed most concerning, with 1 participant describing that his face, from the eye down, consisted of metal and that he felt depressed because his front teeth were gone. Two participants expressed that being shot in the face led to swelling, which was upsetting and tiring. Participant 3 reported a loss of friends after the incident. It was unclear whether this was due to a perception of abandonment, or a distrust of people which led to self-isolation and implied loneliness:

I don’t really give people that much trust anymore, and I kinda have a lot more alone time now. I don’t really have a lot of people hanging around me anymore. I don’t know if they just feel bad or whatever. I don’t know, but it’s not like at first, when this first happened, [and] my face was super swollen and everything was just still healing, but I look pretty much normal now and so I don’t think people really feel bad. I just feel like after that happening, I think a lot of people don’t know how to approach me anymore. (P3)

Participant 3 was given a prosthetic eye after the injury and reported fear that people would notice his appearance but also admitted that the fear was just in his head. He recognized that his physical appearance affected his affect toward people. His coping supports for anxiety included relationships with family, a girlfriend, and smoking marijuana.

Subtheme 2.1: Mental Healthcare was not Sought

A few participants reported being given referrals to psychological services, but the majority did not seek professional mental healthcare after hospital discharge. This behavior did not differ between participants who were accidentally shot versus assaulted. Participant 6 stated, “I do believe I received a packet and a follow-up with—they gave me referrals. But I was leaving the next day and I was trying to get out of there.” When asked whether they had considered consulting with a professional therapist, most participants provided lukewarm responses. Although participants with insurance recognized that mental healthcare would be covered, they were hesitant to pursue help. Responses suggested that seeking professional mental healthcare was not a priority for participants, nor stressed by clinicians prior to hospital discharge. See Table 3 for illustrative quotes. In contrast, Participant 5 sought professional help. Having experienced loneliness post-injury, she was relieved to find a mental healthcare provider to listen. “Somebody’s finally going to hear what I’ve had to live with for the last two years. I never did get to talk about it with anybody. Not a counselor, not a therapist. Nobody.” Participant 5 also described her process toward improved mental health:

Table 3.

Illustrative Quotes, Theme 2—Loneliness, social isolation, and body image.

I just feel like after that happening, I think a lot of people don’t know how to approach me anymore. (P3)

Most of my top teeth were blown out, as I see in the mirror. That’s when it hits me. I feel depressed about it. I just want my teeth back. (P2)

Subtheme 2.1 Mental healthcare was not sought by participants nor stressed by clinicians

It’s a lot to talk about all the time, and I feel like I don’t know. . .I don’t really feel like talking about this stuff. (P3)

I didn’t have anything like a social worker. (P7)

I just got shot; why would you not refer me to go and get mental help? I felt like I wasn’t considered human on [date of injury] and up ‘til today. The hospital, they didn’t get me the help that I needed. Now, two years later, I’m having to do that myself on my own. It’s really hard because I don’t know where to go and don’t know who to turn to. I don’t know if I need to see a psychiatrist or a psychologist. I don’t know. I don’t know the differences between the doctors.. . .I felt like I was failed pretty much by every professional that I’ve came across. (P5)

After it was my time to get the rods taken outta my toes, that was really it. That was the last time I really talked to a doctor. They didn’t have any more follow ups after that. (P8)

I’m just now getting to the point where I can talk about it and not get as emotional as I was before. I’ve seen how it’s taken effect on me physically, mentally, and emotionally. I can’t just not talk about it because, if I can’t talk about it, I’m not gonna get through it.

Theme 3: Firearm Fervor Increases After Getting Shot

“It is so hard to be an angel, surrounded by demons.” (P11)

Participants who were assaulted by a firearm notably expressed fervor for firearm ownership, carriage, and use after the incident. Participants who previously owned a firearm stated that they now carry it on them more frequently or have it more easily accessible within the home for protection. By contrast, participants who accidentally shot themselves did not express an increased fervor for ownership after the injury. While they continued to own firearms after the injury, they were more cautious. P10 stated, “I am much more aware of the danger of a gun.”

Owning, carrying, and using firearms were not new behaviors after being shot. Rather, GSW assault survivors expressed an increased willingness of former behaviors which were linked to safety, power, and control (See Table 4). Participants stated that they now keep firearms more accessible, near the door, and on their body when walking around. Several participants who owned firearms before the injury had used them to threaten others pre-emptively, making others stand down by visually showcasing their firearm (P2, P9, P10, P11). Flashing their guns to intimidate would-be perpetrators or to maintain order among people for work (eg, security guard, drug dealer) was tied to a sense of power and control. Participant 2 implied that flashing his gun was tied to masculinity, being “just a man thing. . .It makes people pay attention.”

Table 4.

Illustrative Quotes, Theme 3—Firearm fervor increases after getting shot.

When I would run into my enemies outside of work, I didn’t have to pull my weapon, but them seein’ my weapon on me was enough. Just stating, hey, it’s here -don’t make me have to use it. (P9)

Untouchable, that’s a good word, very powerful. It’s a lotta power. (P10)

I did recently did go purchase a body arm in my name to be protected recently. (P1)

My shotgun is now by my front door. It’s right here where I can reach it. (P11)

I feel like that’s changed my perspective of living as well because now, I don’t feel safe without me knowing that I have a firearm within reach. (P5)

I don’t like being’ on the other end of the barrel at all. That does offset me a lot. . .. I look for a lot of red flags in people. (P10)

I really carry my gun with me everywhere now. . .Your life can be taken from you in a flash. (P9)

Three participants who previously did not own firearms prior to their injury owned 1 currently or were in the process of acquiring 1. Participants did not report problems acquiring firearms. One participant admitted that his friend would “offer guns, totally illegal, everything like that. He open-carries every day, and that’s where I’m trying to be at.”

Subtheme 3.2: Attitudes Toward Future Gun Firing were Driven by Fear

In contrast to flashing guns as a symbol of power and control, using a gun to shoot another person in self-defense was ascribed to fear. GSW assault survivors talked about their flashbacks and paranoia: “Somebody tried to take me off the earth. That thought goes through your head. . .it’s like, is this person still out here?” (P7). Descriptions of the incidents, which on average occurred 1.5 years ago, were recalled vividly. Participants described interpersonal shootings as manifestations of fear and emotion on both sides. Participant 3 explained that generally both the initiator and person who shoots back are scared. Participant 9 expressed fear about having to take another person’s life to save his own, but that shooting in this case would be a zero-sum game. Indeed, participant 11 stated that “when someone raises a weapon and you don’t have one, you’re fucked.”

Several participants indicated a mental maturation about the use of firearms since the injury. They described using firearms in self-defense to protect children and loved ones (P1, P2, P4, P9). These participants had children under the age of 5, with 2 participants expecting additional births within the next few months. Participants reported a desire to teach their kids and girlfriend how to shoot guns at a firing range so that they would know how to defend themselves (P7, P9). Participant 2 expressed misgivings about using guns in the past:

I remember shootin’ at him and thinkin’, after the fact, I thought, “damn, that gun isn’t worth years [in jail].” A thousand dollars, I can make $1,000 a thousand times in what, the years that I would spend in jail. It’s meaningless. It’s not worth it. It’s the adrenaline in the moment, the anger, the whole ego to it, you know, like, “I can’t let this guy steal from me.

Discussion

In providing contextual depth, our study helps explain why some young, formerly hospitalized GSW patients are at risk for a subsequent violent re-injury. Among the GSW assault survivors, distrust of people, loneliness, and an increased fervor for access and use of firearms was intensely expressed. The emotion that accompanied their interviews suggested that the memories remained fresh and potentially unprocessed after approximately 1.5 years.

Increased firearm ownership after being assaulted by firearm has been shown previously, with most results indicating that violence begets, even perpetuates, the potential for more violence.^28,29 Firearm possession in itself, due to presence, increases the likelihood of being shot, compared to individuals not in possession.³⁰ Scenarios that then escalate firing shootings include confrontations and overreactions with similarly armed parties, or placing oneself in dangerous environments that otherwise would have been avoided, had the person not perceived a sense of increased safety with the firearm. Notably, the 3 participants who survived accidental self-shootings in our study did not report mental health distress to the same degree as the assault survivors. Nonetheless, they described the importance of maintaining possession of firearms for protection, thus strategies to prevent violent reinjury are similar for both groups.

Despite actual data showing that firearm possession increases the risk of injury, GSW survivors perceive increased protection. Quotes among our study participants indicated that they were nervous about being shot again by others, intentionally or unintentionally. Participants who viewed firearms as defense weapons (i.e., flashing guns to ward off confrontations) stated that they would fire if necessary. This underscores a public health imperative to promote healthy conflict resolution and de-escalation communication techniques for the increasing number of gunshot wound survivors who own, carry, and use firearms. Accordingly, an opportunity exists for places that teach firearm safety skills to contribute to responsible ownership and use of firearms.

Violent Injury Prevention and Treating PTSD

Locations that provide firearm safety training courses are opportune venues to teach healthy conflict resolution and de-escalation techniques. Safety courses that currently exist are offered virtually and in person (e.g., at gun shops, clubs, and shooting ranges) and are typically led by credible messengers that likely resonate with firearm owners (e.g., certified instructors, law enforcement). However, these courses currently do not include interpersonal behavioral components, focusing predominantly on safety related to loading and unloading, shooting, and targeting awareness.³¹ Course objectives related to healthy conflict resolution will require a cultural shift, acceptance, and understanding of the behavioral change content. An additional hurdle is the omission in most states of a requirement to take a firearm safety training course prior to purchasing or carrying a handgun in public. As of January 1, 2024, only 8 states and the District of Columbia (DC) require safety training prior to purchasing or carrying a firearm, and the curricula, instructor training, and passing requirements for the training courses differ by state.³² In addition, at the time of this writing, only 26 states and DC require firearm training for concealed-carry permits.³² Although there are many challenges to using firearm training courses to teach interpersonal conflict resolution and de-escalation techniques, it is worth exploring the feasibility and effectiveness of offering healthy behavior curricula as part of the course.

Opportunities for healthcare interventions exist in the immediate aftermath and periodically for follow-up after a violent interpersonal injury of any kind. In the acute phase of trauma, hospitals have the opportunity to screen for individuals at risk for aggression, depression, and body image distortion, with the caveat that symptoms may develop over time.³³ Accordingly, screening for post-trauma symptoms periodically after hospital discharge presents a proactive strategy for reducing psychological distress and the potential for recurrent violent re-injury. Participants in our sample may have sought professional mental help, had clinicians emphasized the need or provided options to find accessible mental healthcare. A study using police and clinical records on nonfatal shootings in Indiana shows that clinical care utilization increased within 24 months after a GSW injury.³⁴ However, only one-third of patients received a mental health diagnosis, indicating that patients either did not meet clinical levels of distress or that healthcare professionals addressed concerns other than mental health.³⁴ Our study indicates that GSW assault survivors exhibit avoid places and people after discharge, experience loneliness andpoor sleep, self-medicate, and have an increased willingness to use and carry firearms. Complicating matters, they also appear to not seek professional mental health help.

Additional research is needed to determine the optimal timing and location of treating post-traumatic stress symptoms. Notably, post-traumatic care after traumatic brain injuries is well researched and may represent effective mental health strategies for a larger umbrella of penetrating, violent injuries.^35,36 Drawing on research from traumatic brain injury survivors would be a pragmatic parallel to understanding and addressing the health needs of post-GSW survivors until specific, interventional GSW research advances.

Treating traditional symptoms of PTSD can also be evaluated through hospital-based violence intervention programs (HVIPs). An assortment of treatment options, given the proper infrastructure and administrative support, can include cognitive behavioral therapy, medication, group therapy, and alternative therapies (eg, yoga, animal-assisted therapy). These can be offered as part of a tailored, precision care program for patients, with the aim of supporting long-term mental recovery.

It is also worth researching the use of medical marijuana after GSW injury as an alternative to commonly prescribed anxiolytics, antidepressants, and pain relievers. Currently, the literature on marijuana use for PTSD and related symptomology is underdeveloped and conflicting.³⁷ The mechanisms driving the positive outcomes reported by our participants after using marijuana requires further investigation, including aspects such as dosage, timing, tolerability, and the potential for misuse.

Addressing Loneliness

Lastly, loneliness and isolation persist after the physical wounds have healed. Loneliness in general occurs when individuals feel that they lack a meaningful social network or a close connection with another person.³⁸ In our study, loneliness was described in various contexts, including within the hospital setting during the acute phase of the injury. Others implied a longer term feeling of abandonment among family and friends. Loneliness is complex, one that both predicts future PTSD and is predicted by past PTSD symptoms.^39,40 Additional research is needed to characterize, recognize, and address symptoms of loneliness after surviving a gunshot wound. Suffice to say, among our assault survivors, a lack of interpersonal connection after leaving the hospital was common, indicating that they did not feel understood. Increased social connection in the acute care phase of the injury can set the precedent for future psychological healing, underscoring the need for clinicians to use trauma-informed care to create a supportive and understanding environment. Additionally, educating caregivers of GSW survivors during hospital discharge should emphasize the patient’s mental health needs, including recognizing PTSD and accessing support resources.

We propose that creating support systems or peer groups can alleviate loneliness. Among our participants with long-term, post-injury physical scarring and deformities, depictions of their body images preceded descriptions indicative of loneliness. Body image and loneliness influence experiences of stigma, confidence, interpersonal relationships, career prospects, and community participation. There is a common need among survivors to process and make sense of the experience. Peer support groups provide therapy to and by individuals with shared experiences, such as body image concerns. The setting allows for the validation of negative thoughts and feelings, which can mitigate loneliness after trauma. The establishment of peer support groups after firearm victimization is novel; however, preliminary evidence among other types of trauma survivor peer groups (eg, suicide, rape, burns) shows promising evidence of healthy peer validation, empowerment, modeling of coping strategies, and hope.⁴¹ Peer support groups among GSW survivors is worth exploring and can be embedded and evaluated within existing hospital-based violence intervention programs (HVIPs), which traditionally engage victims of violence in post-discharge programing to break the cycle of violence. This is typically initiated by hospital case workers that align resources to fit the patients’ needs (eg, housing, employment, counseling), followed by longer-term community-based care management.⁴² Support groups can be offered as an option or addition to individual counseling and mental health therapy.

Community Implications

Importantly, post-shooting distress is not limited to the individual survivor. Multiple studies have indicated negative effects to friends, family members, and others who are indirectly exposed to gun violence (ie, witnessing, hearing about incidents), including heightened depression, substance use, mood disorders, and PTSD.^6,43 Further, a recent systematic review found that exposure to gun violence—as witness or victim—increases the likelihood of aggression and carrying a gun.⁷ Neighborhood disorder, characterized by interpersonal aggression, distrust, and gun carrying can insidiously become normalized within a community through direct and indirect exposure to violence, including firearm violence.⁴⁴ Implementing healing strategies for both GSW survivors and the community is a critical public health approach to prevent normalization and perpetuation of violence.

Limitations

We acknowledge that our sample size was low, despite our best efforts to contact all eligible participants. A small sample size limited our ability to pilot test the complete interview guide on similar non-participants, although the research team had experience interviewing populations affected by trauma and young adults.^20,45,46 Recruitment of young adults after hospital discharge is generally challenging, likely due to increased independence, mobility, and in this population, perceived stigma associated with the injury. Future attempts to recruit this population may be more successful in person, prior to discharge, and by narrowing the time window between consenting and conducting the interview. Additionally, when expecting small sample sizes for future study, it would be prudent to adopt a pragmatic approach to enhance information power, such as narrowing the scope of the study aims or recruiting participants with more similar characteristics.⁴⁷ Also, conducting a mixed methods study may strengthen qualitative findings by allowing researchers to triangulate data (i.e., examine convergence on similar conclusions), thus enhancing the trustworthiness of the data. Furthermore, despite a low sample size, the detailed descriptions provided by our participants provided sufficient conceptual depth to our findings,⁴⁸ and future quantitative designs may use these qualitative findings to drive hypotheses about the relationship between psychosocial outcomes and behaviors following GSW survival.

Conclusion

This study provides context for the extant empirical research that shows an increased risk for violent re-injury after incurring a GSW, via the shaping of psychosocial and behavioral sequelae. Post-traumatic stress symptoms, including flashbacks, paranoia, and distrust, coupled with continued or increased fervor for firearm use, are conducive to interpersonal aggression. Loneliness and body image distortion remain long after physical injuries have healed, contributing to depressive symptoms and avoidance of community settings. We offer suggestions for healthcare and the broader community to consider, such as periodic mental health screenings, studying cannabis use, increasing social connection, promoting healthy conflict resolution, and identifying strategies to prevent the perpetuation of violence in our communities.

Supplemental Material

sj-docx-1-inq-10.1177_00469580251339075 – Supplemental material for Psychosocial Impacts of Non-Fatal Firearm Injuries on Youth: Findings from a Qualitative Study

Supplemental material, sj-docx-1-inq-10.1177_00469580251339075 for Psychosocial Impacts of Non-Fatal Firearm Injuries on Youth: Findings from a Qualitative Study by Annalyn S. DeMello, Jeff R. Temple, Liam de Vassal, Irma Alvarado, Angela Waguespack, Monique R. Pappadis, Jong O. Lee and Leila G. Wood in INQUIRY: The Journal of Health Care Organization, Provision, and Financing

Supplemental Material

sj-pdf-2-inq-10.1177_00469580251339075 – Supplemental material for Psychosocial Impacts of Non-Fatal Firearm Injuries on Youth: Findings from a Qualitative Study

Supplemental material, sj-pdf-2-inq-10.1177_00469580251339075 for Psychosocial Impacts of Non-Fatal Firearm Injuries on Youth: Findings from a Qualitative Study by Annalyn S. DeMello, Jeff R. Temple, Liam de Vassal, Irma Alvarado, Angela Waguespack, Monique R. Pappadis, Jong O. Lee and Leila G. Wood in INQUIRY: The Journal of Health Care Organization, Provision, and Financing

Footnotes

Acknowledgements

We thank Ms. Isamar Ortiz for her assistance with recruitment. Authors have no disclosures.

ORCID iDs

Annalyn S. DeMello

Leila G. Wood

Ethical Considerations

This study was approved by the University of Texas Medical Branch Institutional Review Board on August 3, 2022 (22-0070).

Consent to Participate

Informed consent in written format was obtained from all research participants.

Consent for Publication

Not applicable.

Author Contributions

AD: corresponding principal investigator, conceptualization, methods development, data acquisition, analysis, writing. JT: Conceptualization, consultation, analysis, writing. LD: Analysis, writing. IA: Conceptualization, analysis, methods development, writing. AW: Data acquisition, analysis. MP: Conceptualization, methods development, consultation. JL: Conceptualization, data acquisition, consultation. LW: Conceptualization, consultation, analysis, writing. All authors reviewed and edited the manuscript.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The research and authorship of this publication was supported by two sources of institutional funding at the University of Texas Medical Branch: The John P. McGovern Academy of Oslerian Medicine, and the School of Nursing’s Research Innovation and Scientific Excellence Center.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The authors declare that there is no conflict of interest.

Data Availability Statement

Due to the sensitive and potentially identifiable nature of the interview data, this data will not be made publicly available.

Supplemental Material

Supplemental material for this article is available online.

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