JMIR Publications

ABSTRACT

Background:

Firearm mortality surveillance routinely evaluates risk factors in isolation, obscuring how race, ethnicity, sex, age, and intent intersect to shape youth vulnerability. Furthermore, the CDC’s 2018 race-reclassification policy has historically disrupted long-term trend analysis. Consequently, the 25-year evolution of highly specific intersectional burdens and shifting contemporary disparities remains uncharacterized.

Objective:

To map 25-year national trends in firearm homicide and suicide across intersecting dimensions of race or ethnicity, sex, age, and intent among US youth and young adults (aged 0–24 years), identifying subgroups experiencing the highest and most rapidly changing burdens.

Methods:

This serial cross-sectional, population-based study utilized the CDC WONDER Underlying Cause of Death database (1999-2024). To address the 2018 coding transition, a two-period design was deployed: Period 1 (1999 to 2020) used bridged four-category race data for long-term trend analysis, and Period 2 (2018 to 2024) used six-category single-race data for contemporary intersectional estimation. Crude death rates and disparity ratios (referenced to non-Hispanic White youth) were calculated using the Byar approximation. Average annual percentage changes (AAPCs) were modeled via log-linear regression. Analyses incorporated finalized 2024 data released by CDC WONDER in February 2026. The 25-year window was anchored at 1999 by the first full year of US ICD-10 implementation and at 2024 by the most recently finalized national mortality file.

Results:

Among 199,452 firearm deaths among youth aged 0 to 24 years from 1999 to 2024, overall mortality declined through 2013, reversed in 2014, and rose 30.6% from 2019 to 2020. In 2024, the overall rate fell 20.2% from 2023, marking the first year below the 2019 prepandemic baseline. During 2018 to 2024, Black non-Hispanic male youth had the highest pooled firearm homicide rate (44.03 per 100,000; 95% CI, 43.46–44.61), 23.8 times that of White non-Hispanic male youth. Annual rates rose from 33.28 in 2018 to 53.75 in 2021, then declined to 37.06 in 2024 (AAPC, +2.4%; P=.56); however, the Black-to-White rate ratio widened from 19.3 to 24.4. Black non-Hispanic female youth had the highest female firearm homicide rate (6.03 per 100,000), exceeding rates among males in 7 of 12 other racial and ethnic subgroups. AI/AN non-Hispanic male youth had the highest pooled firearm suicide rate (11.74 per 100,000). Firearm suicide rose significantly among Black non-Hispanic male youth (AAPC, +9.2%; 95% CI, +3.2 to +15.4; P=.01), with a comparable increase among Black non-Hispanic female youth (AAPC, +11.7%; P=.08), while White non-Hispanic rates remained stable (AAPC, −0.1%; P=.91). The Black-to-White non-Hispanic male suicide rate ratio shifted from 0.67 in 2018 to 1.07 in 2024.

Conclusions:

Firearm homicide and suicide among US youth follow distinct demographic concentration patterns that aggregate surveillance obscures. The rapid rise in firearm suicide among Black non-Hispanic male and female youth represents an emerging disparity with direct implications for prevention systems calibrated to historical White male risk profiles. The post-2020 surge in firearm homicide among Black non-Hispanic male youth has substantially reverted by 2024, yet the disparity ratio relative to White non-Hispanic male youth remains essentially unchanged, indicating that the partial reversion does not reflect disparity reduction. Intent-specific, intersectionally disaggregated surveillance and prevention strategies, developed with the affected communities, continue to be the appropriate response.