What doesn’t kill us, hurts us longer: a cross-sectional analysis of gun violence exposure and chronic pain in the United States

Abstract

Background

Gun violence exposure (GVE) has been widely studied for its mental health consequences, but its relationship with chronic pain remains understudied. The study’s objective was to determine the association between direct and indirect forms of gun violence exposure and multiple chronic pain outcomes among US adults using nationally representative data.

Methods

The current study is a cross-sectional observational analysis using a probability-based, nationally representative online survey conducted in May 2024. A total of 12,822 individuals were invited to participate via the Ipsos KnowledgePanel; 8,657 completed informed consent (67.5% response rate), and 8,009 qualified for the final analytic sample (93% qualification rate). Sampling weights were used to reflect national distributions. Six types of GVE were assessed: being shot, being threatened with a firearm, hearing gunshots, witnessing a shooting, knowing a friend/family member who was shot, and knowing someone who died by firearm suicide. A cumulative exposure index (range: 0–6) was also constructed. Four binary pain outcomes were measured using adapted items from the Graded Chronic Pain Scale-Revised: (1) experiencing pain most days or every day, (2) reporting a lot of pain at last episode, (3) pain that limits work/life activities, and (4) pain that affects family or significant others. Weighted logistic regression models were used to estimate associations.

Results

Among 8,009 participants (mean age, 51.8 years; 51.0% female; 61.3% White, 12.1% Black, 17.5% Hispanic), 23.9% reported pain most/every day, and 18.8% reported a lot of pain. Being shot, threatened, or knowing someone who died by firearm suicide were consistently associated with multiple pain outcomes. Cumulative GVE was associated with higher odds of each pain outcome, including pain most/every day (OR, 1.32; 95% CI, 1.26–1.39) and pain limiting work/life activities (OR, 1.26; 95% CI, 1.17–1.36). Supplemental models suggest that exposure frequency is additionally associated with higher odds of pain outcomes.

Conclusions

Gun violence exposure, experienced directly or indirectly, is associated with increased chronic pain in the U.S. adult population. These findings underscore the need to integrate pain assessment and management into trauma-informed care models and public health violence prevention strategies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-026-26386-5.

Despite decreasing rates of homicide and violent crime since the waning of the COVID-19 pandemic, firearm violence remains a pervasive public health crisis in the United States (US). In 2023, the most recent year for which complete official data are available, 46,728 firearm-related deaths occurred in addition to tens of thousands of nonfatal firearm injuries [1]. Although prior research has explored the psychological and behavioral consequences of gun violence exposure (GVE) [2, 3] its implications for physical well-being, particularly chronic pain, have received less attention. Public health discourse frequently centers on mortality or mental illness related to GVE, leaving a critical gap in understanding how both direct (e.g., being shot, threatened) and indirect (e.g., witnessing shootings, hearing gunfire, or losing a loved one) exposures to gun violence influence long-term pain experiences through traumatic stress and sustained threat appraisal [4].

Pain may be especially salient in the face of GVE when exposure is frequent or cumulative, leading to a disruption of biological stress response systems, elevated bodily inflammation, and immune system vulnerability long after the threat of violence has passed [5]. There is growing evidence that traumatic stress and pain are interconnected through the central nervous system. Trauma-related hyperarousal can sensitize pain pathways, a phenomenon often referred to as “central sensitization” [6]. Survivors of firearm injuries report significantly higher rates of chronic pain and functional impairment, highlighting the importance of integrating pain outcomes into gun violence prevention efforts as well as strategies for intervention after a person has been shot [7]. People who survive firearm injuries often live with ongoing physical complications that interfere with everyday functioning and make routine tasks harder [8, 9]. Qualitative research involving shooting survivors reveals that chronic pain is often a defining feature of life after a gunshot wound [10].

Retained bullets and lingering injuries lead to unpredictable, frequently debilitating pain that alters how survivors experience routine activities, embedding the experience of pain in daily life. One study showed that Black men recovering from violent injuries in Philadelphia described long-lasting symptoms including chronic pain, sleep disturbances, and emotional distress up to three years post-injury [11]. Other research finds that indirect exposure to neighborhood violence, including simply hearing gunshots, is associated with reduced physical well-being and increased reports of pain [12]. Indirect gun violence exposure can shape chronic pain even when an individual does not sustain a physical injury. People who witness shootings, hear gunfire, lose someone close to them, or live in places where shootings occur often experience persistent threat appraisal that is not resolved when the incident ends. The ongoing sense of danger can keep stress response systems activated, which may amplify pain sensitivity and increase the likelihood that pain becomes frequent, severe, and functionally limiting over time. Neighborhoods with higher levels of firearm violence also show markedly higher rates of functional disability [12, 13].

Pain is a clinically significant indicator of underlying trauma and psychosocial distress, particularly among populations disproportionately affected by gun violence. Survivors often experience chronic pain linked to both physical injury and psychological trauma, underscoring the need for integrated, trauma-informed healthcare [14]. However, pain is frequently overlooked in firearm violence prevention frameworks, which tend to focus primarily on mortality. Chronic pain produces measurable spillover beyond the individual by straining close relationships, disrupting household functioning, and increasing burden on family members and other informal caregivers [15]. Building on recent nationally representative studies regarding GVE among US adults [16, 17], the current study contributes to a growing body of literature arguing that GVE is a key social determinant of health with significant implications for collective and long-term well-being [5]. We hypothesize that both direct and indirect forms of GVE will be associated with worse pain outcomes, including frequency, severity, and impact on daily activities and personal relationships. Additionally, we hypothesize that cumulative GVE (i.e., multiple forms of exposure) will be associated with greater pain across all measures.

Method

We conducted a nationally representative survey of non-institutionalized adults living in the US in May 2024. Data were collected using Ipsos KnowledgePanel, a large probability-based online panel. Following a preliminary pretest to pilot the survey for technical functionality among a small group of online panel members not included in the final sample, 12,822 surveys were distributed and 8,657 completed the informed consent document (67% response rate). Of those that provided consent, 8,009 respondents completed the survey and qualified for inclusion in the final sample (93% qualification rate). The qualified respondents were entered into a sweepstakes with KnowledgePanel to compensate their participation following informed consent. No personal identifying information was collected from participants. This study was approved by the Institutional Review Board at Rutgers University.

We used design weights to ensure national representativeness. These weights were created based on geodemographic distributions from the American Community Survey (ACS) and the 2023 March Supplement of the Current Population Survey. Weights were generated using an iterative proportional raking procedure for distributions of those 18 + by gender, race/ethnicity, census region, education level, household income, and political identification. Outliers were trimmed and the weights were scaled to aggregate to the total sample size of eligible respondents.

Measures

We measured pain using four items derived from the Graded Chronic Pain Scale Revised (GCPS-R) [18]. Given time and space constraints in the survey used for this study, we asked about four items focused on pain frequency, amount, effect on work and life activities, and effect on others within the past three months across all questions. The four items were not combined for analysis to avoid concerns about validity threat to the GCPS-R. Respondents were first asked, “In the past three months, how often did you have pain?” Response choices included never, some days, most days, or every day. If respondents chose “never,” no further questions were asked about pain. If any other response was chosen (some days, most days, or every day), three additional questions were asked. We generated a binary indicator for respondents who indicated pain most days or every day to measure frequency of pain in the full sample.

In the subsample of those who indicated having pain, respondents were asked, “Thinking about the last time you had pain in the past three months, how much pain did you have?” Responses included a little, a lot, or somewhere in between. We generated a binary indicator of respondents who said they had a lot of pain related to the last instance of pain recalled in the past three months. Third, respondents were asked, “Over the past three months, how often did pain limit your life or work activities?” with responses including never, some days, most days, or every days. A binary variable was generated for those who indicated limitations most days or every day. Finally, respondents were asked, “Over the past three months, how often did YOUR pain affect your family and significant others?” Response options included never, some days, most days, or every day. A binary variable was created to indicate those whose pain affected their family or significant others most days or every day.

We measured six individual types of GVE by asking respondents whether they had ever: (1) known someone personally who died by suicide with a firearm, (2) been intentionally shot with a firearm by another person, (3) been threatened with a firearm by another person, (4) personally witnessed a shooting in the neighborhood where they lived at the time, (5) heard gunshots in the neighborhood where they lived at the time, or (6) personally known someone, like a family member or friend, who had been shot on purpose by another person with a firearm. Following prior studies using the current dataset [16, 17], we created a measure of cumulative exposure for GVE based on the variety of exposure types ranging from 0 to 6 exposure types. Exposures are not weighted by presumed severity in the scale given prior research indicating that both direct and indirect GVE types are meaningful for health and well-being [5, 9].

We controlled for individual demographic factors including racial/ethnic self-identity (White [Non-Hispanic], Black [Non-Hispanic], Hispanic, and Other/2 + Race), self-reported sex (male, female), household income (<$25K, $25K - $74,999, $75K - $149,999, and $150K+), age, military status (current/Veteran, none) and employment status (employed full time, part time, unemployed). To avoid unstable estimates and protect interpretability given small cell sizes, we did not model additional race/ethnicity categories. Respondents identifying with less prevalent categories (for example, Asian or Pacific Islander) were combined with multiracial respondents into an “Other/2 + races” category.

To account for potential differences in respondents’ underlying health profiles, we controlled for self-rated health using the question, “In general, how would you rate your health today?” Available responses included poor, fair, good, very good, and excellent. This measure of self-rated health has been validated as a reliable predictor of overall well-being and mortality [19]. A continuous measure of general mental health derived from the Behavioral Risk Factor Surveillance System (BRFSS) was included in response to the question, “Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?” Finally, we included a measure of chronic illness indicating whether respondents had ever been told by a doctor, nurse, or other health professional that they have had high blood pressure, high cholesterol, angina or coronary heart disease, diabetes, or a stroke. These were summed to create a variety index ranging from 0 to 5.

Statistical analysis

Descriptive statistics were generated for all measures including all demographic and health-related covariates (see Table 1). We conducted multivariate analyses using each of the four pain outcomes as dependent variables, regressing each on the individual measures of GVE and all covariates. Following this, we regressed each of the dependent variables on the measure of cumulative GVE. We calculated predictive margins for each of the four cumulative GVE models to generate linear predictions across pain outcomes based on each level of cumulative GVE (0–6). We used weighted logistic regression models in all multivariate analyses. We used listwise deletion to address missing data across all variables included in the multivariate models given the low rate of missingness (~ 2% missing in the full sample analysis). Models were compared to those using multiple imputation and all results were substantively identical. All analyses were conducted in Stata 18.

Table 1.

Weighted descriptive statistics for full sample (N = 8,009)

	N (%)	95% CI
Race/ethnicity
White	5438 (61.29)	60.04–62.52
Black	859 (12.08)	11.13–12.92
Hispanic	1003 (17.49)	16.47–18.57
Other	709 (9.14)	8.38–9.97
Female	3990 (51.01)	49.81–52.21
Household income
< $25K	851 (11.09)	10.34–11.89
$25K - $74,999	2269 (30.79)	29.64–31.96
$75K - $149,999	2664 (31.84)	30.75–32.96
$150K+	2225 (26.28)	25.25–27.33
Employment
Full time	3805 (48.02)	46.82–49.22
Part time	1082 (13.93)	13.09–14.80
Unemployed	3122 (38.06)	36.89–39.23
Current/former military	867 (9.22)	8.60–9.88

	M (SE)	95% CI
Age	51.75 (0.20)	51.36–52.14
Self-rated health (1–5)	3.22 (0.01)	3.20–3.24
# poor mental health days (0–30)	3.40 (0.08)	3.23–3.55
# chronic illnesses (0–5)	0.96 (0.01)	0.93–0.98

Notes: Counts (N) are unweighted and prevalence estimates (%) are weighted

Prevalence confidence intervals (CI) estimated at 95%

Results

Descriptive results for the main independent and dependent variables are shown in Table 2. In the full sample, about 1 in 4 respondents indicated they experience pain most days or every day. Within the sub-sample of those indicating experiencing pain, about 19% said they experience a lot of pain. Roughly 13% indicated that their pain limits their work and life activities, while about 6% of the respondents said their pain affects their family or significant others. The most common type of GVE was hearing gunshots in the neighborhood (48%), followed by knowing someone who has died by firearm suicide (28%), and knowing a family member or friend that has been shot (20%). On average, respondents indicated cumulative GVE of 1.22 on a scale of 0–6 across all types.

Table 2.

Weighted gun violence exposure and pain descriptive statistics (N = 8,009)

	N (%)	95% CI
Pain
Some/most/every day (full)	1987 (23.92)	22.91–24.98
Lot of pain (sub)	1014 (18.79)	17.68–19.95
Limits work/life activities, most/every day (sub)	693 (12.84)	11.89–13.85
Affects family/significant others, most/every day (sub)	314 (6.10)	5.42–6.84
Gun violence exposures
Intentionally shot w/ firearm	133 (1.59)	1.32–1.91
Threatened w/ firearm	1243 (15.18)	14.34–16.05
Know someone who died by suicide	2414 (27.79)	26.72–28.89
Witnessed a shooting	573 (7.84)	7.19–8.55
Heard gunshots	3762 (47.64)	46.43–48.87
Know family/friend shot	1589 (20.02)	19.07–21.00

	M (SE)	95% CI
Cumulative gun violence exposure (0–6)	1.22 (0.01)	1.19–1.25

Notes: Counts (N) are unweighted and prevalence estimates (%) are weighted. Prevalence confidence intervals (CI) estimated at 95%

Sub = subsample of those who indicated pain some days, most days, or every day (N = 5,794)

The multivariate results for individual GVE types are depicted in Table 3. Being shot was associated with pain some days, most days, or every day (OR = 2.01, CI: 1.05–3.83), pain that limits work/life activities (OR = 2.28, CI: 1.07–4.83), and pain that affects family or significant others (OR = 2.53, CI: 1.14–5.62). ). Being threatened with a firearm was associated with pain some days, most days, or every day (OR = 1.45, CI: 1.15–1.84), having a lot of pain (OR = 1.50, CI: 1.13–1.98), and pain that limits work/life activities (OR = 1.77, CI: 1.28–2.44). Knowing someone who died by firearm suicide was associated with having pain some days, most days, or every day (OR = 1.21, CI: 1.02–1.45). Witnessing a shooting was not associated with any of the pain outcomes, although hearing gunshots (OR = 1.28, CI: 1.07–1.53) was associated with increased odds of pain some days, most days, or every day, but no other pain outcomes.

Table 3.

Individual gun violence exposure types and pain outcomes

	Pain Most/Every Day			Lot of Pain			Pain Limits Work/Life			Pain Affects Family
	OR	SE	95% CI	OR	SE	95% CI	OR	SE	95% CI	OR	SE	95% CI
Exposure: Intentionally Shot	2.01*	0.52	[1.05–3.83]	1.62	0.47	[0.79–3.33]	2.28*	0.68	[1.07–4.83]	2.53*	0.81	[1.14–5.62]
Exposure: Threatened	1.46*	0.14	[1.15–1.84]	1.50*	0.17	[1.13–1.98]	1.77*	0.23	[1.28–2.44]	1.55	0.28	[0.98–2.43]
Exposure: Know Suicide	1.21*	0.09	[1.02–1.45]	1.12	0.10	[0.89–1.40]	1.08	0.12	[0.83–1.41]	1.36	0.19	[0.95–1.94]
Exposure: Witnessed Shooting	1.07	0.14	[0.76–1.49]	1.12	0.17	[0.77–1.64]	1.37	0.23	[0.90–2.10]	1.43	0.32	[0.83–2.49]
Exposure: Heard Gunshots	1.28*	0.09	[1.07–1.53]	0.98	0.09	[0.78–1.23]	0.95	0.11	[0.71–1.26]	0.87	0.14	[0.58–1.31]
Exposure: Family/Friend Shot	1.23	0.11	[0.99–1.53]	1.13	0.12	[0.87–1.47]	1.01	0.13	[0.73–1.41]	0.98	0.18	[0.63–1.53]
Constant	0.58*	0.12	[0.35–0.97]	0.97	0.25	[0.51–1.82]	0.43*	0.13	[0.20–0.94]	0.13*	0.06	[0.04–0.39]
N-Observations	7,731			5,608			5,608			5,608

Notes: * p < .0.0125 with Bonferroni correction; each of the four models include all control variables

The association between cumulative GVE and all pain outcomes is illustrated in Table 4. Cumulative GVE was consistently associated with all pain outcomes including pain some days, most days, or every day (OR = 1.28, CI: 1.19–1.37), having a lot of pain (OR = 1.17, CI: 1.07–1.27), pain that limits work/life activities (OR = 1.22, CI: 1.10–1.35), and pain that affects family or significant others (OR = 1.23, CI: 1.08–1.38).

Table 4.

Cumulative gun violence exposure and pain outcomes

				Pain Most/Every Day				Lot of Pain						Pain Limits Work/Life						Pain Affects Family
				OR	SE		95% CI	OR		SE		95% CI		OR		SE		95% CI		OR		SE		95% CI
Cumulative Exposure				1.28*	0.03		[1.19–1.37]	1.17*		0.04		[1.07–1.27]		1.22*		0.05		[1.10–1.35]		1.23*		0.07		[1.08–1.38]
Constant				1.58*	0.12		[0.35–0.97]	0.91		0.23		[0.48–1.70]		0.39*		0.12		[0.18–0.84]		0.11*		0.05		[0.04–0.32]
Observations				7,731				5,608						5,608						5,608

Notes: * p < .0.0125 with Bonferroni correction; each of the four models include all control variables

The linear relationship between cumulative GVE and all pain outcomes are depicted using predictive margins in Fig. 1. As exposure to more types of gun violence increase, the proportion of those with each of the four pain outcomes increases. This is particularly true for having pain some days, most days, or every day in the full sample of respondents, which increases most sharply compared to other pain outcomes as GVE types accumulate.

Fig. 1.

Predictive margins for cumulative gun violence exposure and chronic pain outcomes

Supplemental analyses

The main analysis focuses on individual and cumulative GVE exposure without accounting for frequency. Since recent research suggests that greater frequency (i.e., separate incidents) of GVE increases the risk of negative health outcomes using the current data [17], we conducted a supplemental test to assess for the influence of exposure frequency on all pain outcomes. For each of the six GVE items, respondents were asked how many times the exposure had occurred over the course of their lifetime. Using this information, we first generated a categorical indicator of lifetime exposure frequency (no exposure, once, more than once) for each type of GVE. We then created a measure of cumulative GVE frequency across all GVE types by combining the individual frequency items. This resulted in a lifetime indicator of number of GVE incidents including no exposure (0), mild exposure (1–2 incidents), moderate exposure (3–4 incidents), and high exposure (5 + incidents). We used this measure alongside all prior covariates in four logistic regression models to mirror the main pain model outcomes of the study.

The results depicted in Table A1 demonstrate that, in general, more frequent GVE exposure is associated with all chronic pain outcomes, especially among individuals with high exposure. Compared to those with no exposure, individuals with high exposure had significantly greater odds of experiencing pain some/most/every day (OR = 2.38, 95% CI: 1.78–3.15), reporting a lot of pain (OR = 1.85, 95% CI: 1.33–2.59), pain that limits work/life activities (OR = 2.03, 95% CI: 1.36–3.04), and pain that affects family (OR = 1.91, 95% CI: 1.14–3.22). Both mild (OR = 1.30, CI: 1.05–1.59) and moderate (OR = 1.67, 95% CI: 1.32–2.12) exposure was significantly associated with increased odds of pain some/most/every day.

Additionally, we assessed differences in the relationship between cumulative GVE and pain outcomes by direct versus indirect exposure. To do this, we created an index of direct cumulative exposure (being shot, being threatened [range: 0–2]) and a separate index of indirect cumulative exposure (knowing someone who died by suicide, knowing a family member/friend who was intentionally shot, witnessing a shooting, hearing gunshots [range: 0–4]). We again used these measures alongside all prior covariates in logistic regression models to mirror the main pain model outcomes of the study. The results are depicted in Table A2. Both indirect and direct cumulative exposure measures were consistently associated with all four pain outcomes. However, the odds ratios for direct cumulative exposure were generally larger in magnitude than comparable ratios for indirect cumulative exposure across indices of pain.

Discussion

This study provides timely, nationally representative evidence that exposure to gun violence, both direct and indirect, is significantly associated with chronic pain outcomes among US adults. Across all four pain measures, we observed a consistent cumulative pattern: individuals who reported more types of gun violence exposure also experienced higher odds of frequent pain, high pain severity, pain-related activity limitations, and pain affecting their families or significant others. Notably, being shot and threatened with a firearm emerged as consistent individual correlates of self-reported pain, although being threatened was not associated with pain affecting one’s family. Indirect GVE like hearing gunshots was associated with increased odds of reporting daily pain. The supplemental results confirmed that more incidents across types of GVE was additionally associated with greater pain outcomes, particularly among those with high exposure over their lifetime (e.g., 5 + incidents). Further, although both direct and indirect cumulative exposure were associated with higher pain outcomes, odds ratios were consistently higher for direct forms of exposure. These findings suggest that gun violence is associated with a broad and enduring toll on the body, not solely through acute injury, but also via persistent physical suffering that lingers after the event.

This work builds on a growing literature connecting GVE to long-term health consequences beyond mental health [9, 20, 21]. Prior research has highlighted the psychological burden associated with various forms of GVE, including elevated risk of PTSD, depression, and anxiety [2–5], yet few studies have examined chronic pain as a distinct and meaningful outcome. Ethnographic research [10] and clinical observations [22] have described pain as a defining feature of the post-shooting experience, yet large-scale, population-based data have been lacking. Our findings help to fill this gap by demonstrating that pain is not only common among those exposed to firearm violence, but also appears to intensify with cumulative exposure and frequency of exposure, a dose-response pattern that aligns with established frameworks linking trauma, central sensitization, and physical pain [23]. Importantly, we also show in the supplemental analysis that even those who were not physically harmed themselves can experience elevated pain as exposure accumulates, suggesting psychosocial and environmental pathways beyond direct injury.

Implications and future research

The results of this study carry several implications for public health policy and violence prevention. First, the findings underscore the need to expand how we define and track the health consequences of direct and indirect forms of gun violence. Pain, both as a subjective experience and a functional limitation, is often excluded from national surveillance systems and intervention frameworks, despite being among the most common and disruptive outcomes reported by survivors [7]. Second, our findings support a broader, trauma-informed model of care that includes assessment and treatment of chronic pain for those affected by violence—not only in emergency and surgical settings, but also through long-term follow-up and community-based support [14]. Integrating pain management into violence prevention efforts, particularly in under-resourced areas where both gun violence and untreated pain are prevalent, could significantly improve quality of life and reduce health disparities.

Moreover, this research adds to calls for policy interventions that target the upstream conditions that drive both gun violence and experiences of chronic pain. Socioeconomic inequities, systemic racial segregation, and neighborhood disinvestment are common roots of both problems, and effective prevention must address them together [24]. Expanding access to safe public spaces, mental health care, and trauma-informed primary care, especially in communities disproportionately impacted by gun violence, could yield cross-cutting benefits. The Trauma Recovery Center (TRC) model offers one promising means of providing comprehensive mental health and wrap-around case management services for those exposed to gun violence and experiencing chronic pain [25, 26]. Our results also suggest the need for public health messaging and clinical protocols that recognize pain as a legitimate outcome associated with GVE, not an incidental or secondary concern.

Limitations

Several limitations in this study warrant consideration. First, while the survey design is nationally representative, its cross-sectional nature limits causal interpretation. Longitudinal data are needed to determine the temporal ordering of exposure and pain, as well as to examine changes over time. Although we included health-related covariates to account for underlying differences in respondent health profiles, they could plausibly function in the data as a mediator or effect moderator between GVE and pain, necessitating long-term studies to examine these pathways directly. Second, although our measure of GVE is based on prior studies using a similar cumulative approach [16, 17], additional research is needed to establish a validated GVE scale, potentially weighted depending on the severity of exposure and differences across direct and indirect experiences. Relatedly, we focused on intentional shooting injury here and did not include being unintentionally shot in the survey. Future research should consider how intention (or lack thereof) for shootings may change GVE risk profiles for mental, physical, and behavioral health outcomes.

Third, pain was assessed via self-report and may be influenced by subjective interpretation or recall bias. Though the GCPS-R items drawn upon are widely validated and we did not combine them into a single measure [18], the items used in this study were slightly different given survey time and space constraints. Future studies would benefit from incorporating clinical or physiological measures of pain, as well as exploring mechanisms such as inflammation, sleep disruption, or access to pain management. Finally, although we controlled for multiple health and demographic variables, unobserved confounders, especially related to environmental stressors or preexisting conditions, remain possible. For instance, future studies should control for other pain-related conditions beyond the chronic illnesses measured in this study such as rheumatic diseases, fibromyalgia, and back pain, where feasible.

Conclusions

Despite these limitations, our cross-sectional findings offer evidence that gun violence exposure, whether experienced directly, witnessed, or absorbed through social ties, has a measurable and enduring relationship with pain. In demonstrating that pain is a consistent outcome associated with GVE, this work calls for integrative, trauma-informed approaches that attend not just to survival, but to the enduring suffering that firearm violence leaves in its wake. In shifting the conversation beyond death and mental health fallout like PTSD to include chronic pain, this study reframes gun violence exposure as not only an acute injury crisis but also a long-term public health burden. Future research should continue to investigate the biopsychosocial mechanisms underlying this relationship and explore intervention strategies that integrate physical, mental, and behavioral healing in addition to opportunities for broader upstream violence prevention.

Authors’ contributions

DS was responsible for conceptualization, data management, analysis, writing, and revisions. LE was responsible for conceptualization, writing, and revisions.

Funding

This work did not receive funding or other financial support.

Data availability

The dataset used and analyzed during the current study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

This study was approved by the Institutional Review Board at Rutgers University. All participants provided informed consent to take part in the study, which adheres to the Declaration of Helsinki. No personal identifying information was collected from participants.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.