The intersection of interpersonal violence and housing instability: Perspectives from women veterans

"Because I Am a Female": Stigma and Safety Perspectives from Racially/Ethnically Diverse Women with Serious Mental Illnesses

Individuals with serious mental illnesses (SMIs) face safety risks related to their mental health conditions that are often compounded by experiences of trauma, victimization, residence in impoverished neighborhoods, and histories of homelessness. Stigma and safety challenges significantly impact community integration for individuals with SMIs, particularly women, who often bear a disproportionate burden of vulnerability, gender-based stigma, violence, and other inequalities. This study investigates how women with SMIs engage in the meaning-making of their safety and stigma experiences that, in turn, influence their community integration. From a large multi-site study exploring community experiences of racially/ethnically diverse participants with SMIs, a subsample of 28 cis and trans-gender women, who reported experiencing gendered stigma and a lack of safety, were chosen for the current study. The interviews were analyzed using modified principles of Interpretive Phenomenological Analysis (IPA) to understand how women with SMIs made meaning of their safety and stigma encounters in their families, communities, and neighborhoods. IPA analysis resulted in the emergence of themes within a broad category of safety that represented participants' meaning-making about their physical safety and stigma experiences. Specifically, we used the broad themes from an existing framework of safety called 'Navigating Safety' model as sensitizing concepts for our analysis. Physical and psychological aspects of safety for this study were experienced in tandem whereby the women made sense of how their experiences of a lack of physical safety in multiple contexts shaped their sense of self, internalized stigma, and their social relationships. Within the broad theme of physical safety, participants described unsafe neighborhoods, exposure to domestic and intimate partner violence, and vulnerability to sexual violence. Additionally, under psychological safety, we identified how gender-based norms, race and ethnicity, sources of stigma (internalized, familial, and societal), and social isolation contributed to their mental health and social relationships (particularly with family). These findings highlight how the compounding influence of the intersection of multiple stigmatized identities exerts safety challenges on the lives and community experiences of women with SMIs. Focusing on access and affordability of appropriate gender-responsive resources for women, including trauma-informed care, could reduce hospitalizations, mental health symptoms, and stigma so they can safely integrate into their communities.

The Impact of Intimate Partner Violence on Homelessness and Returns to Housing: A Qualitative Analysis From the California Statewide Study of People Experiencing Homelessness

Homelessness is a public health concern in California and throughout the United States. Intimate partner violence (IPV) is a risk factor for experiencing homelessness. Few studies have examined the interplay between IPV, homelessness, and housing. Qualitative methods can provide a greater understanding of the lived experience of IPV and homelessness to identify potential solutions. We purposefully sampled 104 adults who reported experiencing IPV in the California Statewide Study of People Experiencing Homelessness (CASPEH), a representative, mixed-methods study. We administered semi-structured interviews focusing on IPV and six other topic areas pertaining to homelessness from October 2021 to May 2022. We created and applied a codebook with a multidisciplinary team using a hybrid of deductive and inductive logic. Our analysis included all participants who discussed IPV and homelessness across the seven studies. We conducted a thematic analysis using an interpretivist approach and informed by grounded theory. We found that violence within a partnership was multidimensional (physical, sexual, emotional, and financial) and bidirectional. We identified six themes: (1) IPV precipitated and prolonged homelessness; (2) Need for housing, financial stability, and material resources influenced staying in abusive relationships; (3) Alcohol and illicit substance use exacerbated violence between partners; (4) Participants struggled to find resources in domestic violence (DV) shelters; (5) The healthcare system did not provide substantial support; and (6) discrimination and stigma influenced equitable access to housing and DV resources. Experiencing IPV contributed to homelessness and impeded returns to housing. Limitations in current IPV resources impede care. We propose equitable expansion of survivor-centered services that improve access to long-term subsidized housing, prevent IPV and homelessness with flexible funding options, and facilitate rapid exits from homelessness through trauma-informed, non-congregate shelter that transitions to permanent housing.

Stressful Life Events and Risk of Homelessness After Active Duty: An Assessment of Risk and Resilience Among Servicemembers

OBJECTIVES

The transition from military to civilian life may present increased exposure to various stressful life events (SLEs) that can increase the risk of homelessness (eg, loss of employment, dissolution of romantic relationships). We assessed the extent to which exposure to SLEs occurring proximal to US Army soldier transitions out of active duty was associated with risk of homelessness.

METHODS

A total of 16 589 respondents who were no longer on active duty but participated while on active duty during 2011-2014 baseline surveys completed follow-up surveys during 2016-2018 and 2018-2019. The follow-up surveys assessed SLEs and homelessness occurring in the past 12 months. We used modified Poisson regression models to evaluate how much differential SLE exposure and effects explained the aggregate association of a risk index with homelessness among a sample of 6837 respondents, weighted to represent the full sample.

RESULTS

More than half (n = 3510, 52.8%) of respondents reported experiencing any SLEs in the past 12 months. Most (60.5%) of the difference in prevalence of homelessness among respondents defined as being at high risk of homelessness (vs lower risk) was explained by differential exposure to, and/or effects of, these SLEs. Personal betrayal by a loved one and economic problems played the largest roles in adjusted risk differences (0.045 and 0.074, respectively).

CONCLUSIONS

Homelessness might be reduced by gearing interventions toward soldiers at high risk of homelessness who are transitioning out of active duty to reduce exposure to and effects of modifiable SLEs on experiencing homelessness.

Voices of women veterans: My Life, My Story

PURPOSE

To explore women veterans' experiences by writing short stories of their lives as part of a program, My Life, My Story (MLMS), and qualitatively analyzing the aggregate stories to identify themes, risks, and opportunities for changes in care.

METHODS

We interviewed women veterans receiving care and/or working at the James J. Peters VA Medical Center in the Bronx, N.Y. Women researchers experienced in the narrative storytelling model, MLMS, wrote participants' short stories. Twenty-two stories were written, aggregated, coded, and reviewed multiple times until saturation; no new themes emerged. The researchers established trustworthiness, consistency, and credibility.

RESULTS

Themes from data from the stories of women veterans included reasons for choosing a military career, military and postmilitary experiences, psychological and military sexual trauma (MST), access to mental health care and support, antiwomen/misogynistic perceptions, relationships, life after military service, experiences with VA care and services, and future goals.

CONCLUSION

Women veterans have very different military and postmilitary experiences from men. Given the increasing number of women veterans who experience homelessness, MST, and posttraumatic stress disorder, providers, the healthcare community, and the public need to hear the voices of women veterans, learn about their military experiences, and redesign women veterans' healthcare to better meet their unique needs by improving supportive mental and physical health care services.

Immigrant Women's Experiences of Domestic Violence in Canada: A Qualitative File Audit

Purpose

Domestic violence (DV) experienced by immigrant women is a global health concern. Precarious immigration status, language barriers, and discrimination can lead to reluctance in seeking support. Is a non-profit charitable organization and support center for immigrant women. Participants in this study were immigrant women who attended Changing Together. The aim of this study is to illustrate immigrant women's experiences of DV and identify the community services they access.

Methods

The files of a social worker at Changing Together were audited for this project. There were 1,034 files available to audit. The six steps of thematic analysis were used to create themes from the notes of each file, specifically to answer the question: what are the experiences of immigrant women with domestic violence and what are the services they access through Changing Together?

Results

Three themes were developed: Building Independence, Surviving Abuse, and Services to Support Surviving. Building Independence centres on women building solid foundations to start their lives in Canada to support themselves and their families. Surviving Abuse encompasses the hardships women endured for the perceived sake of their children until there was an event leading to the unavoidable need for change. Services to Support Surviving explores the services women accessed through the social worker at Changing Together.

Conclusions

This study highlights the complexities of immigrant women enduring DV in a foreign country. The file notes described women's experiences of living with hardships and endurance of challenges. Further research should identify community resources for this population.

Systematic review of access to healthcare and social services among US women Veterans experiencing homelessness

BACKGROUND

Studies suggest female Veterans are under-identified as homeless in the VA healthcare system, which may impact their ability to access necessary services. In addition, the increasing number of female Veterans experiencing homelessness requires a better understanding of their access to necessary healthcare and social care.

OBJECTIVES

The purpose of this systematic review was to examine the barriers and facilitators for access to healthcare and social care among women Veterans experiencing homelessness.

DESIGN

A mixed methods systematic review was conducted and includes quantitative and qualitative primary research studies.

DATA SOURCES AND METHODS

Seven databases were searched for quantitative or qualitative research studies. Studies which addressed access or use of healthcare or social services, which were focused on female Veterans or allowed for comparison between male and female Veterans were included. Data were synthesized using a convergent integrated approach.

RESULTS

Thirty-five studies met inclusion criteria; 27 quantitative, 6 qualitative and 2 mixed methods studies. Three main themes resulted: (1) the comparison of access and use of healthcare and social services between women and men; (2) female specific barriers to access or use of social and health services; (3) female specific facilitators to access or use of social and health services.

CONCLUSIONS

Results showed although women Veterans had similar or better outcomes with permanent housing programming compared to men, gaps remain in the provision of emergency and short-term housing accommodations. In addition, many studies found that homeless women Veterans were unaware of the healthcare and social services available through the VA. Programs and policies need to ensure they are maximizing their reach to women Veterans experiencing homelessness by providing outreach and education, so they understand the benefits available when they discharge from the military and to understand the unique healthcare and social needs of women Veterans.

Military sexual trauma in context: Ethnoracial differences in ecological resources among treatment-seeking veterans

Veterans who have experienced military sexual trauma (MST) are at increased risk for a host of negative outcomes, including posttraumatic stress disorder, depressive disorders, and substance use disorders. Previous studies have shown racial differences in MST exposure, namely that Black veterans experience MST more frequently than White veterans. One way to help clinicians and researchers understand the impact of these ethnoracial differences in MST exposure is through an applied theory of ecological resources, which has demonstrated ecological factors (e.g., aspects of identity, beliefs, and environmental stressors) contribute to veteran well-being in the aftermath of MST. The present study aimed to examine ethnoracial differences in ecological resources (i.e., available social support, spiritual coping, past-year interpersonal violence, financial sufficiency, and stable living environment). Participants (N = 505) were U.S. veterans who sought care at a Veterans Healthcare Administration clinic in the midwestern United States for mental health issues related to MST. Results demonstrated Black veterans were more likely than White veterans to report being financially insecure, U = 18,091.50, z = -2.04, p = .042, r = .10. Black veterans were also more likely to report spiritual beliefs that assisted with coping, Cramer's V = .19, but less likely to report having a social support system, Cramer's V = .16. These findings highlight the importance of assessing and addressing disparities illuminated by ethnoracial differences in ecological resources and barriers in veterans seeking care for MST.

Preventing Suicide Among Women Veterans: Gender-Sensitive, Trauma-Informed Conceptualization

Purpose of Review

There is growing concern regarding suicide among women veterans, who have experienced an increase in suicide rates that has exceeded that reported for other US adult populations. Recent research has bolstered understanding of correlates of suicide risk specific to women veterans. Yet most existing suicide prevention initiatives take a gender-neutral, rather than gender-sensitive, approach. We offer clinical considerations and suggestions for suicide prevention tailored to the needs, preferences, and experiences of women veterans. Discussion is framed around the White House strategy for preventing suicide among military service members and veterans.

Recent Findings

Considering high rates of trauma exposure among women veterans, we propose that a trauma-informed lens is essential for taking a gender-sensitive approach to suicide prevention with this population. Nonetheless, research to inform evidence-based assessment and intervention remains largely focused on veteran men or gender-neutral. Integral next steps for research are posited.

Summary

Extant research provides an initial foundation for beginning to understand and address suicide among women veterans in a gender-sensitive, trauma-informed manner. Additional research that is specific to women veterans or that examines gender differences is critical to ensure women veterans receive optimal, evidence-based care to prevent suicide.

Affordable housing through the low-income housing tax credit program and intimate partner violence-related homicide

The most severe outcome of intimate partner violence (IPV) is IPV-related homicide. Access to affordable housing may both facilitate exit from abusive relationships and reduce financial stress in intimate relationships, potentially preventing IPV-related homicide. We examined the association of the availability of rental housing through the Low-Income Housing Tax Credit (LIHTC) program, a federal program providing tax incentives to support the development of affordable housing, with IPV-related homicide and assessed whether this association differed by eviction rates at the state-level. We used 2005-2016 National Violent Death Reporting System, LIHTC Property, and Eviction Lab data for 13 states and compared the rate of IPV-related homicide in state-years with ≥30 to state-years with <30 LIHTC units per 100,000 population, overall and stratified by eviction rates. We conducted analyses in fall 2020. Adjusting for potential state-level confounders, the rate of IPV-related homicide in state-years with ≥30 LIHTC units per 100,000 population was lower than in state-years with <30 LIHTC units per 100,000 population (RR = 0.89, 95% CI 0.81, 0.98). The reduction in the rate of IPV-related homicide was slightly larger in state-years with higher eviction rates (≥3500 evictions per 100,000 renter population; RR = 0.83, 95% CI 0.74, 0.93) compared to state-years with lower eviction rates (<3500 evictions per 100,000 renter population; RR = 0.91, 95% CI 0.81, 1.03). Overall, at the state-level, increased availability of affordable housing through the LIHTC program was associated with lower rates of IPV-related homicide. Increasing the availability of affordable housing may be one tool for preventing IPV-related homicide.

The Association Between Interpersonal Violence and Unstable Housing Among Veterans

BACKGROUND

Despite programs to address housing for Veterans, they continue to be at high risk of unstable housing. Interpersonal violence is also highly prevalent among Veterans and may contribute to unstable housing. Our study aimed to determine whether interpersonal violence was associated with unstable housing among Veterans, and how this association was influenced by common co-occurring conditions such as substance use and mental illness.

METHODS

Veterans in the Mind Your Heart Study (N = 741) completed survey data on history of interpersonal violence and access to housing in the prior year. Interpersonal violence was defined as experiencing sexual violence, physical violence, or mugging/physical attack using the Brief Trauma Questionnaire. Multivariable models examined associations between interpersonal violence and unstable housing. Primary models were adjusted for age and sex. Potential explanatory factors were added in subsequent models, including marital status, education, income, substance use disorder, PTSD, and other mental illness.

RESULTS

Veterans who had experienced interpersonal violence had almost twice the odds of unstable housing after adjustment for age and sex (AOR 1.9, 95% CI 1.2-3.0). This association was attenuated in the fully adjusted model including substance use, PTSD, and other mental illness, illustrating the interdependence of these factors (AOR 1.5, 95% CI 0.91-2.5). Subtypes of interpersonal violence were individually associated with increased odds of unstable housing after adjustment for age and sex (physical abuse AOR 1.7, 95% CI 1.2-2.5; mugging/physical attack AOR 1.8, 95% CI 1.2-2.7; sexual violence AOR 1.4, 95% CI 0.89-2.2), but were no longer significant in the fully adjusted model.

CONCLUSIONS

Previous experiences of interpersonal violence were associated with unstable housing among Veterans. Substance use, PTSD, and other mental illness played an important role in this relationship-highlighting the potential to improve health outcomes through trauma informed approaches that address mental health, substance use, and housing concurrently.

Neurobiological Alterations in Females With PTSD: A Systematic Review

Most females experience at least one traumatic event in their lives, but not all develop PTSD. Despite considerable research, our understanding of the key factors that constitute risk for PTSD among females is limited. Previous research has largely focused on sex differences, neglecting within group comparisons, thereby obviating differences between females who do and do not develop PTSD following exposure to trauma. In this systematic review, we conducted a search for the extent of existing research utilizing magnetic resonance imaging (MRI) to examine neurobiological differences among females of all ages, with and without PTSD. Only studies of females who met full diagnostic criteria for PTSD were included. Fifty-six studies were selected and reviewed. We synthesized here findings from structural MRI (sMRI), functional MRI (fMRI), diffusion tensor imaging (DTI), and resting state functional connectivity (rs-FC MRI) studies, comparing females with and without PTSD. A range of biopsychosocial constructs that may leave females vulnerable to PTSD were discussed. First, the ways timing and type of exposure to trauma may impact PTSD risk were discussed. Second, the key role that cognitive and behavioral mechanisms may play in PTSD was described, including rumination, and deficient fear extinction. Third, the role of specific symptom patterns and common comorbidities in female-specific PTSD was described, as well as sex-specific implications on treatment and parenting outcomes. We concluded by identifying areas for future research, to address the need to better understand developmental aspects of brain alterations, the differential impact of trauma types and timing, the putative role of neuroendocrine system in neurobiology of PTSD among females, and the impact of social and cultural factors on neurobiology in females with PTSD.

Trauma and cervical cancer screening among women experiencing homelessness: A call for trauma-informed care

OBJECTIVE

Women experiencing homelessness are at increased risk of cervical cancer and have disproportionately low Pap screening behaviors compared to the general population. Prevalence of Pap refusals and multiple kinds of trauma, specifically sexual trauma, are high among homeless women. This qualitative study explored how trauma affects Pap screening experiences, behaviors, and provider practices in the context of homelessness.

METHODS

We conducted 29 in-depth interviews with patients and providers from multiple sites of a Federally Qualified Health Center as part of a study on barriers and facilitators to cervical cancer screening among urban women experiencing homelessness. The Health Belief Model and trauma-informed frameworks guided the analysis.

RESULTS

Trauma histories were common among the 18 patients we interviewed. Many women also had strong physical and psychological reactions to screening, which influenced current behaviors and future intentions. Although most women had screened at least once in their lifetime, many patients experienced anticipated anxiety and retraumatization which pushed them to delay or refuse Paps. We recruited 11 providers who identified strategies they used to encourage screening, including emphasizing safety and shared decision-making before and during the exam, building strong patient-provider trust and communication, and individually tailoring education and counseling to patients' needs. We outlined suggestions and implications from these findings as trauma-informed cervical cancer screening.

CONCLUSION

Discomfort with Pap screening was common among women experiencing homelessness, especially those with histories of sexual trauma. Applying a trauma-informed approach to cervical cancer screening may help address complex barriers among women experiencing homelessness, with histories of sexual trauma, or others who avoid, delay, or refuse the exam.

Demographic Correlates of Veterans' Adverse Social Determinants of Health

INTRODUCTION

Identifying patient populations most affected by adverse social determinants of health can direct epidemiologic investigation, guide development of tailored interventions, and improve clinical care and outcomes. This study explores how demographic characteristics are associated with specific types-and cumulative burden-of adverse social determinants of health among Veterans seeking Veterans Health Administration health care.

METHODS

Data included electronic health records for 293,872 patients of Veterans Health Administration facilities in one region of the country between October 1, 2015 and September 30, 2016. A series of multiple logistic regressions conducted between August and December 2019 examined how demographic variables are associated with 7 adverse social determinants of health. A negative binomial regression examined the association between demographic characteristics and cumulative burden of social determinants of health.

RESULTS

Demographic characteristics were associated with increased odds of each type of adverse social determinant of health: minority race, unmarried status, and Veterans' service connected disability status. Conversely, living in a rural area and being aged >40 years were associated with decreased odds of most of the adverse social determinants of health studied here. Hispanic ethnicity and female sex were inconsistently associated with increased odds of some adverse social determinants of health and decreased odds of others. These results are mirrored in the analysis of predictors of cumulative burden of adverse social determinants of health.

CONCLUSIONS

There is increasing and ongoing interest in ways to identify and respond to patients' experiences of or exposures to adverse social determinants of health. Demographic characteristics may signal the need to assess for adverse social determinants of health. Analyses exploring latent factors among these social determinants (e.g., poverty) may inform strategies to identify patients experiencing adverse social determinants of health and provide responsive interventions.

Cumulative Trauma Exposure and Chronic Homelessness Among Veterans: The Roles of Responses to Intrusions and Emotion Regulation

Veterans with mental health problems and a history of interpersonal and military trauma exposure are at increased risk for chronic homelessness. Although studies have examined posttraumatic stress disorder (PTSD) as a predictor of homelessness, there is limited understanding of specific mechanisms related to cumulative trauma exposure. We sought to elucidate how cumulative interpersonal and military trauma exposure may be linked to homelessness chronicity by examining the role of factors that influence trauma recovery and functional impairment. Specifically, we examined the indirect association of cumulative trauma exposure with homelessness chronicity through distress and responses to trauma-related intrusions and emotion regulation problems in a sample of 239 veterans in community-based homeless programs. Participants completed measures of trauma exposure, responses to intrusions, intrusion distress, difficulties with emotion regulation, and duration and episodes of homelessness. Structural equation modeling was used to test a serial indirect effect model in which cumulative trauma exposure was indirectly associated with homelessness chronicity through distress from and responses to intrusions as well as emotion regulation problems. The results supported the hypothesized sequential indirect effect for episodes of homelessness, indirect effect odds ratio (IE ORs) = 1.12-1.13, but not for current episode duration, IE OR = 1.05. Overall, the present findings elucidate specific trauma-related factors that may be particularly relevant to episodic patterns of homelessness and interfere with efforts to remain housed. These findings represent an important step toward shaping policy and program development to better meet mental health care needs and improve housing outcomes among homeless veterans.

Violence and Emergency Department Use among Community-Recruited Women Who Experience Homelessness and Housing Instability

Women who experience housing instability are at high risk for violence and have disproportionately high rates of emergency department (ED) use. However, little has been done to characterize the violence they experience, or to understand how it may be related to ED use. We recruited homeless and unstably housed women from San Francisco shelters, free meal programs, and single room occupancy (SRO) hotels. We used generalized estimating equations to examine associations between violence and any ED use (i.e., an ED visit for any stated reason) every 6 months for 3 years. Among 300 participants, 44% were African-American, and the mean age was 48 years. The prevalence of violence experienced in the prior 6 months included psychological violence (87%), physical violence without a weapon (48%), physical violence with a weapon (18%), and sexual violence (18%). While most participants (85%) who experienced physical violence with a weapon or sexual violence in the prior 6 months had not visited an ED, these were the only two violence types significantly associated with ED use when all violence types were included in the same model (ORphysical/weapon = 1.83, 95% CI 1.02-3.28; ORsexual = 2.15, 95% CI 1.30-3.53). Only violence perpetrated by someone who was not a primary intimate partner was significantly associated with ED use when violence was categorized by perpetrator. The need to reduce violence in this population is urgent. In the context of health care delivery, policies to facilitate trauma-informed ED care and strategies that increase access to non-ED care, such as street-based medicine, could have substantial impact on the health of women who experience homelessness and housing instability.