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

Abstract

Women veterans in the United States face disproportionate risk of housing instability (HI) and interpersonal violence (IV), largely perpetrated by intimate partners or involving non-partner sexual violence, compared to both male veterans and non-veteran peers. To explore the ways in which IV and HI intersect in the experiences of women veterans, we analyzed transcripts of in-depth qualitative interviews with 20 women veterans who had screened positive for HI at a Veterans Affairs Medical Center. Three broad themes emerged related to the intersection of IV (specifically intimate partner violence or non-partner sexual violence) and HI among women veterans: (1) housing instability can both be precipitated by and increase vulnerability to interpersonal violence; (2) experiences of interpersonal violence impact women’s definitions of housing safety and security; and (3) interpersonal violence can pose a barrier to accessing housing services and other support systems. Findings indicate areas for improvement to screening processes and service provision to more effectively address the co-occurring and interacting safety and housing needs of women veterans.

Background

Housing instability (HI), including actual homelessness as well as the imminent threat of homelessness, is a significant public health problem in the United States and particularly pronounced among the veteran population. One source estimates that 553,742 people in the United States were experiencing homelessness at a single point in time in January 2017; whereas veterans make up less than 9% of the total U.S. adult population, they constitute over 9% of homeless adults (Henry et al., 2017). To identify veterans experiencing HI and connect them with resources, the U.S. Veterans Health Administration (VHA) instituted a routine universal HI screen in 2012 for all veterans enrolled in VHA care (Montgomery et al., 2013; Montgomery et al., 2014).

Women represent a growing minority of veterans, currently comprising 9% of the total veteran population, with steady increases expected in the coming decades (Aponte et al., 2017). Women veterans are overrepresented among homeless women (Perl, 2015) and may be up to four times more likely to experience homelessness than non-veteran women (Fargo et al., 2012; Gamache et al., 2003). Risk factors for HI among women veterans include experiences before, during, and following military service, including: physical or sexual trauma; mental health diagnoses, such as post-traumatic street disorder (PTSD) or anxiety-related disorders; and unemployment after discharge (Hamilton et al., 2011; Washington et al., 2010).

Intimate partner violence (IPV) can increase risk for HI both directly (e.g., when separation from an abusive partner results in loss of housing) as well as indirectly, through traumatic stress reactions to violence that may lead to mental health problems, maladaptive coping behaviors (e.g., substance misuse), and a cascade of further detrimental effects on financial and social stability (Baker et al., 2010; Bonomi et al., 2009; Dillon et al., 2013; Gerber et al., 2014; Gobin et al., 2015; Hamilton et al., 2011; Lagdon et al., 2014; Pavao et al., 2007). As Thomas, Goodman, and Putnins (2015) highlighted, women seeking safety from partner violence often face difficult ‘trade-offs’ and multiple losses, including loss of stable housing.

Women veterans are at significantly increased lifetime risk of experiencing IPV compared to non-veteran women. Analysis of data from the CDC Behavioral Risk Factor Surveillance Survey (BRFSS) found that 33% of women who had served in the military reported experience of lifetime IPV compared with 24% of women who had not served in the military (Dichter et al., 2011). Among women veterans accessing VHA care, an estimated 18.5% experience IPV within a one-year period (Kimerling et al., 2016), and women who have experienced past-year IPV are up to four times more likely to report HI than women who have not experienced IPV (Montgomery et al., 2018; Pavao et al., 2007).

Several scholars have noted that conceptualizations of stable housing among populations that have experienced HI encompass both material, financial, and physical aspects (e.g., adequacy and affordability of housing; Kushel et al., 2006; Ponic et al., 2011), as well as less tangible needs such as emotional wellness and a sense of safety (Daoud et al., 2016; Dunn et al., 2002; O’Campo et al., 2016; Woodhall-Melnik et al., 2016). For many women, resolving HI is key to stabilizing other, interrelated aspects of physical and emotional health (Daoud et al., 2016).

Previous literature has identified experiences of IPV and other forms of trauma as ‘pathways’ to homelessness among women veterans (Hamilton et al., 2011; Washington et al., 2010). However, there is little existing information in the literature regarding how experiences of IPV and other forms of interpersonal violence (IV), including non-partner sexual violence, contribute to women veterans’ experiences, attitudes, and behaviors related to securing and maintaining safe and stable housing. A deeper understanding of women veterans’ experiences with violence is therefore necessary to better tailor both screening and service provision to intervene effectively on their behalf.

Through analysis of in-depth qualitative interviews with women veterans who had recently experienced HI, this study seeks to provide a better understanding of the ways in which HI and IV intersect to shape and inform women’s experiences and safety-related needs. Specifically, we examine the experiences and concerns related to interpersonal violence (including IPV and non-partner sexual violence) that women shared during interviews, and explore how these experiences contributed to women’s vulnerability to HI and impacted their efforts to secure and maintain safe and stable housing.

Methods

This study was conducted at the Crescenz VA Medical Center (CVAMC) in Philadelphia, PA. Study procedures were approved by the CVAMC Institutional Review Board.

Research staff recruited women veterans to participate in qualitative interviews focused on their recent experiences with housing instability. Eligibility for participation was based on veterans’ responses to the Homelessness Screening Clinical Reminder (HSCR; Montgomery, Fargo, Kane, & Culhane, 2014), a universal screener administered by VHA clinicians to identify patients experiencing HI and connect them to supportive services. Research staff mailed recruitment letters and study flyers to women service users at a single VA facility who reported a positive screen on the HSCR (i.e., current or imminent HI) between July 2014 and August 2015 (N=49). The letters asked veterans to contact research staff to opt-out of the study or schedule an interview; if no response was received within 2 weeks, research staff followed-up via telephone. A total of 20 women veterans were recruited from two subgroups: those who screened positive for current HI (n=10) and those who screened positive for risk of HI (n=10).

In-person interviews were conducted by an experienced qualitative interviewer in a secure, private space at the CVAMC between January and April 2016. Interviews lasted approximately 60 minutes. After obtaining informed consent, the interviewer asked questions about background, military service, and health. The interviewer then used a semi-structured interview guide to elicit veterans’ thoughts on and experiences with the HSCR; lifetime experiences with HI, including contributing factors; receipt of housing and other supportive services; and needed services and suggestions for improvement. The guide ensured uniform inclusion and sequencing of topics, allowing for valid comparison across interviews while providing flexibility to explore topics in greater depth according to individual women’s perspectives and experiences. Thus, the interviewer did not explicitly inquire about experiences of violence; rather, violence and personal safety emerged as salient topics during exploration of women’s experiences of HI. Participants received $30 in compensation for participation in an interview.

Digital recordings of interviews were transcribed verbatim by a professional transcription company. A team-based process was used to code and analyze the qualitative data. The team first developed a codebook through an iterative process of open coding to identify core concepts. Codes were revised and refined, and disagreements resolved, through iterative review and discussion. The final codebook included code names, definitions, rules for application to text segments, and exemplar quotations. Each transcript was then coded according to the codebook and a random selection of transcripts was independently double-coded to achieve intercoder reliability. The final codebook included a code for Trauma Exposure, which included psychological, physical, and/or sexual trauma by a current or former intimate partner, and was the primary focus of this analysis. Salient themes and exemplar quotes reflecting each of the themes were identified through a process of team discussion and re-reviewing of the transcripts, and transcript quotes as outlined in the template analysis approach (as described in: Brooks et al., 2015; King, 2004).

Results

Respondent Characteristics

Table 1 displays respondent characteristics. Respondents ranged in age from 26 to 62, with half over age 54, and the majority identified as African American. Half reported that they were single at the time of the interview. One in five indicated that they were unable to make ends meet financially, while most reported having just enough to get along. When asked about mental health conditions, nearly all respondents stated they were depressed and three-quarters reported PTSD; 40% reported a history of drug or alcohol abuse.

Table 1:

Respondent characteristics

	N	%
Age
<35	3	15
35–44	4	20
45–54	3	15
55–62	10	50
Race
Black	12	60
White	6	30
Other	2	10
Relationship status
Married	8	40
Single	10	50
Widowed	2	10
Financial status
Can’t make ends meet	4	20
Have just enough to get along	13	65
Comfortable	3	15
Mental health conditions
Post-Traumatic Stress Disorder	15	75
Substance abuse	8	40
Depression	19	95
Schizophrenia	2	10

Themes related to violence and personal safety

As noted above, themes related to violence and personal safety emerged spontaneously during interviews as women veterans discussed their experiences and views of HI. Eleven of the 20 participants specifically and explicitly referred to experiences of interpersonal violence, including IPV and non-partner sexual violence, in their narratives about housing stability, or lack thereof. Other participants did not explicitly refer to specific incidents of violence but discussed personal safety from interpersonal violence as an important factor influencing their search for safe and stable housing. Interpersonal violence and abuse experienced across the life course were key to understanding women’s pathways to housing instability, their conceptualization of safe and secure housing, and their engagement with and perception of housing related services. Analysis of the interview transcripts revealed three broad themes related to the intersection of IV and HI: 1) housing instability can both be precipitated by and increase vulnerability to interpersonal violence; 2) experiences of interpersonal violence impact women’s definitions of housing safety and security; and 3) interpersonal violence can pose a barrier to accessing housing services and other support systems. The themes are presented below, with supporting excerpts from interviews; pseudonyms are used throughout to protect participant confidentiality.

Housing instability can both be precipitated by and increase vulnerability to interpersonal violence

Narratives revealed ways in which experiences of IV affected women’s housing stability, or lack thereof, illustrating both direct and indirect pathways from victimization to HI. In addition, participants described lack of stable housing as increasing vulnerability to further violence and abuse. For women experiencing violence or abuse, housing needs may be precipitated by a need to escape an unsafe environment. Women are particularly vulnerable to both violence and HI when they decide to separate from an abusive partner, as social isolation and financial control/dependence are often part of the pattern of abuse.

One participant, Raquel, who had relocated to a new city with her husband following discharge from the military, described her husband’s increasing emotional and physical abuse. Without an established support network, and ‘too proud to go back home,’ she stayed until it became so unsafe that she fled to a shelter with her children to escape her husband’s violence.

Another participant, Nadia, described her husband’s literal destruction of her home while she was in the process of separating from him:

We had mutually come to the fact that we weren’t going to be married any longer because he was abusive – mentally, emotionally, financially. And because I had went through so much with him, he said he just needed 30 days to leave the house… so I went to my uncle’s house… just to give him the time to move out; he did the opposite. He tried to press protection from abuse orders on me. He took all my personal information and taped it to the windows and the doors, my social, my name, my height, my age, everything. I had to have multiple contacts with the police department. He changed the locks on my house. …he ultimately destroyed the house to where it was I had to go to the VA [Home Loans] and have a deed in lieu because I literally couldn’t even live in the house.

In addition to violence from a partner, several women described how leaving the relationship increased their vulnerability to other sources of violence. Mona was dependent on cash assistance after leaving her abusive husband and described the cycle of violence and trauma that ensued:

Welfare didn’t afford you much then. I think you got maybe $100 every two weeks, so I had to find a room for $50 a week, something to that effect. They were to be found, but the conditions were very bad. I was always getting in situations where I was being abused. […] I was abused and raped many times after that. As a matter of fact, my whole life after that had been just a succession of abusive relationships, muggings, rapes, just being taken advantage of.

For Mona, fleeing her husband’s violence on a limited income led to her living in unsafe conditions, resulting in exposure to further violence and trauma. Several other women described a similar sequence of events, where escaping abuse from a partner led them into provisional, unstable, or unsuitable living conditions, which then exposed them to additional and continuing episodes of physical or sexual abuse.

Experiences of interpersonal violence impact women’s definitions of housing safety and security

Participants described situations in which they were faced with the option of either being homeless or being abused or assaulted in exchange for shelter (i.e., living with an abusive partner). When considering alternative housing options, women discussed the ways in which concerns regarding potential abuse or re-victimization shaped their conceptualizations of and decision-making around housing and housing-related services. Many had experienced multiple traumatic events or circumstances during childhood, including violence-related HI (e.g., running away from physical and sexual abuse at home), as well as more recent IV. Previous traumatic experiences, both distal and proximal, informed women’s responses to subsequent housing emergencies and their definitions of what constitutes safe and secure housing.

Participants described that, when considering housing options, concerns around personal safety were paramount; they sought housing that was not just structurally sound but that would also minimize risk of further victimization. Mona stated:

When you’re a woman alone, security is very important. I have experienced abuse. I’m apprehensive about being put in a living situation where I’m going to be put in a position where I could be abused.

Nadia also discussed safety considerations particularly tied to concerns of interpersonal violence when seeking housing:

As a single woman who has been through sexual harassment and posttraumatic stress disorder, it’s harder for me to feel safe in a place. So it might have been a problem for me looking at apartment complexes because I would have wanted to live in a gated community. I would have wanted to live somewhere where it’s possibly a doorman and maybe not a lot of floors and apartments on one row, because I don’t feel comfortable if I’m walking down long corridors or dark halls… When I stay in a hotel, I have to stay near an elevator, not too far into a floor, where something could happen to me and nobody hears.

While housing options could be financially palatable, located in a neighborhood accessible to family or ready child care, and acceptable in every other important way, they could still raise concerns around personal safety or potential for abuse. As a result, viable housing options, already limited, are even harder to find.

Interpersonal violence can pose a barrier to accessing housing services and other support systems

Participants spoke about variable experiences with the services they used to find secure housing. When seeking to escape a violent partner, women typically need to maintain secrecy from the partner about their plans to leave and where they are going. Circumstances can shift rapidly, requiring dynamic reappraisals of the risks and benefits of leaving. Participants described a mismatch between the urgency of their situations and the time-consuming process of identifying and securing suitable housing. Ashley described how she navigated a months-long paperwork process to get her own housing while staving off inquiries from her abusive partner, with whom she was still living at the time:

My issue was that while they [the housing agency] were helping me, I still had to go home to my abusive husband. It was hard for me to be able to come to these appointments. I don’t work, so coming out all the time is kind of like all of a sudden ‘Where are you going?’ What I told him I was doing was I told him I was going to anger management. Sort of I was. That is what I told him to keep him kind of cool without having to tell him… Eventually I did have to tell him and that was scary. Some days he took it well and some days it was kind of rough.

Ashley went on to recall her response when the housing agency asked at the last minute to delay her move-in date for another week:

I was like, I have to get out of my house. I cannot stay there another week. I really, like it is not even funny, like I am going to go to jail if I have to stay another week.

Due to the continuing escalation of violence, Ashley feared that if she did not escape she would be forced to use violence to defend herself and risk her own arrest. Eventually, she was able to access resources, establish stable housing, and leave her abusive relationship without experiencing a critical escalation in abuse. Nevertheless, her story demonstrates a critical need for coordination of services and timely access to safe housing in situations of acute and imminent violence.

Study participants also described shame and stigma associated with both victimization and HI that hindered disclosure and help-seeking. Participants reported keeping silent out of pride, embarrassment about their situation, and a need to keep up a semblance of normalcy rather than allowing other people (especially friends or family) to know what was going on, as Clare noted:

I never described to them [my family] my problems. They never knew I was homeless. They never knew that man was beating me. They never knew any of that. I never told them, and I’m still here not telling them what’s going on.

For others, escalation in violence may serve as a tipping point that leads to help-seeking. Ashley described an abusive situation that eventually led her to be admitted to the psychiatric ward for drug use and homicidal and suicidal ideation, where she first learned about VA’s supportive housing programs. Despite the extremity of her situation, she still did not seek help initially:

While I was in the hospital… somebody had mentioned to me just as a sidebar that there is a program called HUD-VASH and that basically they would put me to the top of the list because I was a female veteran with children in an abusive situation. So I was not homeless, but I was in a dangerous situation. I took the note. I wrote it down. … Things got worse. Eventually I called.

Discussion

Our results add to the literature documenting the direct and indirect pathways from experiences of IPV and other IV to HI (e.g., Gerber et al., 2014; Hamilton et al., 2011; Washington et al., 2010). Additionally, this study advances the field by documenting ways in which experiences of, and concerns about, interpersonal violence influence women’s definitions of and access to safe and secure housing. When asked about housing safety and security, women veterans spontaneously described how violence and trauma inform their decision-making about housing, consistent with previous literature that highlights the importance of psychological contributors to housing stability (Daoud et al., 2016; Dunn et al., 2002; O’Campo et al., 2016). The salient questions are not simply, Will this house keep the elements out and my family warm? but also, Will it keep me safe from situations of violence that have the potential to reoccur? Our study findings have implications for improving trauma-informed care in housing services.

Limitations

Participants were interviewed at one VHA facility, and our findings are not necessarily generalizable to a wider population. In addition, we did not ask participants about experiences of IPV/IV explicitly; rather, themes related to experiences of IV emerged spontaneously in the narratives. On the one hand, this demonstrates the salience of IV to women’s perceptions of their housing stories; on the other, it may also have led to our missing some experiences that were not spontaneously disclosed. Future research should more systematically explore the linkage between IV and HI by asking participants about experiences of both and their perceptions of the relationship between the two. Finally, men, whether veterans or not, can and do experience IPV, albeit with generally fewer recorded cases compared to women (Black et al., 2011). More research is needed to delineate male experiences of IV/trauma and how they interact with HI.

Implications

There is growing recognition of HI as a social determinant of health, and assessment for such social factors is receiving greater consideration in healthcare settings. Additionally, there is greater appreciation of the need for trauma-informed care in health and social service systems, especially with regard to populations experiencing HI. The theoretical tenets of trauma-informed care include education for providers, as well as a commitment to providing services with an emphasis on restoring safety and control to the lives of traumatized individuals (Dinnen et al., 2014; Hopper et al., 2010). In addition, frameworks have been created to guide organizational transitions to providing trauma-informed services for homeless veterans (Guarino et al., 2014).

Our findings have implications for further operationalizing these transitions, including the need to consider patient/client confidentiality and safety when screening for experiences of HI. This extends to recordkeeping and documentation of housing and IPV screenings in patient/client charts. As our results demonstrate, housing providers must recognize that standard operating procedures, such as calling and leaving messages on a patient’s provided phone number regarding a housing application, may not be safe if the patient is attempting to escape an active IPV situation. These considerations are widely known in domestic violence service provision, but it is clear from this study that they are equally important in providing safe and effective housing interventions for the populations that access them.

The most recent, legislatively-used definition of homelessness, according to the Homeless Emergency Assistance and Rapid Transition to Housing (HEARTH) Act of 2009, includes: ‘people who are fleeing or attempting to flee domestic violence, dating violence, sexual assault, stalking, or other dangerous or life-threatening situations related to violence; have no other residence; and lack the resources of support networks to obtain other permanent housing.’ In light of this broad definition of homelessness, screening for HI among women should not be limited to asking about narrowly-defined homelessness (e.g., being without a place to sleep that particular night), but should also attempt to assess and intervene in situations of HI, such as suffering through ongoing IV, including intimate partner violence. Critically, screening and intervention efforts should reflect the understanding that these situations of active IV are apt to morph and escalate unpredictably. As other recent research with women who have experienced IPV and access subsidized housing has noted, housing programs not sensitive and responsive to the context of IV can increase stigma, disempowerment, and safety risks for women fleeing violence (Jeffrey & Barata, 2017).

The VHA has protocols for universal and routine screening for both HI and IPV. Given that some individuals will screen positive for both (Montgomery et al., 2018), it may be useful to have coordination between these two screening systems (e.g., such that screening positive for HI would automatically trigger a secondary screening for IPV or vice versa). There are practical implementation issues to consider, as well; we need more evidence on the effectiveness of these screening tools in their current form, and also on the potential burdens and opportunity costs of conducting these screenings.

As our interviews uncovered, and as previous research on IPV screening and disclosure has found (e.g., Dichter et al., 2015), concerns about privacy, stigma, and shame can inhibit disclosure of sensitive topics in healthcare settings. Some patients may not be forthcoming with healthcare and social service workers in disclosing experiences of IV for reasons both internal (shame or stigma) and external (threat of continued violence). Training is critical to ensure that care is supportive, sensitive, and trauma-informed to prevent further safety risks or re-traumatization of a particularly vulnerable population.

Baker and colleagues (2010) present extensive recommendations for housing policy and practice, including expansion of housing provision models to serve diverse populations, the evaluation of housing programs and policies in terms of their potential to meet women’s unique housing needs, and emphasis on flexibility and respect for autonomy (e.g., not requiring participation in mandatory groups in order to access services). We submit that these and other interventions in training, awareness, screening, or clinical service structure would help women veterans feel safer in disclosing and seeking assistance with their housing needs. However, the first steps within the VHA setting remain wider recognition that IV is an important factor in many cases of HI, and further integration and development of screening and response services.

Conclusions

This study provides a voice to the lived experience of women veterans who have faced housing instability and co-occurring experiences of and concerns about violence and trauma. As outlined here and in prior literature, numerous barriers and challenges exist for some women in seeking housing that is both stable and safe. For women veterans, experiences of violence may contribute to situations of housing instability that may not be detected through existing screening protocols. Intervening effectively requires reframing and re-evaluating how we define and measure housing instability. In addition, housing-related services must be structured to account for these violence-related challenges in a way that is flexible and promotes safety and confidentiality. Programs committed to supporting women in seeking safety from violence should strengthen collaboration with housing services to ensure that women can achieve and maintain truly safe and stable housing.

Public Policy Relevance Statement:

This study highlights the ways in which interpersonal violence, particularly intimate partner violence and non-partner sexual violence, can complicate access to safe and stable housing, as well as the ways in which risks of housing instability can increase vulnerability to violence. The findings hold implications for how programs define, assess, and provide services related to homelessness, and suggest that violence intervention and housing services should coordinate to ensure that women can access housing that is stable, safe, and does not increase risk of violence.