Abstract
This commentary attempts to frame the article, “Safer Housing for Homeless Women Veterans,” in a wider context. It defines female veterans, homelessness, and military sexual trauma. This commentary also tackles a question that often confuses civilian providers regarding who has access to care at the Veterans Health Administration. It does not repeat in detail all of the recommendations in the article, but it advocates their broader use in shelters and transitional housing. Finally, I close with some thoughts about a new generation of young, homeless, female veterans who may have children and how to accommodate their needs.
The article by Kim and colleagues1 is a valuable addition to the literature on the importance of safe housing for the homeless, focusing on women veterans with PTSD related to sexual assault. In this commentary, I hope to provide additional context to help frame the paper on the basis of my experience. I write this commentary from the perspective of being both a retired Army psychiatrist and a female combat veteran. I am also a forensic psychiatrist and long-time AAPL member. I have written extensively on the topic of the health needs of female service members.2 In my last job, I worked with the homeless clinic of a Veterans Administration (VA) hospital. I currently practice psychiatry at a large hospital in Washington, DC, where many of our patients are homeless. I am using these skill sets to provide a framework to discuss the topics of female veterans, supported housing, and PTSD.
Definitions
Before I discuss the paper, it is worth defining and expanding on some of the terms and concepts used in the paper, including female veteran, homelessness and transitional and permanent supportive housing, and military sexual trauma. I will also discuss briefly who has access to VA services.
Female Veterans
In the United States, the term “veteran” is used to define someone who has served in the Armed Services. Generally, it refers to someone who is no longer on active duty. The term “combat veteran” refers to someone who has served in a combat zone and may still be on active duty. Members of the National Guard and Reserve forces often transition back and forth from active duty to inactive status.
For the last few decades, about 15 percent of the active-duty U.S. armed services have been female. Of those who deployed to the recent wars in Afghanistan and Iraq, about 10 percent were female. The percentage of total female veterans (i.e., no longer on active duty) is lower, but this figure is increasing as more recent service members come off active duty and become veterans.
Homelessness
Homelessness is a continuum. Some who call themselves homeless stay with friends and family, so called “couch surfing.” Others stay in shelters, some of which are sponsored by local governments, churches, or nonprofit organizations. Many live on the streets or in embankments, either in tents or simply with a few blankets.
There are definitions within the VA and other systems that help govern access to services; the VA has a useful guide on its website.3 Although a full discussion is beyond the scope of this commentary, there is a Permanent Supportive Housing Resource Guide available online.4 Traditional steps in rehousing involve going from homelessness to shelter to transitional housing to permanent housing. The VA Resource Guide advocates a housing-first model, going straight to permanent housing with support services.
Military Sexual Trauma
Kim et al.1 begin by discussing homeless female veterans with a history of sexual assault while in the military, usually termed military sexual trauma. This term is defined by Congress and is important to obtaining benefits in the VA system. The definition used by the VA comes from federal law (38 U.S.C. § 1720D (2017)): “psychological trauma, which in the judgment of a VA mental health professional, resulted from a physical assault of a sexual nature, battery of a sexual nature, or sexual harassment which occurred while the veteran was serving on active duty, active duty for training, or inactive duty training.”
Sexual harassment is further defined as “repeated, unsolicited verbal or physical contact of a sexual nature which is threatening in character.”5 Military sexual trauma can be a misleading term as it implies that the military service caused the sexual event. The assault may have nothing to do with military services, but simply may have occurred when the service member was on active duty. The trauma may have been rape by an acquaintance or stranger in an event totally unrelated to military duties. The results of one meta-analysis revealed that 15.7 percent of military personnel and veterans report military sexual trauma (3.9% of men, 38.4% of women) when the measure includes both harassment and assault.6
Generalizations
There is a common generalization that should be addressed. There is an assumption that being a female veteran who has been assaulted is synonymous with PTSD. Of course, reactions to such assault vary, and both male and female veterans may experience a range of psychiatric disorders, whether related to trauma or not, with depression and substance abuse being quite common.
The homeless population also is likely to have severe mental illnesses, such as schizophrenia, along with comorbid substance abuse. Homeless individuals, especially those living on the streets and in shelters, are highly exposed to all kinds of traumatic events. Therefore, although homelessness and veteran's status are often associated with PTSD, this association should not be automatically assumed.
Access to Health Care for Veterans
The Veterans Health Administration (VHA) is only one of three parts of the VA. The other two parts are the Veterans Benefits Administration (VBA) and Veterans National Cemetery Administration. The rules of the VHA are the most relevant to this discussion.
The policy governing access and priority to health care in the VHA are quite complex. A highly simplified version follows. Two years of active duty time are required to be eligible for the VA. A service-connected health problem receives higher priority for health care and other benefits. If someone is discharged from the services with medical needs, generally those medical needs are addressed by the VHA.7 In the past, any discharge other than honorable precluded eligibility, but now emergency mental health care is available for such individuals.8 A diagnosis of military sexual trauma makes health care available for that specific diagnosis, even if the person served less than two years, did not receive an honorable discharge, or is otherwise not eligible for care through the VHA.5
Many veterans are also seen by practitioners who do not work for the VA. They may or may not be referred by the VA for services. Many have insurance via their school or employer. Thus, it is important for all providers to have at least a general knowledge of what the VA may offer their patients.
In addition to health and other benefits, the VA offers some housing, rehabilitation, and job placement services. Eligibility for these is also dependent on the type of discharge. Ending homelessness is a priority for the VA, with considerable resources devoted to housing and support services. Thus, it is generally much easier to get housing for a veteran in need than for the general population.
Safe and Secure Housing
The article by Kim and colleagues1 focuses on female veterans with PTSD related to military sexual trauma in veteran housing. They comment on the challenges in both transitional and permanent supportive housing. The main thrust of the recommendations focuses on enhancing feelings of safety and security for female veterans. They include segregated spaces for females and adequate locks and lighted exits. Good communication and identification of staff with name badges are highlighted.
These steps make perfect sense, but not just for female veterans; all of those who live in shelters and temporary housing have been exposed to numerous traumatic events. It is common for people who live on the streets to be beaten, robbed, sexually abused, or murdered, or to see those things happen to others. Sorting out the symptoms of schizophrenia, substance abuse, and PTSD is often a daunting task.
Several of the recommendations made by Kim and colleagues1 could be applied much more widely than just to female veterans. I would like to use their work as a platform to focus on the importance of safe housing practices for ever-widening populations: all homeless women veterans, regardless of whether they have PTSD; all homeless women, regardless of whether they are veterans; and all homeless people, male, female, or non-binary (i.e., all genders).
Female Veterans With Children
I would like to expand on some challenges for female veterans with children. Depending on the study, female service members have slightly or significantly higher unplanned pregnancy rates than their civilian counterparts.9 There are numerous factors involved, including, but not limited to, lack of available contraception, especially when deployed, and lack of legal abortion in many countries where service members are assigned. The Armed Services are taking some steps to address the lack of available contraception.
In many cases, the new mother is young and unmarried, and she often finds that she cannot weather both the demands of the military and the demands of motherhood. So, she is discharged, either by her choosing or by not being able to meet the needs of the service.
The young mother often hopes to return to school or to work, but the costs of childcare are prohibitive, and she cannot afford rent. She may start by couch surfing, but she eventually exhausts her family and friends and has no place to go. Traditional veterans housing caters to single males, often with single-room occupancy. To serve the needs of our female veterans, we need more apartment-style housing with room for small families. Many communities are recognizing this need and are moving in that direction.
Conclusions
Several recommendations in this excellent paper about safe and secure housing could be applied much more widely than just to female veterans. These safe housing practices should be extended to ever-widening populations: all homeless women veterans, regardless of whether they have PTSD; all homeless women, regardless of whether they are veterans; and all homeless people, male, female, or non-binary (i.e., all genders).
The recommendations offered by Kim and colleagues1 should be disseminated widely. Perhaps they could be turned into laminated flyers for the bulletin boards at every shelter and every transitional and permanent supportive housing facility.
There are recommendations here for the military and the VHA as well: they should ensure that contraception is easily available, even in a deployed environment. Both the VA and local communities should ensure that their services are safe and secure and, when needed, can accommodate children.
The topic of trans women veterans also deserves more attention. A review of the literature does not reveal any existing information about the prevalence or characteristics of violence directed specifically toward trans veterans. We do know that trans women in general are often victims of hate crimes, so security efforts should be amplified for the trans population.
Footnotes
Disclosures of financial or other potential conflicts of interest: None.
- © 2019 American Academy of Psychiatry and the Law
