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Intimate Partner Violence Victimization and Associated Implications for Health and Functioning Among Male and Female Post-9/11 Veterans

Iverson, Katherine M. PhD*,†; Vogt, Dawne PhD*,†; Maskin, Rachel M. BA*; Smith, Brian N. PhD*,†

doi: 10.1097/MLR.0000000000000741
Original Research
Free

Background: There is increased emphasis on identifying patients who experience intimate partner violence (IPV) in Department of Veterans Affairs and other health care settings. A better understanding of IPV’s implications for health and functioning is needed among post-911 Veterans, and especially male Veterans, to inform IPV screening and response.

Objectives: To identify past 6-month IPV experienced among partnered post-9/11 Veterans and examine sex-based associations between IPV and health.

Research Design: A national sample of Veterans completed a survey that included measures of IPV victimization and health. Types of IPV and relationships with health and functioning were examined separately for male and female Veterans.

Subjects: In total, 407 post-9/11 Veterans (52% women) in intimate relationships.

Measures: IPV victimization was assessed with the Conflict Tactics Scales-Revised. Health and functioning indicators included posttraumatic stress disorder (PCL-5) and depression (Beck Depression Inventory-Primary Care) symptoms, physical health–related quality of life (Short-Form 12-item Health Survey), and occupational functioning (Inventory of Psychosocial Functioning).

Results: Nearly two thirds of both men and women reported past 6-month IPV, with greatest endorsement of psychological aggression (65% of men, 59% of women). A total of 8% of men and 7% of women reported physical IPV and 4% of men and 7% of women reported sexual IPV. Psychological aggression was strongly linked with mental health for both sexes and greater occupational impairment for men. Physical and sexual IPV were associated with more severe mental health symptoms for women while physical IPV was negatively associated with physical health–related quality of life for men.

Conclusions: Recent IPV victimization, especially psychological aggression, is a key health issue for partnered male and female post-9/11 Veterans. Practice and research implications are discussed.

*Women’s Health Sciences Division of the National Center for PTSD, VA Boston Healthcare System

Department of Psychiatry, Boston University School of Medicine, Boston, MA

Supported by 2 grants from the Department of Veterans Affairs, Office of Research and Development, Health Services Research & Development (HSR&D) Services: “Validation of Modified DRRI Scales in a National Sample of OEF/OIF Veterans” (DHI 09-086), awarded to D.V. and “Work and Family Functioning in Women Veterans: Implications for VA Service Use” (IIR 12-345), awarded to D.V. and B.N.S. In addition, K.M.I. contribution to this manuscript was supported by an HSR&D Career Development Award (CDA 10-029) and a Presidential Early Career Award for Scientists and Engineers (USA 14-275). The preparation of this article was also supported in part by K.M.I. fellowship with the Implementation Research Institute (IRI), at the George Warren Brown School of Social Work, Washington University in Saint Louis; through an award from the National Institute of Mental Health (5R25MH08091607) and VA HSR&D Service, Quality Enhancement Research Initiative.

The opinions expressed in this article are the authors’ and do not reflect those of the Department of Veterans Affairs.

Presented as a poster presentation at the November 2016 Annual Conference of the International Society for Traumatic Stress Studies.

The authors declare no conflict of interest.

Reprints: Katherine M. Iverson, PhD, VA Boston Healthcare System, 150 South Huntington Avenue (116B-3), Boston, MA 02130. E-mail: katherine.iverson@va.gov.

Intimate partner violence (IPV), including physical, psychological, and sexual violence perpetrated by a past or current intimate partner, remains a major public health problem in the United States. At least 1 in 3 women and 1 in 4 men in the United States experience IPV during their lifetimes.1 Many medical and professional organizations, including the Joint Commission on the Accreditation of Hospitals and Health Care Organizations, recommend screening in health care settings so that individuals who are at risk for IPV can be identified and linked with services.2 Empathetic and evidence-informed IPV inquiry holds promise for addressing the public health burden of IPV because it can serve as primary prevention for patients with no IPV history, secondary prevention for patients with past IPV, and tertiary prevention (ie, early intervention) for patients with recent IPV.3 Accordingly, the Department of Veterans Affairs, the nation’s largest integrated health care system, recommends routine screening of all female patients and selective inquiry (ie, case finding) of male patients to identify those who are at risk for IPV and may benefit from referrals to appropriate health and social services.4

Although the IPV screening and intervention literature understandably focuses on women because of evidence of greater health-related disparities,1,5,6 there is growing awareness that men are also at risk for IPV, which can negatively impact their health and functioning.1,7 Moreover, some research demonstrates sex differences in the forms and frequency of IPV experienced and associations with specific aspects of health functioning in general population samples.1,5,7 Understanding Veterans’ experiences of different types of IPV and their sex-based associations with health status would help clinicians target their IPV inquiry practices and tailor counseling and referral efforts. Given the recognition that IPV inquiry may be especially important among specific subgroups of patients,4,8–10 it is important to provide data to inform IPV practices among populations who may be most vulnerable to IPV.

Military Veterans are a particularly relevant population for understanding IPV. Unique stressors associated with military services, such as unwanted sexual experiences and warfare exposure, may increase risk for both IPV and poorer health after leaving the military.11,12 Population-based data on IPV victimization among female Veterans suggest that they are 1.6 times more likely to experience IPV during their lifetimes than non-Veteran women.13 Findings from a recent national survey of female Veterans found that 55% reported IPV during their lifetime and 30% reported past-year IPV.14 Such violence is associated with poorer physical and mental health among general samples of female Veterans.13,15,16 Although research in this field has focused on male Veterans’ perpetration of violence,17–19 less is known about IPV victimization and its health impact among male Veterans, or how this differs from the experiences of female Veterans. To our knowledge, only 1 published study has examined the prevalence of IPV victimization among male Veterans. Among a nationally representative sample, Cerulli et al20 found that a slightly lower percentage of male Veterans reported lifetime IPV compared with male non-Veterans (9.5% vs. 12.5%). However, when IPV was examined specifically among men under age of 55, male Veterans had a similar risk for IPV as non-Veterans. Thus, consistent with research among female Veterans,21–23 IPV victimization is a relevant health issue for both young female and male Veterans.

IPV victimization and its impact on health has not been examined in post-9/11 Veterans, a substantial minority of whom are women.24,25 Understanding the proportions of partnered male and female post-9/11 Veterans who experience IPV and the associations of various types of IPV experiences with health and functioning will provide a more comprehensive understanding of the health and service needs of this population. For the purposes of this study we examined overall mental and physical health functioning, as well as occupational functioning, a central yet understudied domain of Veterans’ lives with respect to IPV. The aims of this study were to: (1) identify the occurrence and frequency with which a national sample of partnered male and female post-9/11 Veterans report physical, psychological, and sexual IPV over a 6-month period; and (2) examine sex-based associations between different types of IPV experiences and mental health symptoms, physical health–related quality of life, and occupational functioning.

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METHODS

Study Design and Participants

Data for this study were drawn from a larger longitudinal study of post-9/11 Veterans’ postmilitary well-being. As described in detail elsewhere,26 at time 1 (T1), potential participants were identified from a Department of Defense sampling frame that included all Veterans who had returned from deployment and separated from service within the previous 2 years (2008–2010). A random sample of these Veterans stratified on deployment component (50% deployed from Active Duty, 50% from National Guard/Reservist units) and sex (50% women) were invited to complete a mailed survey.

The T1 survey was completed by 1046 Veterans, and 892 of the respondents agreed to be recontacted for follow-up assessments. The time 2 (T2) survey occurred approximately 3.5 years later. Of the 813 participants thought to have received the survey (73 nondeliverables, 2 deceased), 522 Veterans (54% women) returned surveys (64.2% response rate). For the purposes of the current study, data were drawn from the subsample of 407 participants (52% women) who reported being in an intimate relationship within 6 months before T2 as indicated by a “Yes” response to the question “Have you had a spouse or other romantic partner at any point over the last 6 months?” Participants who did not report a relationship did not complete the IPV measure and were therefore excluded from the current study sample. Table 1 contains participant characteristics.

TABLE 1

TABLE 1

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Procedure

This study used a modified Dillman et al27 mail survey procedure for T1 and T2. The initial mailing contained a cover letter explaining the purpose of the study, an opt-out form, survey, and a $25 Visa gift card. Two weeks later a reminder/thank you card followed by a second survey was sent to those who had not already responded or declined participation. The same procedure was repeated for a third mailing. Participants’ consent was implied, given the return of a completed survey. This study was approved by the local Institutional Review Board.

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Measures

IPV Victimization

IPV was assessed at T2 using the victimization scales from the Short Form Conflict Tactics Scales-Revised (CTS-2S).28 The CTS-2S is a validated IPV screening instrument that assessed the frequency of respondents’ experiences with aggression from an intimate partner within the past 6-months using a 7-point scale from 0 (never) to 6 (more than 20 times). Three types of IPV were examined: physical assault (ie, pushed, shoved or slapped; punched, kicked, beat-up), psychological aggression (ie, insulted, swore, shouted or yelled; destroyed something belonging to me or threatened to hit me), and sexual assault/coercion (ie, physical force or insistence on having sex or unprotected sex). Frequency scores were computed for the 3 types of IPV by summing the midpoints of each item in the subscale.29 Consistent with the varietal method for calculating IPV with the CTS-2S,30 we computed a count score of IPV types endorsed as an indicator of overall IPV exposure (scores ranged from 0 to 3).

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Health and Functioning

Posttraumatic stress disorder (PTSD) symptom severity was assessed at T2 using the 20-item PTSD Checklist (PCL-5).31 Responses regarding past-month symptoms are recorded on a 5-point scale ranging from 0 (not at all) to 4 (extremely). Scores are summed for a total score, with higher scores reflecting higher levels of PTSD symptoms. Coefficient α was 0.96. Depression symptoms were assessed at T2 with an adapted version of the Beck Depression Inventory-Primary Care (BDI-PC).32 The BDI-PC includes 7 items assessing various depressive symptoms over the past 3 months, rated on a 5-point scale ranging from 1 (strongly disagree) to 5 (strongly agree). Scores are summed, with higher scores indicating higher levels of depressive symptoms. Coefficient α was 0.90. Current physical health–related quality of life was assessed with the Physical Component Scale from the Medical Outcomes Study Short-Form 12-item Health Survey.33 Lower scores reflect poorer physical health–related quality of life. Occupational functioning was assessed using the 21-item work subscale of the Inventory of Psychosocial Functioning.34 Items are rated on a 7-point scale ranging from 1 (never) to 7 (always). Higher scores reflect more occupational impairment. Coefficient α was 0.92.

Other highly stressful and potentially traumatic military experiences were addressed in the study to account for potential confounding. Military sexual harassment and sexual assault experiences were assessed at T1 using the Sexual Harassment scale of the Deployment Risk and Resilience Inventory-2.35 This 8-item scale assesses exposure to unwanted verbal and physical interactions of a sexual nature during deployment, including both sexual harassment and sexual assault experiences. Responses were rated on a 4-point scale ranging from 1 (never) to 4 (many times). Higher scores are indicative of greater exposure to sexual harassment and assault. Warfare exposure was assessed at T1 using a sum of the 17-item Combat Experiences Scale and the 13-item Aftermath of Battle Scale from the Deployment Risk and Resilience Inventory-2.35 Items for both scales are rated on a 6-point scale, ranging from 1 (never) to 6 (daily or almost daily). Higher scores indicate higher warfare exposure.

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Statistical Analyses

Descriptive statistics were calculated for different types of IPV experiences and overall IPV exposure. The χ2 and t tests were conducted to test for sex differences in IPV and other study variables. Hierarchical multiple regression was applied to evaluate sex-stratified associations between each type of IPV (physical, psychological, sexual), as well as overall IPV exposure (number of IPV types endorsed), and mental health symptoms (PTSD and depressive symptom severity), physical health–related quality of life, and occupational functioning, controlling for potential covariates. For each model, study variables were entered in 2 steps. Covariates entered at step 1 included age, military sexual harassment and sexual assault, and warfare exposure, as these factors may be associated with both IPV and health outcomes.20,21,36 Race (white vs. nonwhite) was also considered as a potential covariate. However, when included as an additional variable in the 8 regression models, race was not significantly associated with any of the health outcomes under study and was not retained as a covariate. Step 2 examined the unique association between IPV (including each type of IPV as well as overall IPV exposure) and each indicator of health and functioning, after adjustment for covariates. Data were analyzed using SPSS version 24.

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RESULTS

The percentages of male and female Veterans who reported experiencing IPV in the past 6 months are shown in Table 2. Approximately 66% of men and 60% of women reported any experience of IPV. Psychological aggression was the most common type of IPV (65% of men, 59% of women), followed by physical IPV (8% of men, 7% of women) and sexual IPV (4% of men, 7% of women). There were no differences between men and women in the likelihood of experiencing any IPV, specific types of IPV, or overall IPV exposure (number of IPV types endorsed) in the past 6 months.

TABLE 2

TABLE 2

Table 3 presents descriptive statistics for primary study variables. Men reported a higher frequency of physical IPV, and women reported a higher frequency of sexual IPV. There were no sex differences in frequency of psychological IPV or overall IPV exposure. There were also no sex differences in severity of mental health symptoms (PTSD or depression), physical health–related quality of life, or occupational functioning. In terms of military experiences, women reported greater exposure to military sexual harassment and assault and men reported greater warfare exposure.

TABLE 3

TABLE 3

Table 4 presents the results of hierarchical regression analyses applied to evaluate the associations between IPV and health and functioning measures. For both men and women, psychological IPV was associated with increased PTSD and depressive symptom severity. For women only, physical IPV was associated with greater PTSD symptom severity, and sexual IPV was associated with greater depressive symptom severity. Overall IPV exposure was associated with both types of mental health symptoms for men and women.

TABLE 4

TABLE 4

A different pattern of results emerged for women and men for physical health and occupational functioning. For men, physical IPV was associated with reduced physical health–related quality of life, whereas only psychological IPV was associated with physical health–related quality of life for women. Overall IPV exposure was not associated with physical health–related quality of life for either sex. Finally, in examining occupational functioning, while psychological IPV and overall IPV exposure were significantly associated with impairment for men, none of the IPV variables were significant predictors for women.

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DISCUSSION

The predominant focus on women in the Veterans IPV victimization literature has resulted in an incomplete understanding of the occurrence and health effects of IPV for men, compared with women. This report is the first to examine recent physical, sexual, and psychological IPV and associated implications for health and functioning among male and female post-9/11Veterans. We found that almost two thirds of both partnered male and female Veterans experience past 6-month IPV victimization, extending prior research among non-Veterans,1,7 female Veterans,13,21,22 and clinical samples of primarily male post-9/11 Veterans.37,38 These percentages are substantially higher than past-year percentages documented among men and women in the general US population,1,7,39 but are similar to rates of IPV observed in a clinical sample of partnered post-9/11 Veterans (60%).38 Taken together, these findings suggest that partnered post-9/11 Veterans are at high risk for IPV, and especially psychological aggression.

Not only is psychological aggression common among partnered post-9/11 Veterans, our findings extend research within the general population by demonstrating that this type of stressor is strongly linked to different aspects of Veterans’ current health and functioning.7 Although findings indicate that psychological IPV may manifest similarly for male and female post-9/11 Veterans in terms of mental health symptoms, we found evidence that this type of IPV may demonstrate a greater negative impact on men’s occupational functioning. This finding is consistent with a previous study of military Servicemembers that found relationship stress was associated with poorer job functioning for men but not for women.40 Although additional inquiry regarding mechanisms is needed, it is possible that women more effectively use social support in the workplace, which may buffer against potential negative effects of psychological IPV on women’s occupational functioning.41 However, women may experience more adverse consequences for physical health functioning related to experiences of psychological aggression, as evidenced by the finding that psychological IPV was associated with poorer physical health–related quality of life for women but not for men.

Findings regarding female Veterans’ increased risk for more frequent sexual IPV, which has a particularly strong association with depressive symptoms for women, are consistent with results from prior studies of female VA patients42 and non-Veteran women.43,44 Shame and stigma associated with sexual assault and coercion from a partner likely contributes to feelings of helplessness and depressive symptoms for women.43 It is also noteworthy that although women reported lower frequency of physical IPV than men, this form of IPV was associated with higher PTSD symptoms for women, whereas physical IPV was associated with poorer physical health–related quality of life for men but not for women. Although this study did not examine physical injuries or reciprocal violence (ie, both partners engage in violence during an interaction), epidemiological data suggests that physical injuries are more common in reciprocally violence relationships.45 Given research documenting reciprocal violence among a clinical sample of male post-9/11 Veterans,37 it is possible that male victims are more likely to be in reciprocally violent relationships and that such dynamics contribute to injury and overall perceptions of poorer physical health–related quality of life. Finally, analyses examining the implications of exposure to multiple types of IPV (ie, overall IPV exposure) suggest that there is a dose-response relationship between IPV and post-9/11 Veterans’ current health and functioning. For both men and women, exposure to more types of IPV may erode internal and external resources, contributing to greater psychological distress and impairment.46

This study has several limitations. First, it relied on a short version of the CTS29 to assess IPV victimization. Although this is a validated IPV screening measure28 based on the same instrument used to assess IPV victimization prevalence in the United States,1 this measure neither assesses context for violent acts nor allows for an understanding of the motives, causes, or functions of violence.47 This is particularly important to keep in mind with respect to psychological aggression, as it is possible that the assessment of psychological IPV captures high levels of relationship conflict and stressful communication patterns as opposed to abuse per se. Nonetheless, psychological aggression is clearly linked to poorer health for male and female Veterans in this study and warrants continued empirical and clinical attention. In addition, this study did not examine all possible forms of IPV, including stalking, coercive control (eg, isolation and economic abuse), and a broader range of sexually abusive acts. It also did not assess IPV perpetration and cannot speak to whether study participants also engaged in perpetration of IPV, including bidirectional violence (ie, both partners engage in violence during the same or separate episodes). Evaluating perpetration and bidirectional aggression among post-9/11 Veterans is an important avenue for future research, as past work shows bidirectional violence to be common among Iraq and Afghanistan Veterans seeking couples therapy.37 Finally, the cross-sectional nature of this study precludes any firm conclusions about the causal influence of IPV on health and functioning.

There are also important strengths of the study, including the focus on a national sample of recently returned Iraq and Afghanistan Veterans, the oversampling of women to allow for sex comparisons, and the ability to adjust for military experiences that may serve as confounders (ie, warfare exposure and exposure to sexual harassment and assault). Longitudinal research with more comprehensive measurements of IPV can extend current findings and allow for the exploration of potential mediating and moderating variables that may explain some of the sex differences identified. Future studies should focus on the causes, context, and function of IPV, as well as characteristics of the Veterans (eg, sexual orientation) and the partner(s) who perpetrated IPV (eg, sex, Veteran status) to more fully understand IPV risk and its attendant health effects among post-9/11 Veterans. To inform comprehensive and gender-sensitive care, it is also important to identify male and female Veterans’ preferences for IPV-related care, which may be best accomplished via qualitative and mixed methods designs.

Findings point to a number of directions for both clinical care and research, especially within VA. The high rates of IPV observed among this sample highlight the importance of destigmatizing IPV in health care setting so that individuals are willing to discuss such experiences with a knowledgeable and nonjudgmental provider. The strong association observed between IPV and mental health functioning for both men and women underscores the value of IPV screening and assessment in mental health clinics so that clinicians can more fully conceptualize and treat mental health symptoms. Assessment of IPV dynamics, including frequency and severity of IPV types and perceptions of safety, can inform individualized treatment plans to address both IPV-related needs and mental health symptoms. IPV-related counseling may include education about IPV and its health effects, provision of information regarding resources, safety planning, as well as enhancing self-care and coping skills.14 Providers working with men who experience IPV should recognize that some community services may be less readily available for men as compared with women (eg, emergency shelter) so that gender-specific care can be coordinated and accessed by all Veterans. IPV-related counseling can precede or be combined with evidence-based treatments for mental health conditions, such as PTSD and depression that are widely available in VA.12

To effectively address IPV and associated health needs within health care settings, clinicians must first be able to identify IPV. VA recommends use of the Extended-Hurts, Insults, Threatens, Screams48 tool for screening female Veterans for IPV.4 The clinical utility of this tool has been established with female Veterans,22,49 but it is unknown whether the Extended-Hurts, Insults, Threatens, Screams or another instrument should be adopted for use with male Veterans. Given the high proportions of male Veterans who reported recent IPV in this sample, future research should also focus on identifying accurate, feasible, and acceptable screening tools to assist clinicians in assessing IPV among both male and female post-9/11 Veterans to ensure equitable care. It is important that detection and assessment efforts include behaviorally specific questions that sensitively assess psychological IPV, in addition to physical and sexual aggression, given the strong linkages between psychological IPV with health and functioning observed in this study.

In conclusion, recent IPV, especially psychological aggression, is a key health issue for male and female post-9/11 Veterans. Given the strong implications of IPV for Veterans’ health and functioning, there is a need to identify, evaluate and implement health care-based screening and intervention programs that can meet Veterans’ health and service needs. Even for Veterans who do not experience IPV or do not feel ready to acknowledge IPV, routine inquiry can function as primary prevention and help those who are experiencing IPV move closer to seeking help through increasing awareness that IPV is a legitimate health care issue.

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ACKNOWLEDGMENT

The authors would like to thank Timothy Amoroso for his contributions to literature searches informing this manuscript.

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Keywords:

gender; occupational functioning; partner abuse; trauma; Veterans Health Administration

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