Gender-based violence (GBV) defined as any harmful act committed against a person because of his/her gender (1, 2) and disproportionately affects women and girls (3). Globally, one out of three women reports having been a victim of gender-based physical or sexual violence (4), including physical violence, sexual violence (such as sex trafficking, sexual exploitation, and sexual assault), psychological or emotional violence, and economic violence. Studies have shown that homelessness in youth is an important risk factor for GBV, and homeless youth are more vulnerable to sexual exploitation and trafficking (5–7). Furthermore, the proportion of homeless women who have experienced GBV may be underestimated, as women are believed to be overrepresented among the hidden homeless, and as a result less likely to appear in homelessness data (8).

The impact of GBV is experienced long after the violence ends. The health-related impact of GBV includes physical injuries (9), chronic pain syndromes, memory problems, urogenital, cardiovascular, musculoskeletal, dermatological, eye, ear, and upper respiratory complaints, forced abortions, cervical cancer, and sexually transmitted infections (10–12). Mental health problems include depression, anxiety, posttraumatic stress disorder (PTSD), anger, dissociative disorders, grief, guilt, aggressive behaviors, self-harm and suicidal ideation (13–16), as well as substance use and dependence (17).

Apart from life-threatening physical and mental health consequences, survivors of GBV face a number of social consequences, including social isolation and marginalization (18). Lack of trust in the police, social services, or those in positions of authority may further isolate victims from seeking support or assistance (19).

Given the enduring sequelae of GBV, at risk populations, such as youth experiencing homelessness, have a high need for social and community supports. Recent literature reviews of strategies to prevent or reduce GBV or its sequelae suggest that although a number of interventions have shown promising findings, the paucity of evaluative efforts has led to inconsistencies in intervention activities and characteristics across settings (20). Interventions for intimate partner violence are extensively studied and offer women-centered, psychosocially supportive approaches that may be efficient in primary and secondary prevention of intimate partner violence (21). Moreover, trauma informed group therapy has been beneficial in reducing the negative psychological impacts experienced by survivors of sexual assault (22, 23), leading to a reduction in post-traumatic stress symptoms and risk-taking behaviors, and improvements in perceived empowerment, knowledge, and application of coping strategies (22). Although a wide range of interventions to support youth experiencing homelessness have been identified, including individual and family therapies, skill building programs, case management, and structural interventions (24), little is known about community programs aiming to assist youth experiencing GBV and homelessness or housing instability. The dearth of research in this area leaves service providers (e.g., counselors, social workers, and therapists) with little guidance on how to best support this population.

This longitudinal observational study, part of a realist informed evaluation using mixed methods, aimed to quantitatively evaluate changes in quality of life (primary outcome), psychological distress, traumatic symptoms, substance use, resilience, victimization, and sense of mastery (secondary outcomes) in young women experiencing GBV and homelessness, 12 months after enrolment in a community-based, trauma-informed, group psychoeducation intervention. It was hypothesized that the intervention may lead to improved quality of life, resiliency, and a sense of mastery and reduced mental health symptoms, substance use and victimization in this population.

Although several studies have described the impact of interventions on homeless youth health and well-being, the literature on community-based interventions addressing GBV in this population is scant. Prior research with individuals experiencing GBV suggested that community-based, trauma-informed group interventions can improve mental health and quality of life by promoting personal growth and increasing self-esteem, empowerment, and coping skills in adolescent girls victims of sexual violence (23, 43, 44).

The study, part of a realist informed longitudinal evaluation of a community-based 16-week psychoeducation group intervention, identified improvements in quality of life, capturing physical, psychological health, social relationships, and the overall environment, and reductions in experiences of victimization among female identified youth experiencing GBV and homelessness 12 months following enrolment, with no significant changes in other health and well-being outcomes. Prior qualitative research by our team revealed that participants valued the safe, women-only space, the shared lived experiences, and tailored psychoeducation, suggesting the intervention is acceptable to service users (29). Furthermore, our findings of improved quality of life and reduced experiences of victimization are supported by prior qualitative findings by our team, highlighting perceived improvements in self-confidence, coping, health, interpersonal relationships, and future directedness as a result of program participation (29).

Our findings of improved overall quality of life scores are also consistent with prior research demonstrating positive impacts of some interventions on quality of life in female victims of GBV. Using a violence intervention program, Levas et al. (45) found increased scores in most domains of health-related quality of life after six weeks among youth aged between 8 and 18 years who attended a violence intervention summer camp in a Midwest urban city. Similarly, a study by Cripe et al. (46) found a trend toward improved quality of life among women survivors of intimate partner violence receiving supportive counseling focused on empowerment, compared to usual care.

Similar to other interventions such as community mobilization and group-based empowerment training (47), this trauma-informed psychoeducation intervention significantly reduced experiences of victimization 12 months after program entry. These findings are supported by prior research by Gilbert et al. (48), indicating that a brief intervention and referral to services may be effective in reducing physical and verbal intimate partner violence and physical violence in female survivors of GBV with substance use disorders. In contrast, several other intervention strategies such as awareness-raising campaigns (population-based prevention), home visitation and health worker outreach, personnel training, justice and law-enforcement interventions, have not been shown to reduce victimization in survivors of intimate partner violence or non-partner sexual violence (47). Among homeless youth, a mindfulness-based, cognitive, skill-building intervention for promoting risk detection to prevent various types of victimization suggested significant improvements in risk detection abilities in the intervention, compared to the control group (49).

We identified no significant improvements in substance use or trauma symptom severity, resiliency, or sense of mastery at 12 months. Lack of significant changes over time in these domains may suggest that the intervention was not effective in addressing these areas, and that more targeted interventions are needed to observe improvements in these outcomes. It is also possible, given the modest number of individuals with substance use disorders in our sample (32.8%), that the study was not sufficiently powered to identify changes in in this and other domains. In contrast, Gilbert et al. (48) found a significant positive impact on substance use over a 3-month period following a brief intervention and referral service for women survivors of GBV with substance use disorders. Similarly, among homeless youth, studies by Slesnick et al. (50, 51) demonstrated that a cognitive-behavioral intervention significantly improved measures of substance abuse among homeless intervention group participants, compared to control group participants. Given the association between female substance use and experiences of GBV in several studies (52–54), access to targeted interventions to address substance use are important program components for victims of GBV. Finally, studies have shown that social support and empowerment training can significantly reduce the symptoms of psychological distress such as anxiety and depression in victims of intimate partner violence (55, 56) and evidence-informed psychological interventions have the potential to reduce PTSD symptoms in women affected by GBV. Of note, PTSD, anxiety, depression and substance use were not specifically targeted in the intervention under study, although participants were offered information on relevant resources. To improve these outcomes, consideration should be given to engaging service user and provider stakeholders in program improvements, including seamless access to trauma-specific and substance use services, for those who need them.

Nearly 83% of study participants had an ACE score ≥ 4, much higher than the reported prevalence of ACE in a national sample of homeless youth with mental illness in Canada, where approximately half of the participants had an ACE score ≥ 4 (57). Several studies have identified a significant association between ACEs and different types of GBV such as intimate partner violence and family violence, and our findings add to the knowledge based on homeless youth specifically. We found no association between ACE scores and changes in outcomes over time.

GBV remains one of the most persisting and widespread problems faced by women and girls worldwide (58). Addressing the sequelae of GBV requires an understanding of the complex underlying social and/or economic factors, including housing stability. Given the high prevalence of GBV among girls and women experiencing homelessness (59), programs addressing GBV among homeless and marginally housed women and girls are urgently needed.

Trauma-informed care is a key component and philosophy in service delivery to survivors of GBV and has been found to play an essential role in the recovery of GBV survivors as well as homeless youth (60, 61). In addition to trauma-informed principles, trauma specific interventions may be needed to improve health outcomes of survivors of GBV experiencing homelessness, tailored to the needs of specific subpopulations. Although the literature on available interventions is growing, these is a paucity of studies examining how best to engage young women and girls experiencing homelessness in such interventions, which should be the focus of future research.

Study strengths include the uniqueness of the setting and paucity of prior research with this vulnerable population. Furthermore, the intervention was co-designed with service users, co-delivered with peer mentors, and found acceptable and valuable to the target population. Finally, the parent study included both qualitative and quantitative components, to comprehensively explore perspectives, experiences and outcomes of interest to all key stakeholders.

Although we estimated that our sample size had over 80% power to detect significant changes from baseline to 12 months in key outcomes, the small sample size was one of the limitations in this study. In addition, this is an observational, non-experimental study, and findings need to be interpreted with caution, although qualitative data support multiple perceived benefits of the intervention by study participants. Finally, the intervention was offered in Toronto, Canada, and findings may not be generalizable to other settings with different availability of resources and supports for this population. Further research should consider quasi-experimental studies with a control group of participants and randomized controlled trials, including wait-list controls.

A brief, community-based, trauma-informed, group psychoeducation intervention may be helpful in improving the quality of life and reducing experiences of victimization among female identified youth experiencing homelessness and GBV. Further research, using experimental designs, is needed to examine the effect of interventions aiming to improve outcomes in this disadvantaged population, as well as to advance strategies to engage homeless youth in such interventions.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by the Center for Addiction and Mental Health (CAMH) and the University of Toronto Institutional Research Ethics Boards. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.

AB-F analyzed the data, and led the preparation of the manuscript. TR assisted in participant recruitment and data collection. WW assisted in statistical analysis. MM, AN, DK, and VS provided expert advice and aided in manuscript revisions. VS developed the study design and secured study funding. All authors contributed to the article and approved the submitted version.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.