Antecedents of physical and sexual victimization among homeless women: a comparison to homeless men

Trauma Experience Among Women Who Have Substance Use Disorders and are Homeless or Near Homeless

Women with substance use disorders (SUDs) who are homeless or near homeless have high rates of mental health, behavioral health, and SUD treatment needs. To effectively respond to these needs, it is critical to understand the population-specific trauma experiences of these women. This descriptive study examined the extent and nature of trauma experience among women who have an SUD and are homeless or near homeless. Results (n = 851 women) indicated high rates of trauma experience. All participants (100%) reported at least one type of trauma experience in their lifetime, with the majority (75.3%) having experienced five to seven of the seven types of trauma experiences assessed. Participants reported high levels of emotional severity related to the majority of traumatic events experienced. The pervasiveness of the trauma experiences and the related emotional impact among women with SUDs who are homeless or near homeless reinforce the necessity for trauma-informed care in treatment settings.

A Network Analysis of the Relationship Between Mental and Physical Health in Unsheltered Homeless Persons in Los Angeles County

Homelessness is a public health crisis both nationally, in the United States, and internationally. Nevertheless, due to the hidden vulnerabilities of persons who are without shelter, little is known about their experiences during periods of homelessness. The present research adopts a network approach that conceptualizes how the major risk factors of homelessness interact, namely substance abuse problems, poor mental health, disability, and exposure to physical or sexual violence by an intimate partner. Our analysis draws on a large demographic survey of over 5,000 unsheltered homeless persons conducted in 2017 by the Los Angeles Homeless Services Authority. We estimated a network structure for 12 survey items tapping individual risk using the graphical least absolute shrinkage and selection operator algorithm. We then examined network centrality metrics and implemented a community detection algorithm to detect communities in the network. Our results indicated that mental illness and intimate partner violence (IPV) are central measures that connect all other mental and physical health variables together and that post-traumatic stress disorder and IPV are both highly affected by changes in any part of the network and, in turn, affect changes in other parts of the network. A community detection analysis derived four communities characterized by disability, sexual victimization and health, substance use, and mental health issues. Finally, a directed acyclic graph revealed that drug abuse and physical disability were key drivers of the overall system. We conclude with a discussion of the major implications of our findings and suggest how our results might inform programs aimed at homelessness prevention and intervention.

Male Victims of Rape: An Observational Study over Four Years in Paris, France

Sexual violence is a common and under-reported form of violence that affects all categories of individuals. We sought to provide epidemiological data on men aged 15 years and over, victims of rape or suspecting a rape, and who reported it to the police. We conducted a retrospective study at the Department of Forensic Medicine of Hôtel-Dieu, Paris, France, between 2018 and 2021. Two-hundred men were included in the study, with an average age of 28.8 years. A vulnerability was mentioned for 17.5% of them. Most of the patients reported anal penetration, committed by a single male assailant, whom they met on the day of the assault. More than 60% of the patients reported the voluntary consumption of alcohol and/or illicit substances prior to the assault. Most patients were examined shortly after the assault (median 1 day). Anal lesions were found on examination in 37.0% of patients reporting anal penetration regardless of the time frame. The presence of anal lesions was statistically higher when patients were examined within 48 h. Our results reinforce the data in the literature on the risk factors associated with sexual violence among men, notably the consumption of alcohol and illicit substances, and psychological, economic, and social vulnerability.

Examining HIV Risk and Exchange Sex Among Current and Formerly Homeless Young Adults

This study investigated HIV risk among homeless and formerly homeless young adults by examining risky sex behaviors (e.g., condomless sex, exchange sex, and sex with multiple persons) using 90-day and daily recall methods. Data came from a sample of young adults (aged 18–27) with current (n = 101) or past (n = 109) homelessness experience in Los Angeles, California, recruited between 2017 and 2019. Baseline surveys queried demographics and sexual history. Daily retrospective surveys queried sexual events. Multiple logistic regressions were used to test the effects of demographic characteristics including homelessness history, relationship status, substance use, and sexual history on risky sex outcomes. In this sample, 26% reported never using a condom during anal or vaginal sex in the past 90 days, 5% reported testing positive for HIV, 82% had limited to no knowledge of preexposure prophylaxis, and 8% reported having had exchange sex during a 7-day measurement period, with those experiencing homelessness more likely to report. The study suggests supportive housing can reduce the occurrence of exchange sex but that HIV prevention services are still needed in homeless and housing programs to promote safe sexual practices.

Factors associated with homelessness among women: a cross-sectional survey of outpatient mental health service users at The Banyan, India

BACKGROUND

Homelessness has multifaceted and damaging effects on women with mental illness. This makes it imperative to identify and address the factors leading to homelessness among women with mental illness in order to inform policy on providing relevant services for this vulnerable population.

METHOD

A cross-sectional survey was conducted among 346 women in active contact with one of four outpatient clinics at The Banyan, a non-profit organization in the Indian state of Tamil Nadu. A semi-structured instrument and modified version of the List of Threatening Experiences Questionnaire was used for data collection. Multivariate logistic regression analysis was used to examine predictive variables for homelessness among women with mental illness.

RESULT

32.65% of participants reported a history of homelessness. Less than 5 years of schooling (OR = 2.914, 95% CI = 1.027-8.269, P < 0.05) and disrupted relationships (OR = 1.807, 95% CI = 1.23-2.655, P < 0.01) were associated with a greater likelihood of women with mental illness to experience homelessness.

CONCLUSION

In the study cohort, this was explained mainly by factors rooted in gender-based disadvantage. Further practice and research are needed to develop interventions that address issues with a sociological basis to mental illness and prevent these predictive factors.

Intimate partner sexual violence and violent victimisation among women living homeless in Madrid (Spain)

The purpose of this paper is to discover the extent to which women living homeless in Madrid (Spain) have been victims of intimate partner sexual violence (IPSV), analysing the connection between stressful life events (SLE) relating to violent victimisation and having suffered sexual assault by a partner. This study took place using a sample of women living homeless in Madrid (n = 136). The results obtained show that a high percentage of the women living homeless who were questioned had been victims of IPSV. The women interviewed, who had been victims of IPSV, had suffered, to a greater extent, SLEs relating to situations of violent victimisation, both during childhood and adolescence as well as in adulthood. The episodes of violent victimisation that seem to be the most common forerunners to IPSV are incidents of sexual abuse in childhood and adolescence.

Gun violence against unhoused and unstably housed women: A cross-sectional study that highlights links to childhood violence

Background

Unstably housed women experience high levels of violence. While previous studies have investigated psychological, physical, and sexual violence, weapon and gun violence are rarely delineated. We examined factors associated with experiencing violence as an adult among unhoused and unstably housed women, with a focus on gun violence.

Methods

We recruited women with a history of housing instability from San Francisco homeless shelters, street encampments, free meal programs, low-income hotels, and health clinics. Participants completed interviews including questions regarding both childhood and adult violence. We used multivariable logistic regression to examine associations of specific types of childhood violence (i.e., physical, sexual, gun, other weapon-involved violence), age, race, ethnicity, educational attainment, and sexual orientation, with risk of experiencing specific types of violence as an adult (i.e., gun, other weapon-involved, physical violence). Because the violence outcomes were not rare, odds ratios were transformed to approximate risk ratios.

Results

Nearly half of women (n = 110, 45%) had been attacked with a gun as an adult. Violent victimization in adulthood was common, with 33% having experienced all three forms of violence. The probability of being attacked with a gun as an adult was almost 70% higher among women who had been hit or kicked hard enough to cause injury as a child (RR = 1.68; 95% CI = 1.24, 2.11), and this association was present for all three violence outcomes. No other risk factors explored, including other types of violence experienced as a child, met the statistical threshold to be considered significant.

Conclusions

The high prevalence of gun violence reported here is consistent with prior studies of violence conducted in similar populations. Considered in combination with prior research, findings suggest multi-generational violence prevention interventions for low-income women and girls are needed. They also emphasize the need to more actively include people who experience unstable housing in statewide and national violence surveys to better understand the extent of the problem and address on a broader scale the high rates of violence experienced by unstably housed populations, which have been consistently documented in local research.

Construct, concurrent, and real-world predictive validity of the Difficulties in Emotion Regulation (DERS-18) among young adults with history of homelessness

Skills in emotional regulation are vitally important for enabling homeless young adults to navigate the complex and chaotic settings associated with homelessness. The current study seeks to test the construct, concurrent, and predictive validity of the Difficulties in Emotional Regulation Scale (DERS-18) in a sample of formerly and currently homeless young adults. Data come from a study of HIV risk among young adults who have experienced homelessness, including both those currently experiencing homelessness (n = 99) and in permanent housing (n = 120), collected between 2017 and 2019 in Los Angeles, CA. Structural Equation Modeling was used to complete Confirmatory Factor Analysis and Path Models focused on the relationship between mental health symptomatology and emotional regulation. Linear regression models tested the link between affective intensity and instability and the DERS-18. Model fit indices pointed to the five-factor solution of the DERS-18, excluding the Awareness subscale. Clinical scores of anxiety, depression, and PTSD were found to have a significant, positive correlation with DERS. Both intensity and instability of negative affect were associated with greater difficulty in emotional regulation, while the increased intensity of positive affect was associated with increased skills in emotional regulation. This study addressed several gaps in both homelessness and emotional regulation literature. The DERS-18 was found to have construct, concurrent, and predictive validity in our sample. Future work should consider the use of the DERS-18 to assess skills in emotional regulation, understand outcomes, and better tailor interventions for young adults who have experienced homelessness. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Differences in stressful life events between men and women experiencing homelessness

People experiencing homelessness are particularly vulnerable to experiencing stressful life events (SLEs) at some point in their lives; these SLEs are crucial for understanding the etiology and maintenance of homelessness. This study analyses the differences between men and women experiencing homelessness in the suffering of SLEs throughout their lives (childhood, adolescence, and adulthood). The sample consisted of a group of 293 people experiencing homelessness in Madrid (Spain): 156 men and 137 women. The results suggest that the number and type of SLEs experienced by men and women are different. In general, women experiencing homelessness suffer more SLEs than men in all periods of their lives. The differences in the level of sexual violence in childhood, sexual abuse in adulthood, and abuse by a spouse or partner are particularly striking. However, men experiencing homelessness score significantly higher than women for alcohol abuse, police complaints, arrest, and imprisonment throughout their lives. These findings have significant implications for the design of interventions and social policies that should be tailored to the specific needs of men and women who are homeless.

Improving Formal Support After Sexual Assault: Recommendations From Survivors Living in Poverty in Canada

Despite the extensive and often long-lasting sequelae of sexual assault, a significant majority of survivors do not seek assistance from formal support sources, such as police, medical or mental health professionals, and community-based agencies. While growing attention has been directed toward understanding the help-seeking barriers faced by sexual assault survivors, few studies have explored the experiences of survivors living in poverty and how help-seeking can be improved for this marginalized population. The present study sought to understand these issues from perspectives of survivors themselves. Women sexual assault survivors who self-identified as living in poverty (n = 15) were recruited from community-based agencies in the Greater Toronto Area, and participated in semistructured interviews focused on their personal decisions around help-seeking and broader views on access to and quality of formal assistance. Two research questions were of interest. First, what can be done to encourage service use among survivors living in poverty? Second, what is needed to improve the quality of assistance they receive? Thematic analysis revealed three key themes around which participants' recommendations centered: (a) increased accessibility of information, (b) improved training for formal support providers, and (c) greater opportunities for empowerment. Practical implications of these findings improving the service utilization rates and experiences of formal help-seeking among marginalized women survivors of sexual assault are discussed.

"Every Time I Try to Get Out, I Get Pushed Back": The Role of Violent Victimization in Women's Experience of Multiple Episodes of Homelessness

Research shows that, for most people, homelessness is not a chronic state that one enters and never leaves. Instead, homelessness tends to be dynamic, with individuals cycling in and out of multiple periods of homelessness throughout their lives. Despite this recognition, and a wealth of research on the causes of homelessness, generally, there is a lack of scholarship on the pathways to multiple episodes of homelessness. In particular, the relationship between violent victimization and women's likelihood of being homeless multiple times is largely unexplored. Drawing on data collected from 269 structured interviews conducted with women using the services of homeless shelters and/or transitional housing in three U.S. and two U.K. cities, we use multivariate logistic regression to assess whether violent victimization increases women's likelihood of experiencing multiple episodes of homelessness. Our results show that adult victims of stranger-perpetrated physical assault are significantly more likely to be homeless on multiple occasions. In addition, those who experience multiple forms of victimization (e.g., physical and sexual abuse) in childhood, adulthood, and/or across the life course are significantly more likely to experience multiple episodes of homelessness. Given recent efforts to eradicate homelessness, our results suggest specific vulnerable groups that may benefit from targeted social and policy interventions.

Recognizing and responding to women experiencing homelessness with gendered and trauma-informed care

Background

The purpose of this study is to highlight the experiences of women who are often hidden in what we know and understand about homelessness, and to make policy and practice recommendations for women-centred services including adaptations to current housing interventions.

Methods

Three hundred survey interviews were conducted with people experiencing homelessness in Calgary, Alberta, Canada. The survey instrument measured socio-demographics, adverse childhood experiences, mental and physical health, and perceived accessibility to resources. Eighty-one women participants were identified as a subsample to be examined in greater depth. Descriptive statistics and logistic regressions were calculated to provide insight into women respondents’ characteristics and experiences of homelessness and how they differed from men’s experiences.

Results

Women’s experiences of homelessness are different from their male counterparts. Women have greater mental health concerns, higher rates of diagnosed mental health issues, suicidal thoughts and attempts, and adverse childhood trauma. The results should not be considered in isolation, as the literature suggests, because they are highly interconnected.

Conclusion

In order to ensure that women who are less visible in their experiences of homelessness are able to access appropriate services, it is important that service provision is both gender specific and trauma-informed. Current Housing First interventions should be adapted to ensure women’s safety is protected and their unique needs are addressed.

Exposure to Violence and Sleep Inadequacies among Men and Women Living in a Shelter Setting

Background

Exposure to violence may explain sleep inadequacies reported by homeless adults, with women being potentially more susceptible to violence and sleep disturbances than men. This study examined the association between violence and sleep inadequacies among homeless adults and explored differences by sex.

Methods

Adult participants were recruited from a shelter (N=194; 71.1% men, M_age = 43.8±12.2). Participants self-reported victimization and/or witnessing violence (mugging, fight, and/or sexual assault) at the shelter, sleep duration (over an average 24 hours), insufficient sleep (days without sufficient rest/sleep), and unintentional daytime sleep (days with unintentional sleep) in the past month. Linear regressions were used to estimate associations between violence and sleep inadequacies, controlling for sex, age, race, months homeless, and depression. Moderation by sex was examined via an interaction term following mean-centering of variables.

Results

Overall, 20.6% of participants (n=40) reported victimization since moving to the shelter. In the last month, participants reported witnessing an average of 2.9±5.1 acts of violence. Over the same timeframe, participants reported 6.9±2.0 hours of sleep nightly, 11.2±10.7 days of insufficient sleep, and 6.2±8.8 days with unintentional daytime sleep. In adjusted analyses, witnessing violence was associated with insufficient sleep (p=.001). Men and women differed only in age and race in unadjusted analyses; sex was not a significant moderator of any association between violence and sleep in adjusted analyses.

Conclusions

Links between witnessing violence and sleep inadequacies should be considered in shelter health promotion efforts. Successful efforts to minimize violence may reduce insufficient sleep amongst both sexes.

Cardiovascular Disease and Homelessness

Cardiovascular disease (CVD) is a major cause of death among homeless adults, at rates that exceed those in nonhomeless individuals. A complex set of factors contributes to this disparity. In addition to a high prevalence of cigarette smoking and suboptimal control of traditional CVD risk factors such as hypertension and diabetes, a heavy burden of nontraditional psychosocial risk factors like chronic stress, depression, heavy alcohol use, and cocaine use may confer additional risk for adverse CVD outcomes beyond that predicted by conventional risk estimation methods. Poor health care access and logistical challenges to cardiac testing may lead to delays in presentation and diagnosis. The management of established CVD may be further challenged by barriers to medication adherence, communication, and timely follow-up. The authors present practical, patient-centered strategies for addressing these challenges, emphasizing the importance of multidisciplinary collaboration and partnership with homeless-tailored clinical programs to improve CVD outcomes in this population.

Sexual Intimacy, Mental Illness, and Homelessness

The current article reviews the literature on sexuality among individuals with a severe mental illness (SMI) who have experienced homelessness, a topic that has received little attention in the research literature, particularly from a community psychology perspective. The review begins with a synthesis of the literature on SMI and sexuality, followed by a review of the available literature on SMI, homelessness, and sexuality. It concludes with an interpretation of the findings using community psychology values and principles. The findings highlight the importance of intimate relationships to recovery for many individuals with an SMI who have experienced homelessness. Policy implications for homeless shelters and housing interventions are discussed.

Economic Insecurity and Intimate Partner and Sexual Violence Victimization

INTRODUCTION

Previous research has consistently found that low SES is associated with higher levels of both intimate partner violence (IPV) and sexual violence (SV) victimization. Though associated with poverty, two indicators of economic insecurity, food and housing insecurity, have been identified as conceptually distinct social determinants of health. This study examined the relationship between food and housing insecurity experienced in the preceding 12 months and IPV and SV victimization experienced in the preceding 12 months, after controlling for SES and other demographic variables.

METHODS

Data were from the 2010 National Intimate Partner and Sexual Violence Survey, a nationally representative telephone survey of U.S. adults. In 2016, multivariate logistic regression modeling was used to examine the association between food and housing insecurity and multiple forms of IPV and SV victimization.

RESULTS

Robust associations were found between food and housing insecurity experienced in the preceding 12 months and IPV and SV experienced in the preceding 12 months, for women and men, even after controlling for age, family income, race/ethnicity, education, and marital status.

CONCLUSIONS

Food and housing insecurity may be important considerations for the prevention of SV and IPV or the reductions of their consequences, although future research is needed to disentangle the direction of the association. Strategies aimed at buffering economic insecurity may reduce vulnerability to IPV and SV victimization.

Surviving Violence in Everyday Life: A Communicative Approach to Homelessness

In this narrative review, the author synthesizes the literature on homelessness across various disciplines (e.g., public health, social work, sociology, and communication) to demonstrate how the experiences of homelessness can be created, maintained, and reinforced through communication, including interpersonal interactions and public discourse. By conceptualizing homelessness as a culturally constructed and socially situated phenomenon, the author examines (a) the complex conceptualization of homelessness, (b) everyday violence faced by people who are homeless, and (c) coping strategies of people who are homeless. In summary, homelessness is a complex social phenomenon, involving tensions between individuals, families, and social systems, all of which are situated in the larger sociocultural and sociopolitical contexts of a specific time and place.

Differences in Health and Social Support between Homeless Men and Women Entering Permanent Supportive Housing

BACKGROUND

Permanent supportive housing (PSH) is the leading intervention to end chronic homelessness. Little is known, however, about gender differences, including potential disparities in physical and mental health and social support, that might inform services available through PSH.

METHODS

This study included 421 homeless adults, at least 39 years old, English- or Spanish-speaking, who were moving into PSH through 26 different agencies in the Los Angeles area.

RESULTS

Compared with men entering PSH, homeless women (28% of the sample) were younger (p < .01), less likely to have achieved at least a high school education (p < .05), and had lower incomes (p < .01). Women had more chronic physical health conditions (p < .01), were more likely to have any chronic mental health condition (odds ratio, 2.5; p < .01), and had more chronic mental health conditions than men (p < .01). Women had more relatives in their social networks (Coefficient, 0.79, p < .01) and more relatives who provided support (coefficient, 0.38; p < .05), but also more relatives with whom they had conflict (coefficient, 0.19; p < .01). Additionally, women were less likely to have caseworkers (coefficient, -0.59; p < .001) or physical and mental health care providers in their networks (coefficient, -0.23 [p < .01]; coefficient, -0.37 [p < .001], respectively). However, after correcting for multiple testing, three outcomes lost significance: number of chronic physical health conditions, number of relatives who provided any support, and number of relatives with whom there was conflict.

CONCLUSIONS

There is evidence of gender differences in mental health and social support among homeless adults moving into PSH. PSH cannot be a one-size-fits-all approach. Supportive services within housing should be tailored based on gender and other individual needs.

Multiple Types of Childhood and Adult Violence Among Homeless and Unstably Housed Women in San Francisco

This study examined the relationship between different forms of childhood violence (emotional, physical, and sexual) and these same forms of violence in adulthood, using a crosssectional baseline survey of 298 homeless and unstably housed women in San Francisco, California. We also examined other related factors, including mental illnesses diagnosis, sex exchange, jail time, HIV status, and sociodemographic information. Regression analysis indicated that although several of these factors were associated with experiences of violence as an adult, specific types of child violence (e.g., sexual violence) predicted instances of that same type of violence as an adult but not necessarily other types. Thus, risk of adult violence among low-income women may be better predicted and addressed through histories of same-type childhood violence, despite years of intervening exposures and stressors.

Network Approaches to Substance Use and HIV/Hepatitis C Risk among Homeless Youth and Adult Women in the United States: A Review

During the United States economic recession of 2008-2011, the number of homeless and unstably housed people in the United States increased considerably. Homeless adult women and unaccompanied homeless youth make up the most marginal segments of this population. Because homeless individuals are a hard to reach population, research into these marginal groups has traditionally been a challenge for researchers interested in substance abuse and mental health. Network analysis techniques and research strategies offer means for dealing with traditional challenges such as missing sampling frames, variation in definitions of homelessness and study inclusion criteria, and enumeration/population estimation procedures. This review focuses on the need for, and recent steps toward, solutions to these problems that involve network science strategies for data collection and analysis. Research from a range of fields is reviewed and organized according to a new stress process framework aimed at understanding how homeless status interacts with issues related to substance abuse and mental health. Three types of network innovation are discussed: network scale-up methods, a network ecology approach to social resources, and the integration of network variables into the proposed stress process model of homeless substance abuse and mental health. By employing network methods and integrating these methods into existing models, research on homeless and unstably housed women and unaccompanied young people can address existing research challenges and promote more effective intervention and care programs.

Gender Differences in the Rehospitalization of Substance Abusers among Homeless Military Veterans

This two-year follow-up study of military veterans treated in an inpatient drug treatment program was designed to examine any gender differences in predictors of rehospitalization for substance abuse or other psychiatric disorders. A survey was administered to 310 women and 315 men, involving several ecological predictors that rarely if ever had been investigated. For example, Cox's proportional hazard model indicated that childhood and current sexual and physical abuses were stronger predictors among women, whereas degree of substance abuse, cognitive disorders, aggression, and disadvantageous peer associations were stronger predictors among men. Social service implications of those findings were presented.

Subjective Experience and Resources for Coping With Stigma in People With a Diagnosis of Schizophrenia: An Intersectional Approach

In this study, we investigate the subjective experience of a group of individuals, diagnosed with schizophrenia, undergoing outpatient treatment in four psychiatric clinics in Mexico City. Our objective is to use the paradigm of intersectionality to explore the most common forms of stigma and discrimination faced by people with this illness, as well as the coping resources they employ. The major contribution of this study is its use of in-depth interviews and thematic analysis of the information obtained to identify the importance of sociocultural aspects of participants' experience of their illness. Schizophrenia, for them, was a problem of "nerves," whose origins were linked to magical or religious elements they attributed to their illness and which influenced their response to it. This resignification was useful to participants as a coping resource; it helped them find meaning and significance in their experience of the illness.

Eliminating health disparities: innovative methods to improve cervical cancer screening in a medically underserved population

Homeless women have disproportionately lower rates of cervical cancer screening and higher rates of cervical cancer. In 2008, only 19% of the homeless women seen by Boston Health Care for the Homeless Program (BHCHP) were screened for cervical cancer. To improve screening, BHCHP implemented a 6-part intervention that incorporates point-of-care service, multidisciplinary screening, improved health maintenance forms, population management, process improvement, and increased provider and patient education. This resulted in a significant increase in cervical cancer screening, from 19% in 2008 to 50% in 2013. When compared with national and local cervical cancer screening trends, BHCHP surpassed improvement rates seen in other vulnerable populations. Simple and innovative interventions proved to be the most effective and practical methods of improving screening.

The Cedar Project: Residential transience and HIV vulnerability among young Aboriginal people who use drugs

Aboriginal homelessness is considered to be a result of historic dispossession of traditional territories and forced displacement from community structures. Using data collected from 2005-2010 from the Cedar Project, a cohort of young Aboriginal people who use drugs in two Canadian cities, we examined how residential transience shapes HIV vulnerability. At baseline, 48 of 260 participants (18.5%) reported sleeping in six or more places ('highly transient') in the past six months. Generalized linear mixed models identified associations between high transience and sex and drug related HIV vulnerabilities. Transience was independently associated with sex work (AOR:3.52, 95%CI:2.06, 6.05); sexual assault (AOR:2.48, 95%CI:1.26, 4.86); injection drug use (AOR:4.54, 95%CI:2.71, 7.61); daily cocaine injection (AOR:2.16, 95%CI:1.26, 3.72); and public injection (AOR:2.87, 95%CI:1.65, 5.00). After stratification, transience and sexual vulnerability remained significantly associated among women but not men. Ensuring that young Aboriginal people have access to safe spaces to live, work, and inject must include policies addressing residential transience as well as the absence of a roof and walls.

The relationship between victimization and mental health functioning in homeless youth and adults

This study examined the relationship between victimization and mental health functioning in homeless individuals. Homeless populations experience higher levels of victimization than the general population, which in turn have a detrimental effect on their mental health. A sample of 304 homeless adults and youth completed one-on-one interviews, answering questions on mental health, past victimization, and recent victimization experiences. A hierarchical linear regression showed that experiences of childhood sexual abuse predicted lower mental health functioning after controlling for the sex and age of individuals. The study findings are applicable to current support programs for victims in the homeless population and are relevant to future research on homelessness and victimization.

A qualitative study of pregnancy intention and the use of contraception among homeless women with children

We undertook a qualitative analysis informed by grounded theory to explore pregnancy intention and the barriers to contraceptive use as perceived by homeless women with children. Semi-structured interviews (n = 22) were performed in English and in Spanish. The dominant theme emerging from the interviews was a strong desire to avoid pregnancy while homeless. However, few women in our sample used contraception or accessed reproductive health care consistently. There were multiple barriers to using contraception and to accessing reproductive health care services that homeless women reported: (1) inability to prioritize health due to competing demands, (2) shelter-related obstacles and restrictive provider practices that impede access to reproductive health care services and the use of contraception, and (3) change in the power dynamics of sexual relationships while homeless, making women more vulnerable to sexual exploitation. Findings suggest a multifactorial approach is needed to help homeless women use contraception and access reproductive health services.

Injury-related visits and comorbid conditions among homeless persons presenting to emergency departments

OBJECTIVES

The authors examined the clinical characteristics of homeless patients presenting to emergency departments (EDs) in the United States, with a focus on unintentional and intentional injury events and related comorbid conditions.

METHODS

The study included a nationally representative sample of patients presenting to EDs with data obtained from the 2007 through 2010 National Hospital Ambulatory Medical Care Survey (NHAMCS). Descriptive and analytical epidemiologic analyses were employed to examine injuries among homeless patients.

RESULTS

Homeless persons made 603,000 visits annually to EDs, 55% of which were for injuries, with the majority related to unintentional (52%) and self-inflicted (23%) injuries. Multivariate logistic regression analyses revealed that homeless patients had a higher odds of presenting with injuries related to unintentional (odds ratio [OR]=1.4. 95% confidence interval [CI]=1.1 to 1.9), self-inflicted (OR=6.0, 95% CI=3.7 to 9.5), and assault (OR=3.0, 95% CI=1.5 to 5.9) injuries.

CONCLUSIONS

A better understanding of the injuries affecting homeless populations may provide medical and public health professionals insight into more effective ways to intervene and limit further morbidity and mortality related to specific injury outcomes.

Development of a frailty framework among vulnerable populations

Frailty is a public health issue that is experienced by homeless and other vulnerable populations; to date, a frailty framework has not been proposed to guide researchers who study hard-to-reach populations. The Frailty Framework among Vulnerable Populations has been developed from empirical research and consultation with frailty experts in an effort to characterize antecedents, that is, situational, health-related, behavioral, resource, biological, and environmental factors that contribute to physical, psychological, and social frailty domains and impact adverse outcomes. As vulnerable populations continue to age, a greater understanding of frailty will enable the development of nursing interventions.

"The second thing to hell is living under that bridge": narratives of women living with victimization, serious mental illness, and in homelessness

The increasing rates of violence committed against homeless women living with serious mental illness (SMI) have been well documented. These increasing rates of violence need attention as they are a serious public health concern. The purpose of this qualitative study is to increase our understanding of victimization among this population as perceived by those who have lived the experience. The study sample consists of 15 homeless adult women who self-reported having been diagnosed with a SMI. The findings highlight the reality that, provided with the right type of resources, positive growth can occur among these women despite lifelong events of trauma, victimization, and loss.

Military sexual trauma among homeless veterans

BACKGROUND

Military sexual trauma (MST) is the Veteran Health Administration's (VHA) term for sexual assault and/or sexual harassment that occurs during military service. The experience of MST is associated with a variety of mental health conditions. Preliminary research suggests that MST may be associated with homelessness among female Veterans, although to date MST has not been examined in a national study of both female and male homeless Veterans.

OBJECTIVE

To estimate the prevalence of MST, examine the association between MST and mental health conditions, and describe mental health utilization among homeless women and men.

DESIGN AND PARTICIPANTS

National, cross-sectional study of 126,598 homeless Veterans who used VHA outpatient care in fiscal year 2010.

MAIN MEASURES

All variables were obtained from VHA administrative databases, including MST screening status, ICD-9-CM codes to determine mental health diagnoses, and VHA utilization.

KEY RESULTS

Of homeless Veterans in VHA, 39.7 % of females and 3.3 % of males experienced MST. Homeless Veterans who experienced MST demonstrated a significantly higher likelihood of almost all mental health conditions examined as compared to other homeless women and men, including depression, posttraumatic stress disorder, other anxiety disorders, substance use disorders, bipolar disorders, personality disorders, suicide, and, among men only, schizophrenia and psychotic disorders. Nearly all homeless Veterans had at least one mental health visit and Veterans who experienced MST utilized significantly more mental health visits compared to Veterans who did not experience MST.

CONCLUSIONS

A substantial proportion of homeless Veterans using VHA services have experienced MST, and those who experienced MST had increased odds of mental health diagnoses. Homeless Veterans who had experienced MST had higher intensity of mental health care utilization and high rates of MST-related mental health care. This study highlights the importance of trauma-informed care among homeless Veterans and the success of VHA homeless programs in providing mental health care to homeless Veterans.

Missing link in community psychiatry: When a patient with schizophrenia was expelled from her home

Treatment and disposition of homeless patients with schizophrenia represent a great challenge in clinical practice. We report a case of this special population, and discuss the development of homelessness, the difficulty in disposition, their utilization of health services, and possible applications of mandatory community treatment in this group of patients. A 51-year-old homeless female was brought to an emergency department for left femur fracture caused by an assault. She was diagnosed with schizophrenia about 20 years ago but received little help from mental health services over the decades. During hospitalization, her psychotic symptoms were only partially responsive to treatment. Her family refused to handle caretaking duties. The social welfare system was mobilized for long-term disposition. Homeless patients with schizophrenia are characterized by family disruption, poor adherence to health care, and multiple emergency visits and hospitalization. We hope this article can provide information about the current mental health policy to medical personnel. It is possible that earlier intervention and better outcome can be achieved by utilizing mandatory community treatment in the future, as well as preventing patients with schizophrenia from losing shelters.

Association of childhood abuse with homeless women's social networks

OBJECTIVE

Childhood abuse has been linked to negative sequelae for women later in life including drug and alcohol use and violence as victim or perpetrator and may also affect the development of women's social networks. Childhood abuse is prevalent among at-risk populations of women (such as the homeless) and thus may have a stronger impact on their social networks. We conducted a study to: (a) develop a typology of sheltered homeless women's social networks; (b) determine whether childhood abuse was associated with the social networks of sheltered homeless women; and (c) determine whether those associations remained after accounting for past-year substance abuse and recent intimate partner abuse.

METHODS

A probability sample of 428 homeless women from temporary shelter settings in Los Angeles County completed a personal network survey that provided respondent information as well as information about their network members' demographics and level of interaction with each other. Cluster analyses identified groups of women who shared specific social network characteristics. Multinomial logistic regressions revealed variables associated with group membership.

RESULTS

We identified three groups of women with differing social network characteristics: low-risk networks, densely connected risky networks (dense, risky), and sparsely connected risky networks (sparse, risky). Multinomial logistic regressions indicated that membership in the sparse, risky network group, when compared to the low-risk group, was associated with history of childhood physical abuse (but not sexual or emotional abuse). Recent drug abuse was associated with membership in both risky network groups; however, the association of childhood physical abuse with sparse, risky network group membership remained.

CONCLUSIONS

Although these findings support theories proposing that the experience of childhood abuse can shape women's social networks, they suggest that it may be childhood physical abuse that has the most impact among homeless women.

PRACTICAL IMPLICATIONS

The effects of childhood physical abuse should be more actively investigated in clinical settings, especially those frequented by homeless women, particularly with respect to the formation of social networks in social contexts that may expose these women to greater risks.

Barriers to Psychosocial Services among Homeless Women Veterans

Veterans comprise a disproportionate fraction of the nation's homeless population, with women veterans up to four times more likely to be homeless than non-veteran women. This paper provides a grounded description of barriers to psychosocial services among homeless women veterans. Three focus groups were held in Los Angeles, CA, with a total of 29 homeless women veterans. These women described three primary, proximal (current) barriers: lack of information about services, limited access to services, and lack of coordination across services. Compared to non-veteran homeless women, women veterans potentially face additional challenges of trauma exposure during military service, post-military readjustment issues, and few services specific to women veterans. Understanding their service needs and experiences is critical to the development of relevant and appropriate services that move homeless women veterans away from vulnerability, into safety.

Access to housing subsidies, housing status, drug use and HIV risk among low-income U.S. urban residents

BACKGROUND

Much research has shown an association between homelessness and unstable housing and HIV risk but most has relied on relatively narrow definitions of housing status that preclude a deeper understanding of this relationship. Fewer studies have examined access to housing subsidies and supportive housing programs among low-income populations with different personal characteristics. This paper explores personal characteristics associated with access to housing subsidies and supportive housing, the relationship between personal characteristics and housing status, and the relationship between housing status and sexual risk behaviors among low-income urban residents.

METHODS

Surveys were conducted with 392 low-income residents from Hartford and East Harford, Connecticut through a targeted sampling plan. We measured personal characteristics (income, education, use of crack, heroin, or cocaine in the last 6 months, receipt of welfare benefits, mental illness diagnosis, arrest, criminal conviction, longest prison term served, and self-reported HIV diagnosis); access to housing subsidies or supportive housing programs; current housing status; and sexual risk behaviors. To answer the aims above, we performed univariate analyses using Chi-square or 2-sided ANOVA's. Those with significance levels above (0.10) were included in multivariate analyses. We performed 2 separate multiple regressions to determine the effects of personal characteristics on access to housing subsidies and access to supportive housing respectively. We used multinomial main effects logistic regression to determine the effects of housing status on sexual risk behavior.

RESULTS

Being HIV positive or having a mental illness predicted access to housing subsidies and supportive housing, while having a criminal conviction was not related to access to either housing subsidies or supportive housing. Drug use was associated with poorer housing statuses such as living on the street or in a shelter, or temporarily doubling up with friends, acquaintances or sex partners. Living with friends, acquaintances or sex partners was associated with greater sexual risk than those living on the street or in other stable housing situations.

CONCLUSIONS

Results suggest that providing low-income and supportive housing may be an effective structural HIV prevention intervention, but that the availability and accessibility of these programs must be increased.

Social networks of homeless youth in emerging adulthood

Little is known about the social networks of homeless youth in emerging adulthood despite the importance of this information for interventions to reduce health risks. This study examined the composition of social networks, and the risks and supports present within them, in a random sample of 349 homeless youth (33.4% female, 23.9% African American, 17.7% Hispanic) between the ages of 18 and 24. Social network members who were met on the street were among the most likely to be perceived as engaging in risky sex, as well as to engage in substance use with the youth. Youth were more likely to count on relatives and sex partners for support compared to other network members, but they also were more likely to use substances with sex partners and perceived them as engaging in risky sex. Interventions may need to recognize the importance of intimate relationships during the developmental stage of emerging adulthood by enhancing supportive bonds and reducing substance use and risky sex in these relationships.

Prevalence and consequences of adult sexual assault of men: review of empirical findings and state of the literature

Male victims of adult sexual assault (ASA) are understudied as compared with female victims. Further, commonly-held myths about sexual assault suggest that men cannot be victims or that, if men are victims, they are relatively physically and emotionally unharmed by sexual assault. The goal of this paper was to systematically review the empirical literature on ASA among men to evaluate the veracity of these myths. This paper also sought to examine the methodological quality of the body of research in this area, identify limitations and gaps in the current literature, and suggest directions for future research. Eighty-seven relevant studies were identified through a systematic review of the literature. The reported prevalence of men's sexual aggression varied widely depending on the methods used and the population studied; some populations (e.g., veterans, prison inmates, and gay and bisexual men) reported higher rates of ASA than men in the general population. Few studies have systematically examined the consequences of male ASA; however, those that have suggest that ASA can have notable adverse physical and psychological consequences for some men.

Do PTSD symptoms and course predict continued substance use for homeless individuals in contingency management for cocaine dependence?

Homeless individuals (n=187) entering contingency management (CM) for cocaine dependence were assessed for PTSD diagnosis, and a subset of 102 participants reporting traumatic exposure also periodically completed a self-report measure of PTSD symptoms. Patients with PTSD in full remission at 6 months (end of active treatment) and 12 months (end of aftercare) used substances much less frequently during aftercare than those with no PTSD diagnosis. Those whose PTSD diagnosis improved to full remission status during active treatment, and remained in full remission at 12 months, also had superior substance use outcomes. Severity of PTSD symptoms at 6 months, but not baseline or 2 months, was associated with substance use across treatment phases. Substance use during aftercare, however, was better predicted by changes in PTSD symptom severity. Patients whose PTSD symptoms improved more during active treatment fared better during aftercare than those with less improvement. Findings suggest homeless individuals with comorbid PTSD entering CM for cocaine dependence are not necessarily at increased risk for substance use compared to those without the comorbidity. However, course of PTSD does predict substance use, with the potential for CM to be unusually effective for those who respond with substantial, lasting improvements in PTSD.

Situational, psychosocial, and physical health-related correlates of HIV/AIDS risk behaviors in homeless men

A biopsychosocial perspective is employed to assess associations among situational and psychosocial variables related to health, health care, and HIV/AIDS risk behaviors among 479 homeless men (aged 18-64 years). Poor health was not significantly associated with sexual risk behaviors and was only modestly associated with injection drug use (IDU). Health care was not significantly associated with sexual risk behavior or IDU. HIV/AIDS risk behaviors were highly associated with homelessness severity and posttraumatic stress disorder. IDU was significantly associated with greater emotional distress and was more likely among younger men and among White men. Sexual risk behavior was more frequent among those who had particularly poor-quality housing such as living on the street or in abandoned buildings. Because interactions with the medical community are limited and not associated with HIV/AIDS risk, outreach in areas in which homeless men congregate, mental health and substance abuse treatment, and permanent supportive housing may help reduce HIV risk among homeless men more effectively.

Factors associated with violent victimisation among homeless adults in Sydney, Australia

OBJECTIVE

To determine the prevalence and correlates of violent victimisation among homeless people in inner-Sydney.

METHOD

Cross-sectional design. Clients of a shelter for homeless, substance-using adults were interviewed about their drug use, mental health and violent victimisation in the previous 12 months. Logistic regression was used to identify factors associated with victimisation.

RESULTS

Participants reported complex drug use histories and high levels of depression, post-traumatic stress disorder (PTSD) and schizophrenia or other psychotic disorders. Forty-eight per cent of participants reported past year victimisation. In univariate analyses, being female, schizophrenia/psychotic disorder, PTSD, depression and regular use of psychostimulants were associated with increased risk of victimisation. In multivariate analyses, regular use of psychostimulants (odds ratio [95% CI] 5.07 [1.53-16.84]), schizophrenia or other psychotic disorder (3.13 [1.24-7.9], and depression (2.65 [1.07-6.59]) were associated with increased risk of victimisation.

CONCLUSIONS AND IMPLICATIONS

This sample of homeless, substance-using adults experienced high levels of violence. People with poor mental health and regular psychostimulant users were at greater risk of victimisation. A longitudinal study to determine whether victimisation prolongs homelessness is warranted. Clinical staff working with homeless populations need to be aware of the likelihood of past and future victimisation and its effects on mental health. Homeless persons may benefit from learning to identify risk situations for victimisation and how to de-escalate potentially violent situations.

Substance use, mental health problems, and behavior at risk for HIV: evidence from CJDATS

This study examined the relationships between substance abuse, mental health problems and HIV risk behavior in offenders discharged from prison and referred to substance abuse treatment programs. Data from 34 sites (n = 1,358) in a federally-funded cooperative agreement, the Criminal Justice Drug Abuse Treatment Studies (CJDATS), were analyzed. Among parolees referred to substance abuse treatment, self reports for the six-month period before the arrest resulting in their incarceration revealed frequent problems with both substance use and mental health. HIV risk behavior was operationalized as either (a) unsafe injection drug use, e.g., sharing needles and/or sharing injection equipment, or (b) unsafe sex, e.g., sex without a condom. The findings were that (1) unsafe injection drug use was associated with unsafe sex and vice versa, (2) unsafe sex behavior was related to frequency of drug use, and (3) unsafe sex behavior was related to frequency of alcohol use. In these samples, mental health problems did not have a significant effect on risk behavior, controlling for other variables. Future research should probe this "nonfinding" using standardized diagnostic and symptom measures to provide greater detail on the mental health problems (e.g., age of onset, frequency, and severity of the problem).

Severe mental illness and criminal victimization: a systematic review

OBJECTIVE

To estimate the prevalence of criminal victimization among people with severe mental illness and to explore risk factors.

METHOD

Four databases (MEDLINE, ScienceDirect, ERIC, and AMED) were searched for articles published between January 1966 and August 2007, supplemented with hand-search of reference lists from retrieved papers. The author and a Medical Doctor independently abstracted data and assessed study quality. Disagreements were resolved by consensus after review of the article and the review protocol.

RESULTS

Nine studies, including 5195 patients, were identified. Prevalence estimates of criminal victimization ranged from 4.3% to 35.04%. Rates of victimization among severely mentally ill persons were 2.3-140.4 times higher than those in the general population. Criminal victimization was most frequently associated with alcohol and/or illicit drug use/abuse, homelessness, more severe symptomatology, and engagement in criminal activity.

CONCLUSION

Prevention and intervention programs should target high-risk groups and improve patients' mental health and quality of life.

Assault and substance abuse characterize burn injuries in homeless patients

The homeless are at an increased risk for traumatic injury, but little is known about the injury etiology and outcome of homeless persons who sustain burn injuries. In this study, we analyze patient and injury characteristics of homeless persons admitted to a regional burn center. This is a retrospective cohort study of patients admitted to our burn center between 1994 and 2005. A total of 3700 adult patients were admitted during the study period and, of these, 72 (1.9%) were homeless. The cohort of homeless patients was compared with domiciled adult patients admitted during the same time period, analyzing baseline patient and injury characteristics and injury outcomes. Overall, homeless patients had more extensive burn injuries than domiciled patients (17.8% vs 11.2%TBSA, P < .001) and overall longer lengths of hospital stay (22 vs 12 days, P < .001). The homeless population also had significantly higher rates of alcohol (80.6% vs 12.8%, P < .001) and drug abuse (59.4% vs 12.8%, P < .001), history of mental illness (45.2% vs 11.0%, P < .001), and injury by assault (13.9% vs 2.0%, P < .001). Homeless patients tended to have more severe injuries; higher rates of substance abuse and mental illness; increased incidence of assault by burning; and longer lengths of hospital stay. Hospitalization of a homeless patient following injury may provide a unique opportunity to address co-occurring substance abuse and mental illness and approach injury prevention to improve patients' outcomes and reduce injury recidivism.

Outcomes of public concern in schizophrenia

BACKGROUND

Schizophrenia is known to be associated with a range of adverse outcomes, which have an impact atthe societal level and are therefore of public concern.

AIMS

To examine the epidemiology and methods for measuring six adverse outcomes in schizophrenia: violence, victimisation, suicide/self-harm, substance use, homelessness and unemployment.

METHOD

A review ofthe literature was carried out for each adverse outcome, with attention to critical appraisal of existing measurement tools.

RESULTS

Schizophrenia is associated strongly with all six outcomes, although research has mainly focused on violence. Each outcome acts as a risk factor for at least some of the other outcomes. There are few standardised or validated measures for these 'hard' outcomes. Each measure has inherent biases but a growing trend is for these to be minimised by using multiple measures.

CONCLUSIONS

A single instrument which systematically measures multiple societal outcomes of schizophrenia would be extremely useful for both clinical and research purposes.

Health inequalities and homelessness: considering material, spatial and relational dimensions

Homelessness is a pressing health concern involving material hardship, social marginalization and restrained relationships between homeless and housed people. This article links relational aspects of homelessness, and its health consequences, with material and spatial considerations through the use of photo-elicitation interviews with 12 rough sleepers in London. We highlight the relevance of embodied deprivation for a health psychology that is responsive to the ways in which social inequalities can get under the skin of homeless people and manifest as health disparities.

Safe living: the impact of unstable housing conditions on HIV risk reduction among female drug users

The objectives of this article are to explore differences in HIV risk behaviors and subsequent risk reduction among female drug users based on their housing conditions. In addition, we investigate psychosocial characteristics as mediators. Data were collected from 336 adult women. Structured interviews were conducted at baseline and at 6-month follow-up. At baseline, women with unstable housing conditions reported higher levels of HIV drug and sex-related HIV risk behavior. In addition, their levels of behavioral change over time were lower. The findings also show the importance of expanding the stable housing condition into two categories thereby distinguishing between a woman's own and someone else's place. None of the mediating factors were statistically significant and there was no moderation by intervention condition. The findings suggest that unstable housing conditions form a structural barrier to HIV risk reduction irrespective of the message. Future interventions should consider such conditions and the larger social context of the women's lives.