person laying inside drain pipe with building in the background
Position Statement
Homelessness & Its Intersection with Sexual Behavior among Youth

Housing is a universal human right and the absence of safe and stable housing contributes to negative health outcomes for youth.

Adopted by
the Healthy Teen Network Board of Directors on
June 9, 2017

Position

Healthy Teen Network maintains that housing is a universal human right, and by extension, a right all. Americans should enjoy equitably. Furthermore, we recognize the centrality of safe and stable housing to achieving whole health. Accordingly, we support policies, programs, and practices to ensure permanent, safe, and affordable housing for all as a matter of both human rights and human health.

Healthy Teen Network understands that the absence of safe and stable housing contributes to negative health outcomes for youth and puts youth experiencing homelessness in situations that may heighten their risk-taking behaviors, including sexual behavior.

Accordingly, youth experiencing homelessness should have access to comprehensive sexuality education and optimal sexual and reproductive health services. Sexual and reproductive health services should be designed and delivered with consideration for homeless youth such as by developing and implementing sexual health interventions designed specifically to address the unique needs and life circumstances of homeless youth and by integrating SRH services into facilities and programs serving them.

Issue

The unique context for sexual decision-making among youth experiencing homelessness includes that they may be more sexually active1 2 3 4 and may have an earlier sexual debut.15 Homeless youth may be more disengaged from school and family—determinants that have been associated with risky sexual decision-making and greater pregnancy risk.6 Youth experiencing homelessness are also more likely to have survived a history of abuse,7 8 and more likely to experience sexual assault9 or other unwanted sexual experiences.10 Research has also shown that homeless youth are more likely to be addicted to illegal substances than their housed counterparts, which further increases their risk of sexual victimization.11 Homelessness among teens is associated with higher rates of dating violence perpetration and victimization, especially among those with a history of child maltreatment.12 If a young person experiencing homelessness identifies as LGBTQ+, research has shown them to experience more substance abuse, more mental illness, and to have more sexual partners than straight homeless youth.13

Some youth experiencing homelessness report that safe sex practices are largely not discussed with partners or friends.14

Some youth experiencing homelessness report that safe sex practices are largely not discussed with partners or friends.

Relationship factors in condom use are complex for homeless youth, with trust and love, relationship commitment status, HIV testing, and assessing risk through reputation of promiscuity all playing a role.15 16 Migratory subgroups of homeless youth, such as “travelers” report more partners, and more casual or need-based sex than other homeless youth.17

In addition to this complicated picture of high levels of consensual and non-consensual sex, youth experiencing homelessness often report engaging in “survival sex,” which is trading sex for money, drugs, clothing, food, or shelter.18 18 20 21 Of those interviewed, many report not wanting to have sex, but doing so because they lacked alternatives.22 This led to feelings of hopelessness associated with mental illness and suicide attempts.23 Young people experiencing homelessness are also especially vulnerable to commercial sexual exploitation.2425

The consequences of the complex context for sexual decision-making among youth experiencing homelessness include a higher risk of STIs26 and HIV,27 higher risk of unwanted pregnancy,28 and higher likelihood of intended pregnancies29 than their housed peers. If a young woman is pregnant while homeless, she is likely to be at high risk of low birth weight and high infant mortality, unlikely to get prenatal care, have limited information about abortion access and cost, and more likely to self-induce abortion30 31 than her housed peers.

Health interventions for homeless youth often seek to maximize known protective skills, such as goal setting, decision-making, self-reliant coping,32 and to promote healthy attachment, social support, self-efficacy, and positive sexual self-concept.33 34 They do not usually consider their sexual and reproductive health needs.

In general, there are few studies about sexual health interventions for homeless youth. These studies are rated poorly by prevention scientists and tend to be overly focused on substance abuse treatment.35 36 37 Promising intervention models include low-caseload, individualized mental health case management,38 mobile social worker-nurse teams,39 skill-focused HIV prevention programs based on social learning theory;40 multi-systemic Ecologically-based Family Therapy (EBFT),41 and the integrated community reinforcement approach (CRA) with drop-in centers.42 Continuity of care is a major challenge, with homeless youth among those least likely to return to the same sites and providers for health care.43 Research shows that mobile apps for youth and mobile providers can help with continuity.44 Intervention studies also note that among homeless youth, needs and skills vary sharply by gender and by sexual orientation, so separate programs may be indicated.45

Supporting Information

Homelessness among youth is a pressing social problem, with the U.S. government reporting almost 4,000 children and youth homeless on a given night in 2016.46 Recent studies show much higher prevalence, with 4.5 percent of households surveyed reporting a 13-17 year old family member who had run away, was homeless or was living temporarily in another household (“doubled up”) over the previous 12 months,47 and earlier national studies estimated 1.648 or 1.749 million youth having spent at least one night homeless in the previous 12 months. Child maltreatment, family homelessness, running away, and identifying as LGBTQ+50 are all well studied risk factors for youth homelessness. Once homeless, young people are at a far greater risk of being the victim or perpetrator of violence,51 and of suffering a range of health problems.

1 Halcón, L. L., & Lifson, A. R. (2004). Prevalence and predictors of sexual risks among homeless youth. Journal of Youth & Adolescence, 33(1), 71-80.

2 Wolfe, S. M., Levit, D., & Toro, P. A. (1994). AIDS Risk Behaviors, Service use and social networks in runaway vs. housed adolescents. American Public Health Association, Washington, DC, November.

3 Toro, P. A. (1998). Homelessness. In A. S. Bellack & M. Hersen (Eds.), Comprehensive Clinical Psychology: Vol. 9, Applications in Diverse Populations, 119-135.

4 Robertson, M. J., & Toro, P. A. (1999, August). Homeless youth: Research, intervention, and policy. In Practical lessons: The 1998 national symposium on homelessness research. Washington, DC: US Department of Housing and Urban Development and US Department of Health and Human Services.

5 Lacoursiere, T., & Fontenot, H. B. (2012). A second look: The impact of running away on teen girls’ sexual health. Nursing for Women’s Health, 16, 411-417. doi:10.1111/j.1751-486X.2012.01764.x

6 Thrane, L. E., & Chen, X. (2012). Impact of running away on girls’ pregnancy. Journal of Adolescence, 35(2), 443-449.

7 Keeshin, B. R., & Campbell, K. (2011). Screening homeless youth for histories of abuse: Prevalence, enduring effects, and interest in treatment. Child Abuse & Neglect, 35(6), 401-407. doi:10.1016/j.chiabu.2011.01.015

8 Tyler, K. A., & Melander, L. A. (2012b). Poor parenting and antisocial behavior among homeless young adults: Links to dating violence perpetration and victimization. Journal of Interpersonal Violence, 27(7), 1357-1373.

9 Lacoursiere, T., & Fontenot, H. B. (2012). A second look: The impact of running away on teen girls’ sexual health. Nursing for Women’s Health, 16, 411-417. doi:10.1111/j.1751-486X.2012.01764.x

10 Rosenthal, D., & Mallett, S. (2003). Involuntary sex experienced homeless young people: A public health problem. Psychological Reports, 93(3), 1195-1196.

11 Tyler, K. A., Whitbeck, L. B., Hoyt, D. R., & Cauce, A. M. (2004). Risk factors for sexual victimization among male and female homeless and runaway youth. Journal of Interpersonal Violence, 19(5), 503-520. doi:10.1177/0886260504262961

12 Tyler, K. A., & Melander, L. A. (2012b). Poor parenting and antisocial behavior among homeless young adults: Links to dating violence perpetration and victimization. Journal Of Interpersonal Violence, 27(7), 1357-1373.

13 Cochran, B. N., Stewart, A. J., Ginzler, J. A., & Cauce, A. M. (2002). Challenges faced by homeless sexual minorities: Comparison of gay, lesbian, bisexual, and transgender homeless adolescents with their heterosexual counterparts. American Journal of Public Health, 92(5), 773-777.

14 Tyler, K. A., & Melander, L. A. (2012a). Individual and social network sexual behavior norms of homeless youth at high risk for HIV infection. Children & Youth Services Review, 34(12), 2481-2486. doi:10.1016/j.childyouth.2012.09.012

15 Kennedy, D. P., Brown, R. A., Morrison, P., Vie, L., Ryan, G. W., & Tucker, J. S. (2015). Risk evaluations and condom use decisions of homeless youth: A multi-level qualitative investigation. BMC Public Health, 15(1), 1-20. doi:10.1186/s12889-015-1419-9

16 Rana, Y., Brown, R. A., Kennedy, D. P., Ryan, G. W., Stern, S., & Tucker, J. S. (2015). Understanding condom use decision making among homeless youth using event-level data. Journal of Sex Research, 52(9), 1064-1074. doi:10.1080/00224499.2014.961185

17 Martino, S., Tucker, J., Ryan, G., Wenzel, S., Golinelli, D., & Munjas, B. (2011). Increased substance use and risky sexual behavior among migratory homeless youth: Exploring the role of social network composition. Journal of Youth & Adolescence, 40(12), 1634-1648. doi:10.1007/s10964-011-9646-6

18 Halcón, L. L., & Lifson, A. R. (2004). Prevalence and predictors of sexual risks among homeless youth. Journal of Youth & Adolescence, 33(1), 71-80.

19 Gangamma, R., Slesnick, N., Toviessi, P., & Serovich, J. (2008). Comparison of HIV risks among gay, lesbian, bisexual and heterosexual homeless youth. Journal of Youth & Adolescence, 37(4), 456-464. doi:10.1007/s10964-007-9171-9

20 Borgford-Parnell, D., Hope, K. R., & Deisher, R. W. (1994). A homeless teen project: An intensive team case management model. American Journal of Public Health, 84(6), 1029-1030.

21 Whitbeck, L. B., Hoyt, D. R., & Ackley, K. A. (1997). Abusive Family Backgrounds and Later Victimization Among Runaway and Homeless Adolescents. Journal Of Research On Adolescence (Lawrence Erlbaum), 7(4), 375-392.

22 Tyler, K. A., & Johnson, K. A. (2006). Trading sex: Voluntary or coerced? the experiences of homeless youth. Journal of Sex Research, 43(3), 208-216.

23 Walls, N., Potter, C., & Leeuwen, J. (2009). Where risks and protective factors operate differently: Homeless sexual minority youth and suicide attempts. Child & Adolescent Social Work Journal, 26(3), 235-257. doi:10.1007/s10560-009-0172-2

24 Fogel, K., Martin, L., Nelson, B., Thomas, M., & Porta, C. (2017). ‘We’re automatically sex in men’s eyes, we’re nothing but sex…’: Homeless young adult perceptions of sexual exploitation. Journal of Child & Adolescent Trauma, 10(2), 151-160. doi:10.1007/s40653-016-0094-z

25 Borgford-Parnell, D., Hope, K. R., & Deisher, R. W. (1994). A homeless teen project: An intensive team case management model. American Journal of Public Health, 84(6), 1029-1030.

26 Kennedy, D. P., Brown, R. A., Morrison, P., Vie, L., Ryan, G. W., & Tucker, J. S. (2015). Risk evaluations and condom use decisions of homeless youth: A multi-level qualitative investigation. BMC Public Health, 15(1), 1-20. doi:10.1186/s12889-015-1419-9

27 Rotheram-Borus, M. J., Song, J., Gwadz, M., Lee, M., Van Rossem, R., & Koopman, C. (2003). Reductions in HIV risk among runaway youth. Prevention Science, 4(3), 173-187.

28 Kennedy, D. P., Brown, R. A., Morrison, P., Vie, L., Ryan, G. W., & Tucker, J. S. (2015). Risk evaluations and condom use decisions of homeless youth: A multi-level qualitative investigation. BMC Public Health, 15(1), 1-20. doi:10.1186/s12889-015-1419-9

29 Begun, S. (2015). The paradox of homeless youth pregnancy: A review of challenges and opportunities. Social Work in Health Care, 54(5), 444-460. doi:10.1080/00981389.2015.1030058

30 Kennedy, J. T., Petrone, J., Deisher, R. W., Emerson, J., Heslop, P., Bastible, D., & Arkovitz, M. (1990). Health care for familyless, runaway street kids. In P. W. Brickner, L. K. Scharer, B. A. Conanan, M. Savarese, & B. C. Scanlan (Ed.), Under the Safety Net: The Health and Social Welfare of the Homeless in the United States. New York: W. W. Norton, 82-117.

31 Sullivan, P. A., & Damrosch, S. P. (1987). Homeless women and children. In R. D. Bingham, R. E. Green, & S. B. White (Ed.), The Homeless in Contemporary Society. Newbury Park, Ca.: Sage Publications, 82-98.

32 Lightfoot, M., Stein, J. A., Tevendale, H., & Preston, K. (2011). Protective factors associated with fewer multiple problem behaviors among Homeless/Runaway youth. Journal of Clinical Child and Adolescent Psychology, 40(6), 878-889.

33 Taylor-Seehafer, M. A., Johnson, R. J., Rew, L., Fouladi, R. T., Land, L. N., & Abel, E. (2005). Adolescent sexual behavior: risk and protective factors: An exploration of attachment, sexual self-concept, assertive communication, and intention and self-efficacy to use condoms in homeless youth. Journal of Adolescent Health, 36142-143. doi:10.1016/j.jadohealth.2004.11.098

34 Taylor-Seehafer, M., Johnson, R., Rew, L., Fouladi, R. T., Land, L., & Abel, E. (2007). Attachment and sexual health behaviors in homeless youth. Journal for Specialists in Pediatric Nursing, 12(1), 37-48. doi:10.1111/j.1744-6155.2007.00087.x

35 Altena, A. M., Brilleslijper-Kater, S. N., & Wolf, J. R. (2010). Effective interventions for homeless youth: A systematic review. American Journal of Preventive Medicine, 38(6), 637-645.

36 Naranbhai, V., Karim, Q. A., Meyer-Weitz, A. (2010). Interventions to modify sexual risk behaviours for preventing HIV in homeless youth. Cochrane Database of Systematic Reviews, (1).

37 Coren, E., Hossain, R., Pardo, J. P., Veras, M., Chakraborty, K., Harris, H., & Martin, A. J. (2013). Interventions for promoting reintegration and reducing harmful behaviour and lifestyles in street‐connected children and young people. Evidence‐Based Child Health: A Cochrane Review Journal, 8(4), 1140-1272.

38 Wagner, V., Sy, J., Weeden, K., Blanchard, T., Cauce, A. M., Morgan, C. J., … & Tomlin, S. (1994). Effectiveness of intensive case management for homeless adolescents: Results of a 3-month follow-up. Journal of Emotional and Behavioral Disorders, 2(4), 219-227.

39 Borgford-Parnell, D., Hope, K. R., & Deisher, R. W. (1994). A homeless teen project: An intensive team case management model. American Journal of Public Health, 84(6), 1029-1030.

40 Rotheram-Borus, M. J., Song, M., Gwadz, M. V., Lee, M., VanRossem, R., & Koopman, C. (2003). Reductions in HIV risk among runaway youth. Prevention Science, 4(3):173–87.

41 Slesnick N, Prestopnik JL. (2005). Ecologically based family therapy outcome with substance abusing runaway adolescents. J Adolesc. 2005;28(2):277–98. 19.

42 Slesnick N, Kang MJ. (2008). The impact of an integrated treatment on HIV risk behavior among homeless youth: a randomized controlled trial. J Behav Med.; 31(1): 45–59.

43 Anthony, I. (2014). Meeting the challenge: Responding to health care needs of homeless youth. Clinical Pediatrics, 53(1), 38-40. doi:10.1177/0009922813499067

44 Sheoran, B., Silva, C. L., Lykens, J. E., Gamedze, L., Williams, S., Ford, J. V., & Habel, M. A. (2016). YTH StreetConnect: Development and usability of a mobile app for homeless and unstably housed youth. JMIR Mhealth and Uhealth, 4(3), e82-e82. doi:10.2196/mhealth.5168

45 Rew, L., Whittaker, T. A., Taylor-Seehafer, M., & Smith, L. R. (2005). Sexual health risks and protective resources in gay, lesbian, bisexual, and heterosexual homeless youth. Journal for Specialists in Pediatric Nursing, 10(1), 11-19.

46 U.S. Department of Housing and Urban Development. (2016). Homelessness in the United States: The 2016 Annual Homeless Assessment Report to Congress. Available at: https://www.hudexchange.info/resources/documents/2016- AHAR-Part-1.pdf. November 2016.

47 Morton, M. H., Dworsky, A., Matjasko, J. L., Curry, S. R., Schlueter, D., Chávez, R., & Farrell, A. F. (2017). Prevalence and correlates of youth homelessness in the United States. Journal of Adolescent Health, in press. Retrieved: https://ac.els-cdn.com/S1054139X17305037/1-s2.0-S1054139X17305037-main.pdf?_tid=66d32dec-e050-11e7-b921-00000aab0f27&acdnat=1513202339_a179b9ccf2be57a563f9c71b46f3ed7c

48 Ringwalt, C. L., Greene, J. M., Robertson, M., & McPheeters, M. (1998). The prevalence of homelessness among adolescents in the United States. American Journal of Public Health, 88, 1325–1329.

49 Hammer, H., Finkelhor, D. & Sedlak, A. (2002, October). Runaway/Thrownaway children: National estimates and characteristics. National Incident Studies of Missing, Abducted, Runaway, and Thrownaway Children. Washington, DC: U.S. Department of Justice, Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention.

50 Gangamma, R., Slesnick, N., Toviessi, P., & Serovich, J. (2008). Comparison of HIV risks among gay, lesbian, bisexual and heterosexual homeless youth. Journal of Youth & Adolescence, 37(4), 456-464. doi:10.1007/s10964-007-9171-9

51 Tyler, K. A., Melander, L. A., & Noel, H. (2009). Bidirectional partner violence among homeless young adults: Risk factors and outcomes. Journal of Interpersonal Violence, 24(6), 1014-1035.