Reproductive health deals with the reproductive processes, functions and system at all stages of life. Although reproductive health is a universal concern, certain groups face inequalities when accessing healthcare. Socioeconomic status, education level, age, ethnicity and religion can all have an influence on how individuals maintain their reproductive health. As a result, people experiencing homelessness who are economically marginalized often do not have access to the supports, resources and information they need.
According to the World Health Organization, reproductive and sexual ill-health accounts for 20% of the global burden of ill-health for women, and 14% for men. Transgender and non-binary individuals who are disproportionally affected by homelessness also face unique reproductive health issues. They face obstacles to accessing quality healthcare, including gender-based discrimination that may occasionally result in refusal of treatment, and a lack of LGBTQ2S cultural competency. Compounded with the discrimination, erasure and transphobia often normalized in the shelter system, the reproductive health care needs of transgender individuals experiencing homelessness are frequently unaddressed.
Evidently, reproductive health is a universal issue that impacts various populations in different and extensive ways. This blog post will focus on three key areas of reproductive health relating to different populations who experience homelessness: menstruation, pregnancy and contraception.
The difficulties associated with homelessness are extensive, and include a lack of food, shelter, healthcare, mental health supports, and other vital resources. People experiencing homelessness who menstruate have the additional burden of managing their periods — a monthly occurrence that is unavoidable and expensive. Combined with the stigma that surrounds menstruation, women, trans men, and other people experiencing homelessness who menstruate often lack support that would help mitigate many of their problems. The upkeep of menstrual hygiene is a matter of dignity, but it is also crucial in order to avoid damaging reproductive and gynaecological health.
A recent study examined how women experiencing homelessness in the U.K. manage menstruations in a context of financial and social vulnerability. Many of the participants interviewed described the difficulty of prioritizing their limited funds for sanitary products. They were forced to make a decision between cheap self-made solutions and more reliable, but expensive, store-bought products. Those unable to purchase menstrual hygiene products have to manage the problems that arise from using homemade solutions, such as chemical irritation or yeast infections. Homemade solutions can also increase the likelihood of toxic shock syndrome and other life-threatening health risks.
Transgender individuals disproportionately experience homelessness when compared to the cisgender population. Those who were assigned female at birth and are grappling with gender dysphoria (distress because of a mismatch between physical appearance and gender identity) may have preferences over the sanitary products they use to reduce their dysphoria. The experience of homelessness and financial vulnerability removes much of the autonomy people have over how they manage their periods. Therefore, in the interests of both mental and physical health, it is important that menstrual products are widely available to those who are unable to afford them.
In Toronto, there is the Period Project, a street outreach group providing people living unsheltered with free sanitary items. In the U.S., there is Distributing Dignity, a women-led non-profit distributing pads, tampons and bras to people accessing homeless shelters, those who have aged out of the foster care system and families impacted by HIV/AIDS. New York City recently became the first city in the U.S. to require public schools, jails, and homeless shelters to provide free pads and tampons. In the Canadian Observatory on Homelessness’s Point-in-Time Toolkit, we recommend that communities include sanitary products as an honoraria item.
Other activist groups and movements advocate for the “tampon tax” be eliminated from state laws to those who cannot afford menstrual products. They argue the opportunities to enjoy fairly priced, tax-free products are not luxuries; rather, they are necessities. Menstruation is often overlooked and forgotten in reports addressing the health needs of people experiencing homelessness, and therefore fails to come to the attention of policymakers and service managers.
Homelessness and pregnancy
The stress of homelessness can have significant negative impacts for those who are pregnant. Due to compromised health, people who are pregnant and experiencing homelessness face greater health risks. They often have difficulty accessing healthcare and prenatal programs, which can result in potential prenatal complications going unnoticed. No one should be without a safe, stable place to call home, especially during pregnancy since this additional strain on the body can be life-threatening. The emotional and psychological aspects of pregnancy, birth, motherhood and/or the loss of a child can have further negative implications, especially for a vulnerable and marginalized population.
Pregnancy rates are also substantially higher among youth experiencing homelessness than in the general youth population. The adversity of life on the streets means that young people are exposed to increased sexual activity with more partners and increased exposure to STIs. To address this, effective and accessible pregnancy prevention and family planning programs for youth experiencing homelessness are needed.
Moreover, the relationship between substance use and homelessness is complex, and rates of substance use are disproportionately high among those experiencing homelessness. There are numerous potential harms associated with the use of substances during pregnancy, including Fetal Alcohol Spectrum Disorder (FASD), which can occur as a result of alcohol use during pregnancy, and Neonatal abstinence syndrome (NAS), a condition that a newborn may experience if exposed to addictive opiate drugs while in the womb. Homelessness and parental substance use may reduce neonatal well-being through prematurity and low birth weight.
Pre- and post-natal care programs help to prevent potential health problems throughout the course of the pregnancy. Toronto Public Health’s Homeless At-Risk Prenatal (HARP) team provides intensive prenatal case management to high-risk pregnant women experiencing homelessness in Toronto, focusing on service coordination as a primary intervention.
In spite of this, available services go underutilized often because of parents’ reluctance to self-identify as “homeless” or “underhoused.” According to Ontario’s Ministry of Health and Long-Term Care the number of babies born in the past six years to parents while experiencing homelessness in Ontario each year ranged from fewer than five to eight. However, there is a huge discrepancy between the number of pregnancies that occur and the number that are recorded. Young Parents No Fixed Address (YPNFA), a network of organizations working to address the challenges faced by youth experiencing homelessness or street-involved youth, pregnant and parenting youth and their children, have found this number to be much higher. As reported in July 2017 by Toronto Star, an estimated 300 babies were born into homelessness in Toronto each year between 2012 and 2014. Parents’ fear of losing custody has prevented them from disclosing their housing status, and has resulted in a significant underrepresentation of the scope of the issue.
Much like menstrual hygiene products, methods of contraception can often be costly and difficult to obtain. In Canada, street nurses play a crucial role in contraceptive education and provision for people experiencing homelessness. This can include distributing condoms and other contraceptives, HIV and pregnancy testing as well as educating those experiencing homelessness on safer sex practices.
People experiencing homelessness, particularly young women involved in the sex trade, are at increased risk of sexually transmitted diseases, including hepatitis, chlamydia, gonorrhea and HIV infection. Also, both men and women experiencing homelessness are at increased risk for disease due to injection drug use, multiple sexual partners and unprotected sex.
While access to contraception has increased substantially in recent years, low-income individuals are still twice as likely to use no contraceptives compared to higher income earners. Accessible birth control is one of the easiest ways to reduce costs on the healthcare system, but unlike in the U.S., U.K. and several countries in Europe, there is no universal subsidy for contraception in Canada.
A recent survey conducted by the Society of Obstetricians and Gynaecologists in Canada (SOGC) reported that 61% of Canadian women have had an unintended pregnancy. Following these alarming results, SOGC launched SexandU.ca to raise awareness about contraception and sexually transmitted infections. SexandU.ca provides accurate, credible, and up-to-date information and education on topics related to sexual and reproductive health.
Reproductive health is an extensive topic and this blog post covers only three areas of focus; there are still many other important and complex issues. You can learn more about sex workers and the sex trade in the topics section of our website. You can also help to continue this conversation on the Community Workspace on Homelessness at workspaceonhomelessness.ca.