Research Matters Blog
LGBTQ2S (lesbian, gay, bisexual, transgender, transgender, queer, questioning, two spirit) youth experiencing homelessness are in a particularly vulnerable state when it comes to managing their sexual and reproductive health. In addition to the obstacles they face as youth and individuals experiencing homelessness, they face discrimination as a sexual and gender minority. The risks associated with each of these factors interfere with their ability to maintain their sexual and reproductive health. Oftentimes, they have limited access to healthcare services when they experience health problems. That is, if they can access healthcare services at all.
Sexual and Reproductive Health of Individuals Experiencing Homelessness
For those experiencing homelessness, it is incredibly difficult, and at times impossible, to access healthcare services. Without a permanent address, they are unable to obtain a health card or to make a healthcare appointment. Additionally, they cannot afford items that aren’t covered by provincial medical or drug insurance plans. Often they do not receive sufficient care from providers who might discriminate against them based on their homelessness. Even if they are able to access services, they may not have a safe or appropriate space for recuperation after a hospital stay, or have someone to give them care if they are in an especially fragile state.
Additionally, for those experiencing homelessness who menstruate, there exists an additional financial need that cannot be met with their lack of funds. Not only is it a matter of hygiene and dignity, but the inability to upkeep menstrual hygiene can lead to damage to reproductive and gynecological health. Those who are forced to choose cheaper homemade menstruation products, rather than the safer store-bought products, can experience chemical irritation and yeast infections. Moreover, they are at a significantly higher risk of life threatening conditions such as toxic shock syndrome.
Furthermore, those experiencing homelessness who are also pregnant face increased reproductive health risks due in part to their inability to access prenatal programs. This lack of access can result in serious complications going unnoticed and the additional strain of being pregnant while homeless can be life threatening.
LGBTQ2S youth experiencing homelessness
It is important to consider the unique experience of LGBTQ2S youth experiencing homelessness, as rates of homelessness are disproportionately high within this population. In the United States, 40% of homeless youth identify as LGBTQ2S. In Canada, the rate ranges from 25-40%; meanwhile, only 5-10% of the total population identifies as LGBTQ2S. It is shocking to note that on average, at only 14.4 years of age, youth identifying as LGBTQ2S find themselves without a home. This is about the same age they should be starting high school. Even more troubling is that this average age drops to 13.5 years for transgender youth. As such young people, being faced with hardship so early in their lives, their sexual and reproductive health risks are compounded.
Sexual health Risks of LGBTQ2S Youth
To start, those who are low income earners are twice as likely not to use contraceptives as high income earners. Meanwhile, youth experiencing homelessness must face financial strain as well as their increased tendency to behave impulsively. At the adolescent stage of their cognitive development, they tend to be thrill seeking, meanwhile, their cognitive system to regulate these impulses is slow to mature. This finding suggests that youth are more likely to partake in risky behaviour; including risky sexual behaviour. Therefore, along with the financial burden of contraceptives, increased exposure to sexual activity, and the inability to access family planning programs, youth experiencing homelessness are even more vulnerable to STI exposure and unplanned pregnancy.
Among the population of those experiencing homelessness, there is a higher incidence of HIV/ aids, when compared to the general population, due to their compromised immune systems, poor nutrition and hygiene, and frequent overcrowding at shelters. LGBTQ2S youth are at a higher risk for HIV as well. Meanwhile, the risk is even higher for LGBTQ2S youth experiencing homelessness, because they bear both the risk for those experiencing homelessness and those of the LGBTQ2S community.
Public Health Canada has found that a high proportion of street youth have reported not using condoms with both male and female partners. However, males were least likely to report using condoms with their same sex partners; though little is known about why this is the case. Regardless, it is important to understand that the risk of serious sexually transmitted illnesses is particularly high within this population.
Unfortunately, when LGBTQ2S youth do reach out for health care services, they are particularly likely to receive unfair treatment and stigmatization because they belong to a sexual or gender minority. What’s more is that Indigenous LGBTQ2S individuals face additional stigmatization and discrimination due to racism. Transgender youth are particularly at a disadvantage as they report obstacles in accessing supportive and knowledgeable health care. The healthcare needs of transgender youth differ greatly from that of others. For instance, They may choose to start hormones which require monitoring and regular blood work. Lack of supports has lead to trans youth turning to street suppliers for transition-related treatments which can cause severe health complications.
Needs for the Sexual Health of LGBTQ2S youth experiencing Homelessness
In light of these findings, LGBTQ2S youth who are experiencing homelessness have a specific set of supports that they require to protect their sexual and reproductive health; though it must be noted that this is not an exhaustive list. First, they need access to contraceptives, to protect them from STIs and pregnancy. They require access to health care services if they do become pregnant or ill, to prevent the worsening of their conditions. This healthcare must not require a health card, as it is unlikely that an individual experiencing homelessness will have the permanent address necessary to acquire such documentation.
Moreover, it is necessary that health care providers have the knowledge to support them; this is especially urgent for the supports of Transgender and Indigenous LGBTQ2s youth. Indigenous communities have healing methods that differ from the western medical model prominent in Canada. It is important to take this into consideration when discussing the health of Indigenous youth experiencing homelessness.
First and foremost, there needs to be continued progress in policy targeting the issue of homelessness. Individuals require housing and finances for the overall health and safety. This study finds that those who are housed have greater physical and mental health outcomes. Additionally, another study shows that those with HIV who are housed tend to better adhere to their prescribed medical regimes. So while short term solutions like providing contraceptives and healthcare access are important, housing is a solution that will ease the healthcare obstacles faced by those experiencing homelessness in the long term.
In this bi-weekly blog series, I explore recent research on homelessness, and what it means for the provision of services to prevent or end homelessness.
Community belonging, community integration, social support, social capital, engagement -- whatever the concept, there is a common understanding that a supportive response to both mental illness and homelessness is to actively promote citizenship. This is because both living with a mental illness and being de-housed carry the risk of marginalization, being pushed to the margins of society by other persons, by systems, or even by the services meant to support. It is not sufficient that we support recovery and re-housing. We must also support citizenship.
Allison Ponce and Michael Rowe present a framework for citizenship, building on existing theory and research including their own work with those experiencing housing loss. This work is timely as Canada recognizes CMHA Mental Health Week, with the authors providing recommendations for community psychology and psychiatry.
Ponce and Rowe provide a justification for a focus on citizenship that likely rings true for those of us who work in the homeless-serving sector: front-line workers are best prepared to provide those they assist instrumental supports and referrals to direct services, but find it more difficult to meet “affective needs of positive identity and a sense of belonging in their communities and society.” Another good fit for the sector is the social justice and equity underpinnings of their citizenship framework, that it’s not just about belonging and participation, but explicitly about “opportunities for persons of difference.”
So, how do we support citizenship in practice? Some ideas their research presented or stimulated for me include:
- Engage those with lived and living experiences into councils, committees, planning groups, etc.
- When engaged, actively avoid having services providers dominate these committees and taking on all action items.
- Educate the community about mental health and homelessness through the voices of those with lived experience directly.
- Use trained peers to assist in the intentional development of broader social networks.
- Support those who are newly independent in the community to identify an explicit community based task (ex. volunteering at an event, supporting a fundraising project, attending free library sessions, etc.), and support them in following through with this task.
- Provide free classes on the rights and responsibilities of citizens.
- If local projects or services are engaging in evaluation, train peers as community researchers to support these activities.
I conclude with their point that citizenship is not just for those who have reached some pre-determined or culturally conceived level of ‘stability,’ but is for all people.
There are many myths and stereotypes that people believe about homelessness. This misinformation is problematic, as it further contributes to the stigmatization of a population that is already marginalized. In order to appropriately tackle the issue of homelessness and create a society where individuals feel comfortable accessing supports, these myths must be deconstructed and understood to be false by the general public.
Below are six of the many misconceptions about homelessness, compared to the realities for people who are experiencing homelessness.
1. Myth: People choose to be homeless.
Fact: A variety of different factors can contribute to an individual’s experience of homelessness. Often, people experience homelessness when all other options have been exhausted, and/or they are dealing with circumstances that make it difficult to maintain housing. Some of the obstacles that may lead people to their experiences of homelessness include:
- The affordable housing crisis
- Coping with mental illnesses or addictions, which makes it difficult to maintain independent housing
2. Myth: People experiencing homelessness are lazy.
Fact: In order to survive, many people who experience homelessness are constantly in search for the necessities of life, such as food, shelter and a source of income. Therefore, due to the barriers that they face, many people experiencing homelessness do not have the option of being stagnant or lazy. For example, searching for a job becomes even more challenging when an individual does not have access to a phone, computer, or fixed address on a regular basis.
3. Myth: All people who experience homelessness are addicts.
Fact: Many people who experience homelessness do not struggle with substance abuse problems or addictions. Just like in the general population, only a percentage of those who are experiencing homelessness deal with addictions. People experiencing homelessness may deal with other issues related to their experiences of homelessness, including trauma and mental illness, for example.
4.Myth: People experiencing homelessness should just find a job.
Fact: There are already people experiencing homelessness who are employed; however, it is much more difficult to find a job while experiencing homelessness. A number of different challenges, such as: lacking a permanent address, not having regular access to showers, barriers to transportation, and other difficulties like mental illness, make it difficult to obtain employment. Even when individuals experiencing homelessness find jobs, they are often part-time or minimum wage positions. This work fails to adequately meet their needs, due to expensive housing costs.
5. Myth: There are plenty of adequate services and supports to help those experiencing homelessness.
Fact: Many of the solutions and supports for homelessness have focused on emergency services, such as shelters and food banks. For individuals who are trying to escape a cycle of poverty and homelessness, emergency services alone are not adequate. There is a need to focus on the larger systemic factors, including the lack of affordable housing and the criminalization of homelessness that prevent people from obtaining permanent and suitable shelter.
6. Myth: Property values will go down if we let homeless shelters into our neighbourhoods.
Fact: Downtown Toronto, Canada is a concentrated area with supports and services for people experiencing homelessness. Despite the large numbers of people who go into the downtown core to access these services, housing prices remain high and there is no evidence to support this myth. This common misperception and attitude is referred to as “Not in My Backyard” (NIMBY) and can have detrimental effects for people who need to access services in different neighbourhoods.
Overall, the myths that exist about homelessness are generalizations of a more complicated reality. It is important for those who have never experienced homelessness before to understand that every homeless individual faces a different and complex set of circumstances. It is the responsibility of the general public to educate themselves about issues related to homelessness. This will hopefully result in sensitive and compassionate conversations and solutions to homelessness.
Welcome back to the “THIS is” blog series! This month’s installment goes back to the basics of Making the Shift by looking at one of the fundamentals of our research design: the Randomized Controlled Trial.
In developing Making the Shift (MtS), a primary objective has always been to establish a base of sound, scientific evidence for prevention and Housing First for Youth (HF4Y) interventions. We’ve certainly talked about this before! But this evidence base is so fundamental to MtS that it warrants a deeper discussion – in my opinion, anyway. And since I’m the one writing this blog series, I’ve decided to take you all along with me on this exploration of one of the more nuanced and controversial aspects of our work. It’ll be fun (read: informative), I promise!
What is a Randomized Controlled Trial?
Now that I’ve piqued your curiosity with those buzzwords, let’s talk for a minute about Randomized Controlled Trials. Wait, come back! Known among the research community as “RCT,” Randomized Controlled Trial is simply a formal term for a study in which participants are randomly divided into groups of comparable size and defining characteristics. One group is known as the “control” or “treatment as usual” group, which is the standard against which everything else is compared. The other group(s) is the “intervention” in which participants are involved in the field testing of a theory, approach, idea, or condition. Having distinct groups of participants allows us to directly compare participants’ experiences, both individually and as groups, which is enormously helpful in assessing whether or not the proposed intervention had an effect compared to the “treatment as usual” and what exactly the effect was (as it could be positive or negative). Another large-scale example of a RCT that you have probably heard of, currently underway, is the Government of Ontario’s Basic Income Pilot.
So, from a research standpoint, it’s all good – you get controlled data that you can compare and cross-compare. And further, the study can be developed as a mixed methods research design. This kind of design – which we are using for HF4Y – relies on both quantitative and qualitative data to provide a comprehensive idea of how the study is going. Within some research communities, the RCT is regarded as a “gold standard.” The side diagram offers one illustration on how, for some, RCTs measure up to other research methodologies, with the most rigorous options situated near the top and anecdotal evidence comprising the base. From the RCTs’ position in the middle of the pyramid, we can be assured that there is a balance between rigour and flexibility, which is especially important when working with vulnerable populations such as youth.
Busting RCT Myths
There are many opinions out there on the merits and demerits of the RCT design. This is common to any approach to research; as virtually any researcher will tell you, there is no official “right” or “wrong” research methodology. Differing perspectives are to be expected, with specific attention to the subject matter under investigation. However, there are a number of concerns about RCTs, particularly those involving youth, so I thought it would be best to address some of them directly:
RCTs withhold resources from participants in the control group
Participants who are randomized into the “treatment as usual” group receive the services that already exist in the community. Access to service is not in any way withheld from participants. It helps to think of what the participants would do if the RCT didn’t exist – what other resources and services would they be directed to? That’s exactly what the “treatment as usual” group receives.
RCTs are not suitable for youth
There are many other examples of successful RCTs working with young participants. While it’s true that most RCTs are designed for adult participants, RCTs can also be appropriate involving young participants, dependent on their own informed consent – meaning each participant is able to fully understand the scope of the research, what they can expect to happen, the potential risks and rewards of participating, and their role in the study before signing up. The condition under study should, of course, be developmentally appropriate and ethically sound.
RCTs trap participants in interventions they may not want to participate in
Participants in either group are able to withdraw their involvement from a RCT study at any time. They are similarly able to refuse to answer any questions, and withdraw their data and previous input from being used in the study. Of course, participants are encouraged to participate through the entire process but are not obligated to do so. For any time given to research participation, young people receive compensation – even if they choose to withdraw their data or stop participating.
RCTs are unfair
RCTs are regarded in the research community as being one of the fairest methods of allocating new and limited services/resources by randomly dividing participants into groups; participants have an equal chance of being assigned to any group. The randomization process removes all elements of human bias, as the decision is made independent of any emotional factors.
RCT Meets HF4Y
At this point, you might be asking yourself why MtS is using a RCT design, which is absolutely a fair question (and one the top questions we get asked, in fact!). The most straightforward answer is that the At Home/Chez Soi (AH/CS) study on Housing First used the RCT research design; people might not realize that MtS was created as a direct successor to AH/CS, and that MtS is running a mini AH/CS on HF4Y. This is a direct response to the findings from AH/CS, specifically: “We suggest considering modifications of ‘Housing First’ to maintain fidelity to core principles while better meeting the needs of youth”. So, it follows that, like AH/CS, MtS is also implementing a RCT study.
As mentioned, the RCT design is being used to assess the HF4Y intervention for MtS. Youth who are participating in the Ottawa and Toronto HF4Y projects have been randomized into either the “intervention” or “treatment as usual” group, with researchers closely monitoring their outcomes as groups and individuals. In the end, the goal is to understand and support an approach that promotes better outcomes for youth.
The key message to bear in mind is that nothing is guaranteed with the RCT process; and it is indeed a process of evaluating whether or not a proposed intervention works, not an established solution. This is a crucial distinction to make. People might look at a RCT study and think, “Here is an intervention that we know works and it’s cruel to keep it from some participants; why are we doing this?”. I can absolutely sympathize with that perspective, and the concern at its core, but the truth is that we really need strong data to back up our hypotheses.
In the case of MtS, we need to ensure that we are supporting the best option for youth. Strong data establishes “proof of concept” and the aforementioned evidence base that will inform policy and practice shifts concerning youth homelessness. Rigorous research and evaluation techniques – including the RCT design – are how we will get there.
The “THIS is” blog series is a monthly look into the concepts and ideas at the heart of the Making the Shift Youth Homelessness Social Innovation Lab project. This blog is the sixth installment in the blog series; click to read the first, second, third, fourth, and fifth installments.
1 Kozloff et al., (2016) At Home / Chez Soi
Photo credit: University of Canberra Library. Available here
In this bi-weekly blog series, I explore recent research on homelessness, and what it means for the provision of services to prevent or end homelessness. Read the first blog here, and the second blog here.
Housing is foundational to ending homelessness, foundational as a determinant of health, and foundational to community integration. However, housing itself does not guarantee health or integration.
Chris Chamberlain and Guy Johnson explore the question of community integration as outlined in Housing First models. They use the concept of ‘liminality’ to question integration after homelessness, a term referring to being between two worlds.
To address this question, they analyzed 157 interviews with 64 individuals exiting chronic homelessness through a Housing First program. All participants were housed at the final interview, and majority having been housed for over a year. Half of the participants had their first experience of homelessness as youth, three quarters identified as male, and all were receiving government income support.
Chamberlain and Johnson noted a sense of material “liminality” on first becoming housed, based on three challenges:
- Participants lacked resources to furnish their new home and meet basic needs
- Participants felt suddenly lonely in their new spaces
- Participants were either new to or had been some time since managing a home.
However, the research team observed progress over time as participants gained control, acquired possessions, and settled into new autonomy.
Relational 'liminality’ proved more complex. While participants recognized new friendships and casual acquaintances developed in accessing services for people experiencing homelessness, these were often not built on the same bonds and common values of friendships of familial relationships from which they had become disconnected. While many participants disconnected from relationships built during their period of homelessness, they also struggled to reconnect with prior relationships. Familial relationships were often sources of past trauma, so participants were more likely to reconnect with their own children rather than with parents, siblings, or other blood relatives.
Lastly, participants experienced psychological “liminality” which involved carrying the stigma of the experience of homelessness, feeling both “discredited” and “discreditable.” While this sense declined over time, half the participants still felt this stigma by the final interview, despite having been in housing for a year on average.
The authors conclude that while Housing First programs continue to demonstrate good outcomes for rapid re-housing, that community integration needs to be an intentional process of such programs rather than a presumed outcome. While the material components of becoming housed might be more straight-forward to address (such as through furniture bank programs), the relational and stigma components are more complex. They conclude with a call for funding to be focused on community integration.
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The analysis and interpretations contained in the blog posts are those of the individual contributors and do not necessarily represent the views of the Canadian Observatory on Homelessness.