Sexual & Gender Minority Youth Chronic Homelessness

A systems thinking approach to understanding the chronic youth homelessness experienced by a portion of the sexual and gender minority youth population as a response to an assignment for a graduate epidemiology course.

Each year, almost 4.2 million unaccompanied youth and young adults, ages 13 to 25, in the United States, experience homelessness (Petry et al., 2022). Sexual and gender minority individuals make up 20-40% of the homeless population, while in the general population, they only comprise 5-10% (Fraser et al., 2019). Sexual and gender minority youth are at a 2.2 times higher risk of experiencing homelessness than their cisgender and heterosexual peers (Morton et al, 2018). The cause of sexual and gender minority youth chronic homelessness is multifactorial and compounding and should be evaluated through the larger structures of youth and adult homelessness. You will see below that each of the factors represented here, intersect, and each of the sections build on the ones that came before. We find that homelessness is a temporal continuum, existing as situational and episodic, sometimes resulting in chronic, but all cycling from one to another, unless a hard-to-reach exit is found (Nooe & Patterson, 2010). This cycle over time also goes from one housing status to another, with individual and social consequences to each episode (Nooe & Patterson, 2010). 

Avoiding Homelessness

Homelessness, of course, can be avoided in its entirety (Grattan et al., 2022). However, this requires multiple protective factors, such as a supportive family, high social economic status (SES), employment, and school achievement (Grattan et al., 2022). These protective factors decrease the level of risk posed by individual, family and community risk factors, and additional proximal risk factors (Grattan et al., 2022). 

Homelessness

In this section:

• Proximal risk factors & proximate causes: poverty, mental health, substance use, race and ethnicity, and sexual abuse
• Perpetrating risk factors & individual outcomes: sexual abuse, increased substance use, and health impairment
• Individual biopsychosocial & static risk factors: physical health

Poverty & Survival Sex

The cooccurring variables of mental health issues and substance abuse are both drivers and consequences of poverty (Fraser et al., 2019). The homelessness structural factor of poverty comes from elevated levels of income inequality and makes the exit from homelessness ever more difficult (Fraser et al., 2019). Homeless individuals may engage in sex as a means of survival, due to poverty (Fraser et al., 2019). Survival sex is the use of sex in exchange for food, shelter, or illicit substances, rather than money (Fraser et al., 2019). 

Racial & Ethnic Minorities and Stigma & Discrimination

Racial and Ethnic minorities have an increased risk of homelessness, with African American individuals at a 42% increased likelihood and Hispanic individuals at a 20% increased likelihood (Fraser et al., 2019).  

Substance Use & Mental Health

Substance abuse can be a direct cause of homelessness, as well as an outcome, often worsening because of the experience of homelessness (Fraser et al., 2019). Like substance abuse, mental health issues can both cause homelessness, as well as be an outcome of homelessness (Fraser et al., 2019). 

Sexual Abuse & Physical Health

People experiencing homelessness experience higher levels of sexual abuse prior to homelessness and during (Fraser et al., 2019). Homeless people are vulnerable to harsh weather, injuries, and assault, as well as barriers to health care (Chang et al., 2018). The risk of hospitalization increases due to the hesitation of these individuals to seek care initially because of these barriers, such as cost and transportation (Chang et al., 2018).  

Sexual & Gender Minority Homelessness

In this section:

• Perpetuating risk factors & individual outcomes: increased substance use, increased mental health problems, health impairment, and high risk sexual behavior
• Perpetuating risk factors & social outcomes: survival sex and sex work
• Proximal risk factors & proximate causes: substance use, discrimination and stigma, family, mental health, housing status, heterosexism and transphobia, and physical health
• Individual distal risk factors: substance use, poor mental health
• Individual biopsychosocial & static risk factors: health

Discrimination & Stigma

Sexual and gender minorities who are also racial and ethnic minorities have an even higher chance of experiencing victimization, poverty, and discrimination (Fraser et al., 2019). Homelessness adds an additional stressor to the lives of these individuals experiencing multiple types of minority stress (Fraser et al., 2019). Stigma often results in shame and self-blame for sexual and gender minority individuals (Kidd, 2007). Sexual and Gender minorities also experience discrimination and stigma for their identity status from other individuals experiencing homelessness (Fraser et al., 2019). This disproportionate level of stigma experienced, leads to higher rates of physical abuse for sexual and gender minority homeless individuals (Gattis, 2013). 

Mental Health

The first discrimination experienced for this population is often in the home (Fraser et al., 2019). Internalized stigma affects the mental health of sexual and gender minorities (Kidd, 2007). External and internalized stigma leads to feelings of isolation and loneliness, worsened when this stigma is compounding, which make the exit from homelessness difficult to reach (Fraser et al., 2019). 

Homeless Shelters

Discrimination also leads to problems for sexual and gender minority individuals within homeless shelters (Abramovich, 2016). Staff within shelters lack training for working with these populations and do not always intervene when discrimination occurs between shelter residents (Abramovich, 2016). Single gender shelters often do not allow gender minorities (Spicer, 2010). When shelters do allow gender minorities, they assign placement for the individual based on their anatomy, and not on their identity which leaves the individual vulnerable to violence and victimization (Spicer, 2010). 

Substance Use & Survival Sex

Homeless individuals with a sexual minority identity have higher substance use rates than their heterosexual peers (Fraser et al., 2019). Individuals who identify as gender minorities have an even higher rate of substance use than their sexual minority peers (Fraser et al., 2019). Also, homeless sexual and gender minorities engage in risky behaviors, survival sex, and sex work at a much higher rate than that of their cisgender and heterosexual peers (Fraser et al., 2019).  

Youth Homelessness

In this section:

• Perpetuating risk factors & individual outcomes: sexual abuse, violence and victimization, increased mental health problems, high risk sexual behaviors, juvenile justice involvement and increased substance use
• Proximal risk factors & proximate causes: childhood sexual abuse, childhood physical abuse, family conflict, housing status, poverty, mental health, foster care, race and ethnicity, running away, and substance use
• Individual biopsychosocial & static risk factors: substance abuse, gender, and age
• Structural biopsychosocial risk factors: housing cost
• Individual distal risk factors: mental health, educational attainment, and substance use
• Family distal risk factors: familial poverty, and history of foster care
• Community distal risk factors: negative peer engagement

First Time Experience of Homelessness

Homelessness experienced as a child with the family can lead to later unaccompanied youth homelessness (Grattan et al., 2022). Physical abuse inflicted by a parent account for 40 to 60% of youth running away from their homes (Ingram er al., 2016). Other reported causal factors of youth running away from home include neglect and consistent family conflict (Ingram er al., 2016). Family may instead force the youth to leave the home due to financial strain from parental unemployment or low wages (Ingram er al., 2016). Due to a lack of affordable housing, youth may choose to live with others, stay in transitional housing, or reside in shelters, motels, or structures not intended for habitation (Ingram er al., 2016). Youth on their own cannot afford a place to live (Ingram er al., 2016). A portion of these youths are teen parents with school aged children, making affording housing even more difficult (Ingram er al., 2016). Unmarried parents with children are three times more likely to become homeless or remain in the temporal continuum of homelessness (Grattan et al., 2022). Older youth had a 50% unemployment rate in 2010 because of declining employment opportunities (Ingram er al., 2016). The fleeing of violent situations, unemployment, rejection by family and a lack of affordable housing are proximate causes of youth homelessness (Ingram er al., 2016). But when youth leave these unstable or unbearable living situations, they have few alternative housing options (Barman-Adhikari et al., 2016). This new challenge leads to a struggle of finding safe spaces to sleep and to maintain connections to stable systems (Barman-Adhikari et al., 2016). This then leads to difficulty in finding employment and turning to risky forms of income generation, such as selling drugs, substance abuse, and selling sex (Barman-Adhikari et al., 2016). In navigating these scarce resources, youth experience discrimination, and marginalization and are at higher risk of poor health and safety, and higher rates of crime and arrests (Barman-Adhikari et al., 2016). Time on the street further increases the barriers to formal employment and increases the risk of emotional and behavioral problems (Barman-Adhikari et al., 2016). 

Child Abuse, School & Street Victimization

Prior to leaving home and becoming homeless, over 50% of youth report having experienced physical abuse in childhood (Tyler & Schmitz, 2021). Between 25 and 33% of homeless youth report having experiences childhood sexual abuse (CSA) (Tyler & Schmitz, 2021). Of these youth, 24% on the street show symptoms of PTSD (post-traumatic stress disorder) (Milburn et al., 2019). Those who experience childhood physical abuse are more likely to experience physical victimization on the street, such as being robbed or beaten up, and greater than 50% of this population report these occurrences (Tyler & Schmitz, 2021). Similarly, those who experienced CSA are more likely to experience sexual victimization on the street after becoming homeless and 21 to 32% of this population report these occurrences. Female youth are at a greater risk of CSA, and having experienced sexual assault, may become bullies at school, and are at a higher risk of sexual street victimization (Tyler & Schmitz, 2021). Male youth are at a higher risk of childhood physical violence, and having experienced this are more likely to become bullies at school and experience physical street victimization and bullying on the street which then leads to more street victimization experiences and further bullying of others (Tyler & Schmitz, 2021). The affiliation with deviant peers, risky sexual behaviors and substance use increases the risk of additional victimization and increased depressive symptoms (Ingram er al., 2016). These traumatic events both before and during homelessness cause a derailed trajectory of healthy development (Milburn et al., 2019). Homelessness increases the effects of previous traumatic events, leading to subsequent trauma with negative mental health and behavioral outcomes (Milburn et al., 2019). 

The Hierarchical System for Youth on the Street

For youth on the street there is a male-controlled social hierarchy (Valente & Auerswald, 2013). Females in this realm lack ways to gain power and respect (Valente & Auerswald, 2013). Homeless female youth are the core of the homeless youth social networks, but this keeps them isolated from mainstream society, and they become associated with more street involved contacts (Valente & Auerswald, 2013). This social isolation increases their risk of chronic homelessness (Valente & Auerswald, 2013). 

Female youth often seek protection through sexual relationships with men (Valente & Auerswald, 2013). White heterosexual females often have injection drug users as their social network contacts (Valente & Auerswald, 2013). They also tend to have overlapping drug use and sexual networks and are less likely to use condoms (Valente & Auerswald, 2013). This greatly increases their risk of STIs (sexually transmitted infections) (Valente & Auerswald, 2013). Homeless male youth, however, are more likely to have same sex friendships and stably housed contacts (Valente & Auerswald, 2013). The latter leads to an increase in condom use and a decrease in STI prevalence in the male youth of this population (Valente & Auerswald, 2013).  

Student Homelessness

Homeless preschoolers often have emotional and behavioral problems and vocabularies lesser than 99% of their peers (Ingram er al., 2016). Seventy five percent of elementary schoolers experiencing homelessness are below their grade level in reading and math (Ingram er al., 2016). Fifty percent of these elementary schoolers are held back one grade, and another 22% are held back two grades (Ingram er al., 2016). Homeless middle and high school students have lower rates of course completion, often do not graduate on time, and their ability to remain focused is severely impacted (Ingram er al., 2016). Sixty three percent of these students had over six absences and at least one course failure in the ninth grade (Ingram er al., 2016). Only 51% of these students completed high school or passed their GEDs (General Educational Development Tests) (Ingram er al., 2016). 

Homelessness is a contextual risk factor for student absenteeism (Kearney, 2008). Many homeless students attend multiple schools in the course of a school year which was shown to have an effect on academic achievement including higher school dropout rates and lower standardized test scores (Ingram er al., 2016). Of the homeless youth surveyed in the middle and high school age range, 76% were not in school, only 20% of which had chosen to leave school (Ingram er al., 2016). These youth reported having difficulties getting to school, no place to study, shower or wash clothes and troubles in their personal lives as their barriers to school attendance (Ingram et al.,] 2020). Further, when guardians are present in the lives of these students, they report that the required documentation, such as proof of guardianship, immunization records, birth certificates, proof of permanent address, and academic records are barriers to enrolling their children in school (Kearney, 2008). While homeless students are at a 16% higher likelihood of school disciplinary action, students who are currently housed, but have had a homeless experience within the previous 8 years are as a higher, 18% likelihood of disciplinary action (Erb-Downward & Blakeslee, 2021). 

Homeless students of all ages have increased rates of learning and emotional disabilities and are more likely to have engaged in the juvenile justice system (Ingram er al., 2016). Engagement with criminal justice leads to a lower likelihood of graduating, a risk of falling behind in school, and future involvement with law enforcement (Ingram er al., 2016). Homeless students are also often either under or over identified for special education and learning accommodations (Ingram er al., 2016). The movement to new schools and not having a consistent adult advocate is often the cause for not having accurate school placement (Ingram er al., 2016). These misplacements lead to students falling further behind in their coursework, a lack of consistent schooling and further stress in their daily lives, which then contribute to continued housing instability (Ingram er al., 2016). However, if students become housed again after their first homeless experience, 20% get back on track with their grade level or above (Ingram er al., 2016). 

Child Welfare

Older youth in foster care have a considerable risk of aging out of the system or emancipating themselves (Rosenberg & Abbott, 2019). There is a shortage of families willing to take older youth as there is often a higher rate of risky behavior among these youth (U.S. Department of Health and Human Services (HHS), 2020). Aging out of foster care increases the risk of becoming a young parent, low educational attainment, and high unemployment rates (Rosenberg & Abbott, 2019). These older youth often enter care because of neglect or behavioral issues, while younger youth are more likely to be in the child welfare system because of physical abuse or parental substance use (Rosenberg & Abbott, 2019). Youth who enter the child welfare system between the ages of 14 and 17, who age out of foster care, and those already homeless, with a history of foster care are the most at risk of experiencing homelessness, or continued homelessness (Ross & Selekman, 2017). Youth transitioning out of foster care have a higher rate of substance use referrals and of incarceration than others of the same age (HHS, 2020). The number of foster care placements, a history of running away from placement, being placed in a group home, a history of mental or behavioral health issues, involvement with juvenile justice, substance use, and being a teen parent all increase this already elevated risk of homelessness (Ross & Selekman, 2017). If however, the area in which the youth is exiting foster care has higher levels of housing support or housing cost is aligned with the average income, the youth’s risk of experiencing homelessness somewhat decreases (Grattan et al., 2022). 

Mental Health

As with foster care, youth exiting psychiatric care or with a history of psychiatric hospitalization have an increased risk of homelessness (Grattan et al., 2022). Emotional regulation and mental health difficulties are both drivers to and outcomes of homelessness (Grattan et al., 2022). Eighteen- to twenty-five-year-olds with a past diagnosis of depression have a higher likelihood of becoming homeless than those without a depression diagnosis (Grattan et al., 2022). Increased mental health problems from the experience of homelessness lead to and cooccur with maladaptive externalizing behaviors, such as substance use and delinquent behavior, as well as victimization, trauma, school difficulties, and sexual abuse and exploitation (Milburn et al., 2019). All of these factors increase the risk of chronic homelessness (Milburn et al., 2019). 

Sleeping Location & Substance Use

Youth experiencing homelessness may change sleeping locations daily (Petry et al., 2022). Compared to other chosen sleeping locations, couch surfing, staying for a night at the home of another, may put homeless youth at a higher rate of poor housing outcomes (Petry et al., 2022). Higher rates of substance use, poor family support, involvement with the criminal justice system, and child abuse and neglect may lead to youth choosing to couch surf (Petry et al., 2022). Racial ethnic and gender, minorities, and females, ages 13 to 24, are more likely to choose to couch surf, instead of staying in a shelter (Petry et al., 2022). Youth who had threatened to harm themselves within the past year or said their homelessness was due to an abusive relationship are more likely to either couch surf or stay on the street without shelter (Petry et al., 2022). The latter is at a 20 times greater risk of living on the street than those who reported other causes of their homelessness (Petry et al., 2022). 

Travelers, youth who have lived in at least two non-neighboring states since experiencing homelessness, tend to be older white male youth with their high school diplomas or GEDs (Martino et al., 2011). These youth typically leave their homes at a younger age and report having a desire to be on their own (Martino et al., 2011). Travelers mostly choose to spend their nights outdoors, but may also choose motor vehicles, storage structures or abandoned buildings (Martino et al., 2011). These youth are at just under two times the risk of non-travelers for recent heavy drinking (Martino et al., 2011). They are also 37% times more likely to have recently used marijuana, five times more likely to have recently injected drugs (Martino et al., 2011). This elevated substance use is due to their deviant peer associations and disconnection from standard individuals and institutions (Martino et al., 2011). Travelers often tend to have more recent sex partners than their non-traveling peers (Martino et al., 2011). This sex is casual or needs base and often combined with substance use (Martino et al., 2011). 

Sexual & Gender Minority Youth Homelessness

In this section:

• Perpetuating risk factors & individual outcomes: health impairment, sexual abuse, violence, and victimization, increased mental health problems, increased substance use, and minority stress
• Proximal risk factors & proximate causes: physical health, childhood sexual abuse, family conflict, housing status, and mental health
• Individual biopsychosocial & static risk factors: substance abuse
• Individual distal risk factors: mental health, educational attainment, sexual and gender minority status, and substance use
• Family distal risk factors: history of foster care

Family Conflict

Family conflict is the main driver of sexual and gender minority youth homelessness (Semborski et al., 2022). Caregivers who disagree with the youth’s identity may kick them out of the home (Semborski et al., 2022). The same is true for when youth choose to come out, meaning to reveal their identity, to the adults in their home (Semborski et al., 2022). Youth released from foster care, back into the care of their family, may then experience severe family conflict due to their identity status, that the youth run away from the home (Semborski et al., 2022). Gender non-conforming youth have reported that their chosen homelessness, over choosing to stay with their non-accepting families, saved them from killing themselves (Shelton et al., 2016). Because of this, re-connecting sexual and gender minority youth is not an appropriate goal of foster care as family conflict is a primary factor of LGBTQIA+ homelessness (Fraser et al., 2019). 

Child Welfare

Youth having spent time in foster care often report having run away from placement because of sexual abuse experienced in that time (Fraser et al., 2019). Sexual and gender minority youth are overrepresented in the foster care system (Fraser et al., 2019). These youth represent 19.1% of those in foster care (Wilson & Kastanis, 2015). They also have higher risk of not receiving permanent placements due to foster parent rejection and foster care staff’s lack of competency training (Fraser et al., 2019). In a 2007 study, foster parents reported fears that sexual and gender minority youth would molest other children in the home, anti- LGBTQIA+ identities because of religious beliefs, varying attitudes depending on the specific minority identity of the youth, and other misconceptions about these youth (Clements & Rosenwald). Fifty six percent of sexual and gender minority homeless youth who had spent time in foster care during their lives reported that they felt safer on the street than in their foster care placements (Feinstein et al., 2001).  

Sexual Abuse

Prior to leaving home, sexual minority youth have experienced CSA 3.8 times and childhood physical abuse 1.2 times the rate of their peers (Tyler & Schmitz, 2021). Forty four percent of sexual minority youth reported sexual abuse by adult guardians in a study published in 2004 (Whitbeck et al.). That same year, 58.7% of homeless sexual minorities surveyed reported experiencing sexual victimization on the street (Whitbeck et al, 2004). Sexual and physical abuse in the home is a common reason that youth report having run away from home (Tyler & Schmitz, 2021). 

Survival Sex & Sex Work

Those abused in childhood are more likely to enter the field of sex work as they know there is a demand (Lankenau et al., 2005). Sexual and gender minority youth report a significantly higher number of clients within their sex work, as well as a more inconsistent use of condoms, than their peers even though they have reported to also know the risks involved with these behaviors (Marshall et al., 2010, Ream et al., 2012). 

School

Sexual minority youth also experience a heightened rate of verbal and physical assault in schools (Tyler & Schmitz, 2021). Homeless sexual minority youth experience this assault at an even higher rate (Tyler & Schmitz, 2021). These experiences of victimization and bullying of sexual minorities lead to school dropouts and difficulties completing education (Tyler & Schmitz, 2021).  

Substance Use

Experiences of sexual abuse are a proximal factor for youth choosing to use illicit substances (Fraser et al., 2019). Sexual and gender minority older youth are also more likely to report having experienced violence at home, and developing substance use issues since becoming homeless (Petry et al., 2022). For homeless sexual minorities, the experience of multiple forms of victimization like child abuse, bullying, and street victimization, may lead to substance abuse as a way to cope with the compounding trauma which can then lead to prolonged substance use and longer-term homelessness (Tyler & Schmitz, 2021). When studied, 75.9% of homeless youth who used drugs, hospitalized within the previous 6 months, identified as sexual and gender minorities (Chang et al., 2018). 

Sleeping Location

Sexual and gender minority youth are at a much higher risk of sleeping on the street, with those under the age of 18 being less likely to choose to couch surf, and those from the ages of 18 to 24 being at a greater couch surfing risk (Petry et al., 2022). Seeking shelter involves risky situations with strangers on the street 

Exiting Homelessness

Once homeless, exiting becomes increasingly difficult (Grattan et al., 2022).. However, the more protective factors in a homeless youth’s life, the more likely exiting homelessness becomes a potential outcome (Grattan et al., 2022).. A positive school climate with a sense of safety and connectedness, meaningful participation opportunities for students, a well developed organizational structure with applicable goals and values, and the building of interpersonal relationships leads to higher academic achievement, lower risk of poverty, less substance use,  less school violence, less discriminatory bullying, and less weapons involvement (Moore et al., 2020). Social support that enables early detection of drop out risk and responsive services could also be a useful school measure (McCann & Brown, 2019).  

While homeless sexual and gender minorities face a increased risk of HIV (Human Immunodeficiency Virus) when compared to non-LGBTQIA+ (lesbian, gay, bisexual, transgender, queer, intersex, asexual, plus) homeless individuals, they are also more likely to get tested for HIV (Gangamma et al., 2008, Barman-Adhikari et al., 2016). Accessible screenings for HIV, of which bisexual women are at the highest risk, and effective drug screening are both needed as means to keep this population safe and continue to lower their risk factors for chronic homelessness (McCann & Brown, 2019).  

Clear and specific guidelines are necessary to address the foundation of youth homelessness which is the family home (McCann & Brown, 2019). These guidelines would need to address resilience, mental health concerns with access to therapy, access to approachable personnel, nondiscriminatory services, and psychosocial interventions to help families deal with conflict communicate, and understand the experience of coming out (McCann & Brown, 2019).Government organizations should also collect data on this population and develop educational materials to inform the public and decrease misconceptions (McCann & Brown, 2019). In addition to educational materials, agencies should establish housing assistance policies and shorten section 8 waiting lists, with admittance to family shelters during the waiting period (Bucker, 2008).  

In interviews with youth, researchers established that young people should be engaged in decision making when it comes to program planning and policy making (Barman-Adhikari et al., 2016). Agency and government policies need to be aligned to address the multifaceted issue of homelessness (Barman-Adhikari et al., 2016). Youth desire to be independent and to have resources to transition out of homelessness (Barman-Adhikari et al., 2016). This requires addressing stereotypes and building empathy and awareness in order to gather public interest in helping with these changes in policy (Barman-Adhikari et al., 2016). These preventions need to be targeted, rather than universal prevention and should focus on the strengthening of familial ties (Semborski et al., 2022).  

Discussion

The following is my own opinion formed from the above causal literature review and should only be taken as such. If it is possible to track down the families that kicked their children out of the home, or abused their children, causing them to run away, there should be criminal implications, especially when no missing child report was filed. The foster care system also needs to be revamped, and while I need to look more closely at the full system, there should be more appropriate placement opportunities for gender and sexual minority youth, as well as increased staff and social and case worker trainings. In lieu of the other circumstances in a homeless LGBTQIA+ youth’s life, positive school environments are likely to be the most supportive as they can provide social structures and supportive environments that other areas of daily life cannot.

More research to be conducted on implemented solutions and best practices. As of initial research, little success was found in the literature.

References

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