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Studies demonstrate high rates of assault and unmet health care needs among homeless women

On any given night, over 700,000 people are homeless in the United States, and up to 2 million people experience homelessness during the year. While most of the homeless population are men, women and families are the fastest growing segments of the homeless population. Homeless individuals have higher rates of hypertension, arthritis, mental illness, tuberculosis, substance abuse, and victimization than the rest of the population.

Two recent studies supported by the Agency for Healthcare Research and Quality examined victimization and use of health care among the homeless. The first study concluded that sexual and physical assault are common experiences for homeless and marginally housed people, and the second study demonstrated significant unmet need for medical care among homeless women. The two studies are summarized here.

Kushel, M.B., Evans, J.L., Perry, S., and others (2003, November). "Victimization among homeless and marginally housed persons." (AHRQ grant HS11415). Archives of Internal Medicine 163, pp. 2492-2499.

These investigators interviewed 2,577 homeless adults (living on the streets or in homeless shelters) and marginally housed adults (living in low-cost hotels) in San Francisco, CA, about their history of recent sexual and physical assault, housing history, sexual practices, substance use, health status, and criminal justice history. Overall, 32 percent of women, 27 percent of men, and 38 percent of individuals who identified themselves as transgendered reported a history of either sexual or physical assault in the previous year. Overall, 9 percent of women, 1 percent of men, and 12 percent of transgendered individuals reported sexual assault, and 31 percent of women, 27 percent of men, and 33 percent of transgendered individuals reported physical assault.

After adjusting for other factors, being homeless (as opposed to marginally housed) was associated with more than triple the likelihood of sexual assault for women but not for men. Housing status was not associated with physical assault for women or men. Both mental illness and sex work were common. The researchers found a strong association between mental illness, poor health, and sex work, alcohol and drug use, and both sexual and physical victimization. Mental illness may represent the consequence of previous victimization and may be a cause of increased vulnerability to victimization by compromising a person's ability to identify and avoid danger signals.

Lewis, J.H., Andersen, R.M., Gelberg, L. (2003, November). "Health care for homeless women: Unmet needs and barriers to care." (AHRQ grant HS08323). Journal of General Internal Medicine 18, pp. 921-928.

Over one-third (37 percent) of the 974 homeless women, aged 15 to 44, interviewed in this study needed medical care, that is, they needed to see a doctor or nurse practitioner in the 2 months before the interview but did not. The investigators examined the relationship between this unmet need for care and demographic variables, place of stay, source of health care, health insurance, and perceived barriers to care. They found that having a regular source of care was more important than health insurance in lowering the odds of unmet need. Homeless women who had a regular source of care were 65 percent less likely than those who did not to report unmet need for health care.

The odds of unmet need were about twice as high among those who experienced the following barriers to care: not knowing where to go for care, long office waiting times, and being too sick to seek care. Factors associated with increased odds of homeless women not getting needed care included more than a high school education compared with less than 12 years, a history of drug abuse, living in limited housing (for example, an abandoned building or car as compared to living in a shelter), being accompanied by children, experiencing serious physical health symptoms, and being in fair or poor health.

Women who had been homeless for more than a year or who had a regular source of health care were less likely to have unmet health care needs. More than 65 percent of the homeless women surveyed felt the following factors were very helpful in obtaining care: receiving treatment for all health care problems at the same place, free transportation to health care, health care and social services at the same place, living in a house or apartment, weekend or evening clinic hours, and help from shelters or soup kitchens in finding health care. Also, 81 percent of the women who had children with them felt that obtaining health care at the same time that their children got care would be very helpful. These findings are based on an analysis of data from the University of California, Los Angeles/RAND Homeless Women's Health Project, a study of homeless women of reproductive age in Los Angeles county.

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