A Primary Care Approach to Treating Women Without Homes

Roseanna H. Means, MD, MSc

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In This Article

Medical Illnesses of Homeless Women

Women without homes experience extremes of common health problems and are uniquely vulnerable to medical problems because they are homeless.[14] The aspects of the homeless condition that separate this population from their domiciled counterparts are listed in Table 3.

Common health problems are exacerbated by homelessness because of limited access to regular and preventive care. These include such chronic conditions as hypertension and diabetes, sexually transmitted diseases (STDs) and other pelvic infections, HIV disease, gastrointestinal disorders, complications of alcohol and drug abuse, urinary tract infections, peripheral vascular disease, foot and joint disorders, tuberculosis, skin disorders, dental disease, and prenatal care.[32,33,34,35,36,37,38,39,40,41,42] Homelessness itself is a risk factor for premature death.[43,44]

Elderly homeless women are particularly vulnerable. Chronic conditions in the elderly such as hypertension, heart disease, osteoporosis, Alzheimer's disease, and cancer are difficult to treat and follow when the records are scattered and incomplete. Preventive medicine is also affected by homelessness. Postmenopausal women who are candidates for estrogen replacement therapy, pelvic and breast exams, and mammography may need all their resources for the day-to-day struggle and therefore have little energy for enrolling in preventive health practices. It has been observed that homeless women in their mid-fifties are as physiologically aged as housed women in their seventies[45] and are afflicted to a similar degree with chronic diseases, yet they don't qualify for elderly housing assistance because of their age.

Other conditions seen frequently in the homeless population are HIV/AIDS, mental illness, and substance abuse. HIV status in homeless women is not well known. One small study conducted in Boston between 1985 and 1990 found that among 40 homeless individuals, 18% of the women had AIDS.[46] The theoretical risk of HIV in homeless women is very high because of the prevalence of STDs. STDs are seen frequently in the homeless population because of casual sex associated with alcoholism and drug addiction, the exchange of sex for drugs or protection, and rape. Knowledge of HIV status is important because some cities have special medication and housing programs for homeless persons with AIDS.

Mental illness is reported in 30% of all homeless persons,[48] with a range of 50% to 60% in women.[49,50] Several factors make these data difficult to interpret. Methodologically, some studies only looked at Axis I disorders, while others included both Axis I and Axis 2 or dual diagnosis (mental illness plus substance abuse). In addition, the hyperarousal, paranoia, constriction, and dissociation seen in some women who are struggling to stay alive on the streets are normal responses to chronic trauma, not evidence of primary mental illness.[20] Deinstitutionalization of the mentally ill in the 1950s and 1960s is often cited as a source of homelessness, but this accounts for only a small fraction of the currently homeless[51] and does not take into account the recent knowledge regarding the effects of trauma in the lives of homeless women.

Few studies have documented the extent of alcoholism and drug abuse among homeless women; estimates range from 16% to 26%.[52,53] Substance abuse may be a self-medicating response to trauma. Without the appropriate background information and treatment, the addiction cycle is apt to repeat itself until the patient has successfully been treated for both her substance abuse and her trauma.

Unique aspects of homelessness that affect health include the dependency on shelters for basic needs, the chaos and unpredictability of services, the outdoor exposure, and the constant threats to one's safety. Shelter services for such basic needs as food and clothing require long waits in lines. Most homeless persons walk to their destinations. Consequently, peripheral vascular disease, corns, calluses, blisters, and lower extremity joint disorders are common. Shoes given out at the shelters may not be the correct size and frequently fall apart. Prolonged exposure to wet footwear causes trench foot.[47] Patients with peripheral neuropathies from alcoholism or diabetes run the greatest risk of complications from lower extremity vascular compromise. Crowded dormitory-style housing leads to increased cases of tuberculosis, respiratory and skin infections. Hypothermia, frostbite, and severe sunburn are common consequences of an outdoor lifestyle.

It is difficult to achieve wellness when life is so fragmented by the sheer struggle for survival, when there is limited understanding, limited access to benefits and physical or mental disability. Add to this a lack of appropriate healthcare facilities and personnel trained to work with homeless persons. It is difficult for women without homes to access prenatal care if they are asked to move often, if they fear state intervention, or if their shelter placement is distant from familiar medical care. Drug-addicted women may ignore the obstetrician to avoid having their urine screened for drugs and risk losing their babies to state care. Women who are pregnant because of rape may avoid the obstetrician while they face more pressing emotional challenges.

For many women without homes, life is one of constant fear. In one retrospective chart review of 17,000 homeless adults in Boston, the principal causes of death of women aged 18-24 and 25-44 included homicide.[54] The risk of physical or sexual assault on the streets is very high. There may be no safe place to go to, no door to lock one's self behind. One must be constantly vigilant. Women may align themselves with inappropriate partners in order to feel temporarily safe. Women who have fled domestic violence may limit their medical care to avoid exposure or identification. Repeated, unpredictable physical and sexual trauma threaten emotional stability. Because the threats cannot be eliminated until the individuals are housed, safe, and economically stable, posttraumatic sequelae can persist unresolved for years. Symptoms such as irritability, hypervigilance, hyperarousal, emotional lability, helplessness, insomnia, depression, irrationality, constriction, denial, intrusive thoughts, and personality disorders are all part of the spectrum of complex posttraumatic symptoms.[20]

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