Homelessness in the United States: History, Epidemiology, Health Issues, Women, and Public Policy

Martin Donohoe, MD, FACP

Disclosures

July 07, 2004

In This Article

Health Problems of the Homeless

On average, homeless adults have 8 to 9 concurrent medical illnesses.[18] The homeless commonly suffer from dermatologic conditions (eg, skin lice, scabies, eczema, and allergic rashes), respiratory infections, tooth decay, foot problems (eg, trench foot, tinea pedis), vision disturbances, sexually transmitted infections (STIs), and trauma. Functional limitations, substance abuse, and mental illness (particularly depression, schizophrenia, posttraumatic stress disorder, and personality disorders) are very common. Mental illness is reported in 30% of homeless persons, and in 50% to 60% of homeless women.[8] The usual chronic diseases, such as hypertension, diabetes, and asthma, are quite prevalent and difficult to manage. Preventive tests are underutilized because of time and funding constraints[5] and because patients tend to present with acute care needs that require immediate attention. Homeless children frequently suffer from respiratory, ear, and skin infections, failure to thrive, developmental delay, and face neglect and abuse.[19]

STIs are common among homeless girls and women, a function of limited access to reproductive health services, prostitution, and survival sex (ie, sex in exchange for food, drugs, or temporary shelter). Twenty-six percent of female street youths (28% of male street youths and 10% of shelter youths) report having participated in survival sex, which is associated with older age, more days away from home, victimization, criminal behaviors, substance use, suicide attempts, STIs, and pregnancy.[20] Homeless women have a pregnancy rate about twice the national rate.[16]HIV rates are higher than in the general population, which has been attributed to higher prevalence of intravenous drug use, STIs, prostitution, survival sex, and limited access to condoms.[5]

Unique aspects of homelessness that contribute to hard-to-manage medical and psychiatric illness include enhanced vulnerability to crime and violence; prolonged standing; excessive outdoor exposure; infectious disease transmission due to overcrowding; high risk of being robbed of medication; limited access to water for showers, dental care, and personal hygiene; inability to follow complex treatment and home care regimens; lack of privacy; and social isolation.[8] Those with language barriers -- particularly those who lack citizenship and work long hours under dangerous conditions -- such as homeless migrant and seasonal farm workers, face particular challenges and are often afraid to access even emergency care.[21,22]

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