Introduction

Homeless sexual minority youth (SMY) are among the most marginalized and vulnerable populations in the United States (US). Compared to their heterosexual peers, homeless SMY are at greater risk for negative health outcomes including substance abuse, sexual risk behaviors, victimization, mental health problems and physical abuse.1-4 Sexual minorities are overrepresented among homeless youth and identifying as a sexual minority is in itself a risk factor for homelessness.5,6,7 According to a report published by the National Gay and Lesbian Task Force, as many as 42% of the estimated 1.6 million homeless youth in the US identify as gay, lesbian, bisexual or transgender (LGBT).8 In Los Angeles (LA) County alone, an estimated 40% of the 4,200 youth who are homeless on any given day identify as LGBT.8, 9 Despite the magnitude of this problem, little evidence-based literature is available, especially from the field of nursing, on the health and health care of this population. With the education and training in the psychosocial aspects of care and a traditional focus on vulnerable populations, the nurse practitioner (NP) is uniquely prepared to address the health needs of SMY using existing models of care. The purpose of this article is to provide an overview of the evidence related to the health of homeless SMY and offer a theory-based model of care.

Background

The problems faced by homeless SMY, especially those related to disparities in health and access to healthcare, gained increased recognition over the last decade primarily due to the work of LGBT and homeless advocacy groups such as the L.A. Gay and Lesbian Center, the Gay and Lesbian Medical Association (GLMA), the National Gay and Lesbian Task Force, and the National Coalition for the Homeless. In 2010, the US Department of Health and Human Services (HHS) included the health, safety, and well-being of LGBT individuals as one of the goals of Healthy People 2020.10 Reports by the National Institutes of Health (NIH) and the Institute of Medicine (IOM) identified the need to address the research gaps, disparities in care, and for identifying methods to improve culturally competent care for sexual minorities.11 The landmark study by the Human Rights Campaign, Growing Up LGBT in America,12 provided valuable insights into the perceptions and beliefs held by SMY and reinforced findings from the Centers for Disease Control Youth Risk Behavior Surveillance System (YRBSS) of increased health risk behaviors and health disparities for SMY.13 A 2012 report by HHS announced a number of new initiatives and opportunities for funding studies in LGBT health and called for the Administration for Children and Families to “establish core competencies and non-discriminatory service expectations for all runaway homeless youth program grantees that are inclusive of sexual orientation and gender identity considerations”.14, p.3

Clarification of Terms

Avoidance of unintentional bias requires a working knowledge of the terms frequently used when referencing the LGBT community (Table 1).  For the purposes of this article, the term youth refers to anyone who has reached adolescence and but has not yet reached the age of twenty-five.  The US federal government’s definition of homelessness as “lacking a fixed, regular and adequate nighttime residence” is used.15

Table 1

 Common Terms Related to Sexual Orientation and Gender Identity

a Reprinted from Dohrenwend27
bThis model depicts how environmental factors, individual psychological characteristics, psychological mediators and interventions influence and affect psychological change in an individual faced with a stressful life event.
(The following permission statement is not part of the above Figure 1.).  Adapted from Dohrenwend BS.  Social stress and community psychology. Amer J Community Psychol.1978;6(1), p.2. Copyright© 1978 by American Psychological Association.  Reprinted with permission of Springer New York LLC via Copyright Clearance Center.

Literature Review

A systematic review of the literature was conducted to determine the state of the evidence with respect to the health of homeless SMY. An electronic, systematic literature search of the Cumulative Index for Nursing and Allied Health (CINAHL), MEDLINE, and PubMed databases was used to identify pertinent research articles. The search provided 531 articles that contained the keywords “intervention,” “homeless,” “sexual minority,” “youth,” and “health;” were written in English; and published between 2002 and 2012. Additional searches with variations of the keywords provided no additional results. After removing duplicates, a broad selection based on the article title and publication yielded 85 articles for further review. From the results, 9 articles met pre-established selection criteria, including parameters to assess study quality. Additional searches of key references from the selected articles led to 1 additional article for inclusion.  These search findings were consistent with a similar recent systematic review by Altena, Brilleslijper-Kater, and Wolf.19

Evidence Summary

Evaluation of the literature found most studies to be quantitative, exploratory, and descriptive in design.  One study by Hein20 was a quantitative comparative study and Christiani et al.21 had a qualitative design. With the exception of Milburn et al.22 and Rosario et al.4, all of the studies were cross-sectional. Conceptual definitions differed between studies and were not always clear. For example, variations exist between each study in the definitions of adolescent, youth and homelessness. Not all studies included transgender persons in the sample and some did not differentiate between the sexual orientations. Three different theories were used. Gattis2 and Hein20,23 both used an adaptation of the Ecological Model.  Cochran et al.1 used the Coping Mode, and Rew et al.3 cited Cognitive Behavior theory. The authors of the studies selected represented the fields of psychology, social work, nursing and medicine. Limitations reported included the difficulty of conducting research in this population, ethical challenges, consent issues, geographical limits, and sample sizes.  Each selected study used standardized measures.

Findings

Review of the selected literature confirmed disparities in the health and health care for homeless SMY.  Approximately 7.6% of the 2 million adolescents in the US were homeless.22 Sexual minorities were overrepresented with estimates ranging between 29-60%.1, 2, 4, 23 Homeless SMY were at greater risk for negative health outcomes compared to their heterosexual counterparts including suicide, depression, substance abuse, sexually transmitted infections, physical abuse and sexual victimization.1,2,3,21 Key findings included data concerning family acceptance and mode to homelessness; substance use, mental health and sexual behaviors; and the experience of discrimination, stigma and victimization.1, 2, 3, 21, 23

Family acceptance and mode to homelessness

A statistically significant difference in satisfaction related to family communications existed, with homeless SMY having lower satisfaction than non-SMY.2 The mode to homelessness for heterosexual youth was more often attributed to their own behavior, while for SMY, homelessness more likely resulted from parental physical abuse, parental sexual abuse, or from disclosure of sexual identity to family members.1, 3, 20 Between 60 - 75% of SMY were homeless as a result of their parents’ behavior while only 23% of heterosexual youth cited parental behavior as their mode to homelessness.1,3,20  Between 32-37% of homeless SMY ran away from home compared to 12% of homeless heterosexual youth.2, 20

Substance use, mental health and sexual behaviors

No correlation existed between sexual identity and substance use except that SMY who did use, used more frequently and used more types of drugs than non-SMY.1, 2 Homeless youth reported the use of substances as a coping strategy, considering marijuana use to be a medicinal substitute for necessary medications for which they no longer had access.21 They perceived methamphetamine to “have important arousal properties that assist with survival on the streets.”21 

Compared to their heterosexual peers, homeless SMY experienced higher rates of depression and suicidal ideation. Gattis2 found that over a 12-month period, among SMY, 42% seriously considered suicide and 27% had attempted suicide compared to 12% and 8% respectively for their non-sexual minority counterparts. Negative social relationships and low levels of support from peers resulted in a significant correlation to depressive symptoms and increased anxiety for homeless SMY compared to non-homeless SMY.4  Rew et al.3 found higher rates of HIV diagnosis (25.4% vs. 3.5% heterosexual) and HIV treatment (23.8% vs. 3.1% heterosexual) among SMY. Engaging in survival sex was more common among homeless SMY (26-44%) compared to non-sexual minority homeless youth (4-9%).2, 23

Stigma, discrimination and victimization 

Homeless SMY faced stigma and discrimination from health providers, at shelters and from the police which caused them to hide their sexual identity at times.20, 22 SMY experienced significantly higher levels of stigma related to homelessness and more discrimination compared to heterosexual homeless youth.2, 22 SMY reported higher rates of discrimination compared to heterosexual youth from their family (62% vs. 30%), from peers (77% vs. 46%) and from police (46% vs. 24%).22 Homeless SMY were more likely to be victimized and physically assaulted than non-sexual minority youth.2 Between 62-77% of homeless SMY reported they had been victims of past sexual abuse compared to 37% of heterosexual homeless youth.3, 4

Other relevant findings 

Homeless youth who identified as “gay” or “lesbian” differed from those who identified as “bisexual” or “heterosexual.” Gay and lesbian youth engaged in survival sex more often, utilized fewer shelter-based resources, had more unprotected sex, and scored lower on assertive communications measures.1, 3, 22 Chistiani et al.21 found that SMY wanted culturally competent and sensitive health care, specific to their unique situation. Barriers to receiving care included perceived insensitivity by health care providers to the needs of this population and legal barriers related to consent for treatment.1, 21

Discussion

Homeless sexual minority youth belong to a heterogeneous group with different needs based on their own individual traits, personal history, and their sexual orientation and gender identity. All SMY face a number of challenges in achieving and maintaining their health and safety.  Homelessness complicates this already difficult situation.  Research confirms homeless SMY are at greater risk for serious negative health outcomes and substantial barriers exist which prevent accessing care. Unfortunately, despite an increasing amount of attention and calls to address disparities in this population, a lack of evidence-based research useful to the NP remains. 

A Framework for Clinical Practice

A theoretical or conceptual framework may be useful, if not necessary, for the NP to incorporate knowledge into practice. A framework helps identify and organize key concepts, complex phenomena, and their relationships.24   In selecting a theoretical framework for use in a population such as homeless SMY, it is essential to accept the environment and individual are interrelated. With its emphasis on the individual’s role within the environment, ecological systems theory is useful in conceptualizing the differences between homeless SMY and their heterosexual peers.2, 25  Hein advocated an ecological basis and explained “the central tenet within the ecological paradigm is that an individual cannot be considered outside of the context within which they function.” 26, p. 43 According to Hein,26 an ecological framework is consistent with nursing’s focus on both the patient and environment.

Dohrenwend’s Ecological Model of Stress 27 (Figure 1) is one application of the ecological paradigm which can be adapted and applied to nursing practice. The model includes the concepts of individual personal characteristics, stressful life events, individual skill training, situations in the environment, socialization and other factors that contribute to a transient reaction and eventually an outcome.27 In Dohrenwend’s model, all of the personal and environmental factors culminate into a transient stress reaction by the individual at which point an opportunity exists for a crisis intervention or corrective therapy followed by one of the following outcomes: psychological growth, no substantial psychological change, or psychopathology. 27

Figure 1

Ecological Model of Stress
 

a Reprinted from Hein23
b This model is an adaptation of Dohrenwend’s Ecological model (Figure 1).  The model depicts how the environment, homelessness, and personal characteristics influence a survival strategy which results in a survival outcome.
(The following permission statement is not part of the above Figure 2.). Adapted from Hein LC. Survival strategies of male homeless adolescents. J Am Psychiatr Nurses Assoc. 2011;17(4), p. 276. Copyright© 2011 by L.C. Hein.  Reprinted by Permission of SAGE Publications.

Dohrenwend’s model is a psychological model and identifies interventions and potential outcomes in terms more suitable to psychology than nursing. The model does however provide a framework from which nursing interventions at the individual and environmental levels can be devised with only minor modifications. Hein’s model of male adolescent homelessness20, 23 (Figure 2) is an example of such a model. The model acknowledges the effect the environment, traumatic events and characteristics of the individual have on behavior and outcome.

Figure 2

Model of male adolescent homelessness
 

aAdapted from Dohrenwend27 and Hein23
bWithin the framework of the nursing process, the model depicts how environmental and historical factors affect the individual and how health outcomes result from actions influenced by an individual’s survival strategy and health interventions.

A New Clinical Model for Homeless Sexual Minority Youth

Adaptation of an established ecological model for use by the NP in clinical practice requires only reorganization and relabeling of the concepts. One example is the Model of Homeless Sexual Minority Youth (Figure 3), an adaptation of Hein’s model23.  This new model reflects the impact that the environment and historical factors have on the individual. The model illustrates that health outcomes result from decisions, influenced by a survival strategy, leading to actions. Survival strategies are effective methods for the given individual to survive given the individual’s unique situation.  Strategies can be positive-effective (i.e., seeking care at a free clinic when sick) or negative-effective (i.e., shoplifting food from a convenience store). In practice, the NP would first assess the environmental, historical, and individual factors as they pertain to the presenting problem. Planning requires learning about the individual’s survival strategies and identifying interventions which fit into one or more positive-effective strategies already in place. Next, the planned intervention is implemented and the resulting action or inaction yields an outcome to be evaluated.

Figure 3

Model of homeless sexual minority youth
 

Methodological Considerations

With a population such as homeless SMY, it is beneficial to consider the problems of methodology when attempting to develop an evidence-based nursing intervention at the advanced practice level. Validation of interventions through empirical methods such as randomized controlled trials (RCT) would be difficult, if not impossible, with this population due to the variations within the population itself and the difficulties in conducting research as previously described.  An RCT, for example, will only provide evidence of the efficacy of an intervention for a group of similar individuals and may not be reliable on a case-by-case basis with this population.28

Application of the new model (Figure 3) with respect to the development of an evidence-based intervention may also require a methodological approach more common to social sciences and economics such as methodological individualism. Methodological individualism proposes that phenomena are best explained in terms of the motivations, actions, and interactions of individual persons.29 A necessary assumption of this methodology is to accept a priori that all human action is purposeful.30 The implication is not that all behavior is rational, only that for any given person, an action is a purposeful means to an end at one point in time. In a population for which decisions are made based on a perceived immediate survival need, accepting a given behavior as purposeful instead of trying to understand the reasoning or relate on a rational level may best serve both the practitioner and patient.
 
Implications for Nursing

Nurse practitioners are well-suited to address the health needs of homeless SMY.  NPs have advanced training and education that incorporates psychosocial factors into their care, and they have a long history of caring for vulnerable populations in the US.31 With so many variables affecting health outcomes for this population, care should occur within a theoretical framework. When working within a framework and utilizing a model like the Model of Homeless Sexual Minority Youth (Figure 3), the NP will be better able to identify opportunities to intervene at different levels. All interventions should be specific for gender, gender identity, and sexual orientation. The NP who works with homeless SMY should become familiar with available resources to ensure safe and culturally competent care. Cultural competence, both at the provider and institutional level, is crucial and affects provider-patient interaction, care-seeking behavior and utilization of services.32 Because of the potential for safety risks, the NP should always verify the availability of orientation-specific services prior to making any referrals and should assume that returning home is not a safe or available option until proved otherwise.

Conclusion

Environmental, historical, legal and cultural factors continue to contribute to the disparities in health and healthcare experienced by homeless sexual minority youth making them one of the most vulnerable populations in the US and worldwide.  Despite efforts by advocacy groups and the recent attention of government agencies, new research, especially from the field of nursing is limited, generally lacks a theoretical basis, and provides little guidance for the development of evidence-based interventions for clinical practice. Ecological systems theory provides a theoretical basis for the development of a clinical practice model for use by nurse practitioners and other health care providers working with homeless SMY.  Additional research is needed to address issues of methodology, ethical challenges, and the existing legal and institutional barriers.