Who Is Couch-Surfing and Who Is on the Streets? Disparities Among Racial and Sexual Minority Youth in Experiences of Homelessness

Novel methods to construct a representative sample for surveying California's unhoused population: the California Statewide Study of People Experiencing Homelessness

Existing literature on people experiencing homelessness (PEH) draws on nonrepresentative samples from service providers, populations with comorbidities, or areas with disproportionately high amounts of sheltered homelessness, leading to bias. Nearly one-third of PEH in the United States and more than half of unsheltered PEH live in California. We designed a rigorous state-representative survey of PEH to investigate the antecedents of homelessness, understand health, and inform policy solutions. The multistage design randomized at 3 levels: county, venue, and individual. Stratifying the state into 8 regions, we sampled 1 county per region to reflect statewide demographics. Within counties, sampled venues matched the expected proportion of sheltered and unsheltered residents. Within venues, interviewers randomly sampled individuals. We adjusted for nonresponse and incorporated poststratification to benchmarks. In parallel, respondent-driven sampling reached subpopulations through social networks who may otherwise have been undersampled. Our community-engaged study yielded 3200 quantitative surveys. We purposively sampled 365 participants for qualitative interviews. Demographic estimates match those found in the PIT with the added strength of statistical inference. To our knowledge, this is the first large representative study of PEH, beyond a single county, to draw inference on a large population that did not depend on service utilization. Our methods may inform future efforts to understand homelessness.

Homelessness and First-Episode Psychosis: An Integrative Review

BACKGROUND

About 115,000 young people in the United States experience a first episode of psychosis (FEP) annually. FEP is associated with functional decline and long-term executive functioning impairment. Schizophrenia is a risk factor for homelessness with up to 20% of individuals diagnosed experiencing homelessness. Homelessness conveys many burdens including higher rates of victimization, incarceration, and substance use. The intersection of homelessness and FEP represents a uniquely vulnerable population undergoing the compounding effects of two highly stigmatizing burdensome experiences that negatively impact health outcomes, treatment engagement, and life expectancy.

AIMS

This study reviews the literature to explore what is currently known about the impacts of homelessness on individuals with FEP, knowledge gaps, directions for research, and recommendations for action.

METHODS

An integrative review was conducted in April 2023 with APAPsychInfo, APAPsychArticle, Medline, and CINAHL.

RESULTS

This is the first known review to examine available literature on homelessness and FEP. Current literature examines aspects of FEP and homelessness, but not the likely compounding and interacting relationships between multiple variables. Although the associations among variables such as FEP, homelessness, substance use, legal involvement, family involvement, and treatment engagement have not been studied, the literature available may be suggestive of a compounding negative effect on FEP outcomes.

CONCLUSION

FEP programs should define homelessness, report rates of homelessness, and conduct research examining the compounding effects of homelessness and FEP as well as other factors like race and ethnicity. Research and policy should support housing interventions for homeless individuals to improve treatment engagement and health outcomes.

Mortality among sexual and gender minority populations: A systematic review

Sexual and gender minority (SGM) populations experience elevated rates of negative health outcomes (e.g., suicidality) and social determinants (e.g., poverty), which have been associated with general population mortality risk. Despite evidence of disparities in threats to well-being, it remains unclear whether SGM individuals have greater risk of mortality. This systematic review synthesized evidence on mortality among studies that included information about SGM. Three independent coders examined 6,255 abstracts, full-text reviewed 107 articles, and determined that 38 met inclusion criteria: 1) contained a sexual orientation or gender identity (SOGI) measure; 2) focused on a mortality outcome; 3) provided SGM vs non-SGM (i.e., exclusively heterosexual and cisgender) or general population comparisons of mortality outcomes; 4) were peer-reviewed; and 5) were available in English. A search of included articles' references yielded 5 additional studies (total n = 43). The authors used the NIH's Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies to assess included studies. Mortality outcomes included all-cause (n = 27), suicide/intentional self harm (n = 23), homicide (n = 7), and causes related to drug use (n = 3). Compared to non-SGM people, 14 studies (32.6%) supported higher mortality for SGM, 28 studies (65.1%) provided partial support of higher mortality for SGM (e.g., greater mortality from one cause but not another), one study (2.3%) found no evidence of higher mortality for SGM. There was considerable heterogeneity in operational definitions of SGM populations across studies. Although mixed, findings suggest elevated mortality for SGM versus non-SGM populations. Integrating SOGI measures into mortality surveillance would enhance understanding of disparities by standardizing data collection, thereby reducing heterogeneity and increasing capacity to aggregate results (e.g., meta-analyses).

Are social supports always protective? A seven-city study on heavy drinking among sexual and gender minority young adults experiencing homelessness

PURPOSE

Sexual and gender minority (SGM) young adults are disproportionately impacted by homelessness and heavy drinking (i.e., having five or more drinks of alcohol in a row within a couple of hours). Social support, in general, is protective in reducing individuals' risk of heavy drinking. However, whether and how support from different sources may have different implications on heavy drinking among SGM young adults experiencing homelessness (SGM-YAEH) remains unclear. Informed by the risk amplification and abatement model (RAAM), this study examined the associations between support sources and heavy drinking among SGM-YAEH.

METHODS

A purposive sample of SGM-YAEH (N=425) recruited in homeless service agencies from seven major cities in the U.S. completed a self-administered computer-assisted anonymous survey. This survey covered heavy drinking behaviors and social network properties. Logistic regression models were conducted to identify social support sources associated with SGM-YAEH's heavy drinking.

RESULTS

Over 40 % of SGM-YAEH were involved in heavy drinking in the past 30 days. Receiving support from street-based peers (OR=1.9; 95 % CI=1.1, 3.2) and home-based peers (OR=1.7; 95 % CI=1.0, 2.8) were each positively associated with SGMYAEH heavy drinking risks.

CONCLUSION

This study was not able to identify the protective role social supports may play in reducing SGM-YAEH's heavy drinking. Furthermore, receiving support from network members was correlated with elevated heavy drinking risks among this population. As heavy drinking prevention programs develop interventions: they should use affirming and trauma approaches to promote protective social ties, as research points to its association in reducing alcohol use disparities among SGM-YAEH.

Sexual Abuse, Commercial Sexual Exploitation, and Cumulative Adversity Among Sexually Diverse and Non-Sexually Diverse Girls in the Juvenile Justice System

Despite awareness about high rates of sexual abuse among girls in the juvenile justice system, little is known about the additional risk conferred upon sexually diverse (SD) youths, as well as the combined vulnerability of sexual abuse and commercial sexual exploitation of children (CSEC) - frequently a survival behavior amplifying disproportionate juvenile justice contact among SD and non-SD juvenile justice-involved (JJI) girls. In a sample of JJI-girls, we compared SD (n = 52) with non-SD (n = 46) JJI-girls on sexual victimization (e.g. sexual abuse occurring within different relationship-types, CSEC), and broader developmental adversity burden disadvantage (cumulative trauma/loss exposure-types) and distress (posttraumatic stress disorder [PTSD]; cumulative stressor-reactivity, grief-specific, and adversity-related symptoms), health distress/impairment, and sexual and physical health-risk indicators. While comparable on childhood sexual abuse frequency, SD JJI-girls reported greater cumulative sexual abuse severity across relationship-types, higher sexual abuse within non-familial contexts, and more CSEC involvement. They also reported more social determinants of health (e.g. trauma/loss exposure-types) and showed elevations on all health-risk indicators, and most cumulative adversity burden indicators, despite comparable PTSD severity. Our findings emphasize the need to consider multiple sexual victimization facets, including the combined vulnerability of sexual abuse and CSEC, and utilize cumulative developmental assessment approaches among youths vulnerable to maltreatment and exploitation.

Housing instability among young men who have sex with men in a US national sample

Background

Youth, including those experiencing housing instability, are among the fastest growing groups of individuals with new STI diagnoses, including HIV. The unpredictable nature of the lives of youth experiencing housing instability often leads to inconsistent or non-existent health care and preventive follow up, leaving gaps in our knowledge about the most prominent needs for intervention.

Methods

Using data from the Together 5000 (T5K) study, we examined factors associated with housing instability in a sample of 2,228 youth between the ages of 16-24 who identified as sexual and gender minority (SGM) men having sex with men. Logistic regression was used to assess the most prominent factors associated with housing instability. The model included seven significant factors - former peer victimization, gender, age, sex work, IPV, social support, and health insurance status.

Findings

Participants who reported more behavioral risk factors for STI and those who reported sex work in the last three months were more likely to experience housing instability (OR = 2.5 and 2.76 respectively). Youth with higher levels of reported social support, health insurance, and older age were more likely to report stable housing (OR = .98, 1.61, and 1.13 respectively). Surprisingly, youth with stable housing were more likely to report intimate partner violence than those experiencing housing instability (OR = .89).

Discussion

Implications for addressing STIs among adolescent SGM men having sex with men are discussed including bolstering support systems and addressing basic needs deficits and trauma associated with sex work and behavioral risk factors for STI.

Implications and contributions statement

The study examines correlates of housing instability among a sample of young sexual and gender minority men who have sex with other men. Correlates of housing instability included behavioral risk factors for sexually transmitted infection and reporting sex work in the last three months. Health insurance, older age, and higher levels of social support were correlated with more stable housing.

Editors' Best of 2023

In our inaugural year as JAACAP Open, we are proud to support the dissemination of some of the highest quality research being conducted in our field. Choosing the "best" among stars is a tall order and most certainly misses the many ways articles make an impact: is the "best" the most interesting, most surprising, most educational, most important, most provocative, or most enjoyable? How to decide? This time around, we made some picks based on those that were methodologically rigorous and clinically salient. It is our pleasure to give a special "hats off" to the 2023 articles that we think deserve your attention or at least a second read!

Predictors of Housing Trajectories Among Young Adults Experiencing Homelessness in Los Angeles

Experiencing homelessness during young adulthood is associated with negative health outcomes and understanding housing trajectories of young adults experiencing homelessness may aid in the development of evidence-based public health programs designed to serve this at-risk age group. In the present study, the authors examined baseline predictors of 24-month trajectories of housing stability and unsheltered housing among a sample of 271 young adults aged 18 to 25 recruited from drop-in centers in Los Angeles. In multivariate models, the authors found that identifying as multi-racial/other and better friendship quality at baseline were associated with less steep increases in the likelihood of stable housing over time. Being employed at baseline was associated with a less steep decrease in the probability of being unsheltered over time, while illicit drug use days associated with a steeper decrease in the probability of being unsheltered over time. Continued research is needed to establish important factors determining young adults' long-term housing trajectories in the effort to promote greater access and engagement with housing services.

COVID-19 vaccine attitudes among youth experiencing homelessness: a qualitative analysis with opportunities for action

Youth experiencing homelessness (YEH) are uniquely vulnerable to COVID-19 infection, yet are often excluded from response planning during the COVID-19 pandemic and other public health crises. As part of a larger community- and youth-engaged project through a national network of Prevention Research Centers, our qualitative study sought to describe youth perspectives that influence COVID-19 vaccine confidence and uptake, and identify youth-driven strategies to guide public health efforts to improve vaccine confidence and access. We conducted focus groups with youth experiencing homelessness (n = 20) and semi-structured interviews with staff members (n = 10) at youth-serving agencies to solicit youth perspectives about COVID-19 vaccination. Focus groups and interviews were recorded, transcribed, and analyzed using thematic qualitative analysis. In partnership with youth and cross-sector partners, we distilled eight salient themes that influenced COVID-19 vaccine uptake and confidence among YEH: 1. historical harms and mistrust of systems, 2. access to reliable health information, 3. prioritization of basic needs, 4. personal health influence, 5. barriers to healthcare, 6. fear and uncertainty of the vaccines, 7. sense of bodily autonomy, and 8. community influence. We also identified three youth-driven opportunities to increase COVID-19 vaccination among this population: emphasizing autonomy, leveraging trusted sources of information, and improving vaccine access.Our study elucidates perspectives of YEH on COVID-19 vaccination, and identifies several opportunities to improve youth vaccine confidence and access. It also underscores the importance of centering youth voice in response planning during current and future public health crises.

Housing Instability and Evictions Linked to Elevated Intimate Partner and Workplace Violence Among Women Sex Workers in Vancouver, Canada: Findings of a Prospective, Community-Based Cohort, 2010-2019

Objectives. To model the relationship of unstable housing and evictions with physical and sexual violence perpetrated against women sex workers in intimate and workplace settings. Methods. We used bivariate and multivariable logistic regression with generalized estimating equations to model the association of unstable housing exposure and evictions with intimate partner violence (IPV) and workplace violence among a community-based longitudinal cohort of cisgender and transgender women sex workers in Vancouver, Canada, from 2010 through 2019. Results. Of 946 women, 85.9% experienced unstable housing, 11.1% eviction, 26.2% IPV, and 31.8% workplace violence. In multivariable generalized estimating equation models, recent exposure to unstable housing (adjusted odds ratio [AOR] = 2.04; 95% confidence interval [CI] = 1.45, 2.87) and evictions (AOR = 2.45; 95% CI = 0.99, 6.07) were associated with IPV, and exposure to unstable housing was associated with workplace violence (AOR = 1.46; 95% CI = 1.06, 2.00). Conclusions. Women sex workers face a high burden of unstable housing and evictions, which are linked to increased odds of intimate partner and workplace violence. Increased access to safe, women-centered, and nondiscriminatory housing is urgently needed. (Am J Public Health. 2023;113(4):442-452. https://doi.org/10.2105/AJPH.2022.307207).

Couch-Surfing and Mental Health Outcomes among Sexual Minority Adolescents

Background

Sexual minority youth are at more than twice the risk of experiencing homelessness than their peers and both sexual minority youth and youth experiencing homelessness have disproportionate risk for mental health disorder symptoms. Couch-surfing is a common form of homelessness experienced by youth, but research on the relationship between couch-surfing and mental health outcomes, especially among sexual minority adolescents (SMA), is limited.

Methods

Utilizing a sample of 2,558 SMA (14-17 years old) recruited via social media and respondent-driven sampling, this study explores the relationship between different forms of homelessness (exclusive couch-surfing vs. multiple types of homelessness) and symptoms of depression, anxiety, suicidal ideation, and suicide attempt.

Results

Nearly 21% of participants experienced any homelessness in their lifetime, with 14% reporting exclusive couch-surfing. All forms of homelessness were associated with large increases in symptoms of anxiety, depression, suicidal ideation and suicide attempt.

Conclusion

Homelessness - primarily couch-surfing - is a common experience for SMA in this sample. All forms of homelessness - including exclusive couch-surfing - were associated with large increases in depression, anxiety, suicidal ideation, and suicide attempt, emphasizing the importance of services that are available to couch-surfing young people and responsive to the needs of sexual minority adolescents.