The numbers of young people experiencing homelessness in the UK continue to increase year on year (Homeless Link, 2018) and, in 2018, there were 86 000 people estimated to approach local authorities experiencing homelessness or at risk of it (Centrepoint, 2018). There are many definitions, classifications and reasons for homelessness (Springer, 2000), but, for young people, these include leaving local authority care, being a runaway, repeat involvement with the criminal justice system and a black, minority and ethnic (BME) background (Shelter, 2015).
Young people experiencing homelessness are extremely vulnerable. Further, this situation can make them more susceptible to sexual exploitation (Department for Education (DfE), 2017). Local authorities hold an obligation to ensure housing for those who have been in care because of the extra risks encountered (DfE, 2017). All young people who experienced homelessness within the age groups examined in this study were deemed to be vulnerable.
Overall, young people have higher rates of sexually transmitted infections (STIs) than any other groups (Public Health England, 2018). Although the level of unintended pregnancy in the UK has declined in recent years, in this group, rates could be further improved, especially in areas of high deprivation (Local Government Association, 2018). Little is known about the sexual health needs of homeless young people, as research is extremely limited, and STI statistics are not specifically collected for this population.
Although policy exists in the form of addressing the sexual health needs of many other vulnerable groups, there is no policy to guide delivery of sexual healthcare for young people experiencing homelessness. Generally, policy for sexual health focuses directly on testing and cure, but, in respect to, young people experiencing homelessness (MedFASH, 2018), it additionally needs to focus on the deep-rooted underlying cause and effect of the extreme vulnerability that is both a cause and consequence of homelessness.
Sexual health is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence (World Health Organization, 2006). Therefore, sexual health cannot be considered in isolation from the social, and thus cultural, aspects of individuals' lives.
This study is relevant and of interest to community nurses because they are the most likely professionals to have first contact with the population under study. Homeless people do not readily engage with mainstream health services, which is one of the reasons for making them more likely to have both high rates of early mortality and poor health outcomes (Homeless Link, 2014). The results of public surveys frequently show that nurses belong to a profession that is the most trusted (Munro, 2017). Therefore, these health professionals are in a strong position to start building confidence and trust to help with engagement to improve the outcomes of the homeless population.
The aim of this study was to examine the knowledge and attitudes of young people experiencing homeless around sexual health and contraception in order to improve outcomes related to STIs and unintended pregnancy. This study specifically focused on young people who were placed in hostels for those experiencing homelessness in London. The research question was: how can sexual health and contraception use be improved for homeless young people who are resident in local authority hostels?
Methods
Patient/public contribution
Youths experiencing homelessness together with staff in hostels and community healthcare professionals were involved in the study design.
Methodology
Qualitative methodology within a constructivist theoretical framework was used. This enabled a perspective through the lens of the researcher's nursing experience with vulnerable groups and delivering sexual healthcare for them. An ethnographic case study following Burawoy's (1998) extended case method was conducted. This involved immersion in the world of the person (experiencing homelessness), while observing them from a naturalistic perspective in the natural settings. Reflexivity was also ongoing throughout the research process (Denzin and Lincoln, 2011).
Selection, recruitment and consent
Permission was gained to access two London hostels and a day centre attended by young people experiencing homelessness. Purposive sampling with stratification was undertaken, and 29 young people (YP) aged 16–21 years were recruited along with a sample of their key workers (n=5). Advertisements and participant information sheets/invitations were used to invite the young people and key workers via the hostel and day centre managers. A £10 voucher for ‘Love to Shop’ was given to each participant by way of a thank you for their time. Attention was paid to selecting equal numbers of male and female participants, through the range of ages. Written consent was obtained from participants for interviews and questionnaires. Verbal consent was obtained from hostel and day centre management and YP present at the time of residents' meetings and observations on the premises. Observational sessions were not audio or video-recorded. Descriptive quantitative data was collected to capture the demographic features of the participants.
Data collection methods
Data were collected during a 5-month period between October 2015 and January 2016.
YP completed demographic questionnaires based on a validated questionnaire for sexual health patients (McGregor et al, 2018) before they were interviewed. Semi-structured face-to-face interviews of approximately 30 minutes using topic guides and open-ended questions were conducted by FM (a registered nurse with experience of working with vulnerable children and young people in sexual health services). Digital recordings were transcribed verbatim by FM and a university-validated transcriber. Observational data among the recruitment settings (18 sessions) and during interviews were collected using structured field notes guidance, which included in depth contextual detail, written and reflexive and reflective notes (Creswell and Poth, 2017). Policy and documentation (i.e. local and national policy, internal hostel policy and job descriptions for staff) were examined from a macro- and micro-perspectives (Burawoy, 1998).
A total of 34 interviews were conducted, and approximately 48 hours of observation carried out.
Data analysis
Questionnaires provided basic statistics, which were analysed descriptively using MS Excel. The interviews, observational data, reflexive notes and documentation were thematically analysed using Braun and Clarke's (2006) six-stage approach and NVIVO 10 (2010) by FM and validated by AR and JS.
Ethics statement
Ethics approval was granted by the University of Surrey ethics committee (Ref: UEC/2015/053/FHM).
Results
Quantitative findings
Table 1 presents data on the demographic characteristics of the 29 YP who participated in this study. The salient findings from these data were that the greatest proportion of the participant group disclosed their ethnicity as Black or Black British. Further, most of the participants had been resident in their hostel for less than 12 months, indicating the unsettled nature of their experience.
Table 1. Demographic characteristics of the young people in this study (n=29)
| Characteristic | Number | Percentage |
|---|---|---|
| Ethnicity | ||
| White | ||
| British | 4 | 14 |
| Irish | ||
| Other white | 6 (from the EU) | 21 |
| Mixed | ||
| White and black Caribbean | 1 | 4 |
| White and black African | ||
| White and Asian | 2 | 7 |
| Other mixed | ||
| Asian or Asian British | ||
| Indian | ||
| Pakistani | 1 | 4 |
| Bangladeshi | ||
| Other Asian | ||
| Black or black British | ||
| Caribbean | 6 | 21 |
| African | 8 | 28 |
| Other black | ||
| Other ethnic groups | ||
| Chinese | ||
| Other | ||
| Other as stated on form | ||
| Not stated | 1 | |
| Years in hostel residence | ||
| Less than 12 months | 17 | 59 |
| 12–24 months | 3 | 10 |
| 25–36 months | 1 | 4 |
| More than 3 years | 0 | - |
| Not stated | 8 | 28 |
| Gender | ||
| Male/transgender | 14 | 50 |
| Female/transgender | 15 | 50 |
| Participant age in years | ||
| 16 | 1 | 3.4 |
| 17 | 3 | 10.3 |
| 18 | 5 | 17.24 |
| 19 | 3 | 10.3 |
| 20 | 5 | 17.24 |
| 21 | 11 | 38 |
| Age | Range (mean) | Median |
| 16–24 (19.4) | 20 | |
| Smoking | ||
| Smokers | 19* | 65 |
| Non smokers | 7 | 24 |
| Not reported | 3 | - |
Themes
Three broad themes were identified, with cross-over and blending between them: (1) risks and extreme vulnerability to danger, exploitation, shame, and mental illness; (2) relationship and communication difficulties; and (3) a consequent emergence of a culture of homelessness.
Risks and extreme vulnerability
Risk and danger appeared to be both a cause and a consequence of the state of homelessness, and they increased vulnerability.
‘I came to live there due to the fact that I couldn't live with my family because of domestic violence … the police arrested my mum.’
(YP25, female)
A variety of incidents and observations during the insider observational sessions indicated fears surrounding hostel living and interactions with other residents, which could be overwhelming. One participant was not even able to pinpoint it, but felt it was related to the homeless experience.
‘… always it's like I get the fear, a little bit of fear, what's going to be … if something was going to be something and … do you know what I mean? That's why it's keeping me a bit like scary.’
(YP12, male)
Some disclosed being involved in overt violence:
‘… because I was fighting or something with another guy who was using a knife and getting angry.’
(YP03, male)
Risk and danger influenced the YP's knowledge, attitudes and ability to understand the subsequent sexual health impact, as well as their mental, behavioural and other aspects of their lives. This was confirmed by the key workers and noted by the researcher during the observational sessions. Examples of these risks and dangers included fighting, knife carrying by some of the males, violence, substance use, suicidal tendencies and unsafe sexual practices in both genders. Lack of use of effective contraception was also noted, sometimes due to lack of education and sometimes through embarrassment at service use.
‘There's so many options available, from the implant to the coil to the injection. The fact that [they] only know about the pill is kind of a bit concerning.’
(KW1, female)
Using the sexual health services provided in the community kept this population away:
‘It's embarrassing … it's like you run the risk of when you go to a clinic you'll see other people that you know.’
(YP14, female)
Another YP personal violation in the form of female genital mutilation. She had clearly been traumatised and displayed signs of fear, as indicated in the reflection notes:
A young female wearing a burkka. Very reticent, embarrassed and uninformed. Hostel dweller. Caused me concerns about her FGM which she mentioned on two occasions. I will follow this up. Impression-very lacking in knowledge and a terrified expression, quiet voice, full of shame.
(interview 19)
There were other complaints of distress and disruption concerning people with mental illnesses, screaming and shouting and disturbing others in the hostels. However, there was a tendency to refer to others having the mental health issues rather than themselves:
‘There's a lot of people in there who are very mentally ill, so you do get a lot of screaming and a lot of all of that.’
(YP26, female)
Relationship and communication difficulties
Barriers to having satisfactory intimate and sexual relationships presented issues, which were far-reaching and affected the types of relationships formed, wider family relationships of any type, confidence to form relationships and whether the young people felt able to enter into relationships at all. Reasons ranged from hostel rules, being in an inappropriate situation and feelings that young people experiencing homelessness had too many things to mend in their own lives. A participant tried to express their uncertainty about relationships in view of a background where there was loneliness, isolation, difficulty in making connections and a lack of love:
‘I'm afraid of being lonely … I never experienced any kind of love from family.’
(YP15, female)
One YP was at a loss as to how to conduct a relationship and appeared relieved at the opportunity to be able to ask the interviewer about this.
(laughs) ‘Okay, because basically to be honest I never sleep with a virgin girl, yeah. If I go sleep with her can I do it like … slowly, or like, how do I do it, I don't know how that is because I never sleep with a virgin girl.’
(YP03, male)
Key workers were aware of difficulties with relationships and how they could be unhealthy. They noted that relationships in the hostels between the residents were not always satisfactory: residents were unable to open up and appeared to misunderstand the meaning of a healthy relationship.
‘It's very interesting their perception of what a relationship is and what a healthy relationship is, and sometimes there's a bit of work that needs to be done on that.’
(KW1, female)
Boundaries between ‘real’ relationships became blurred because of the vulnerability needs, for example, trying to find money to feed themselves, feed drug habits or falling prey to exploitation. Some also felt too frightened to find out if they had caught a STI. Others had concerns about relationships with healthcare staff, who they worried could be judgemental.
‘I've got a friend who's had sex with over 50 people, she's never been to the clinic and she's too scared. She's too scared that she's got something and she's too scared because of the judgement.’
(YP26, female)
However, it was also noted that some had been able to form positive relationships with their GPs.
‘I think you need to check every time you go [out clubbing]; you need to go to your GP and check. Yes, I'd trust my GP the most.
(YP07, male)
A consequent emergence of a culture of homelessness
The tangle of negative situations which lead to negative outcomes, such as danger and fear, being unable to maintain close relationships, unsure of how to show intimacy and tenderness resulted in a culture of homelessness reflecting vulnerability, social chaos and separation. Many were trapped in cycles of periods in hostels, on the street, sofa surfing and squatting. They found it difficult to settle and to conform to the regulations imposed on them when in hostels.
‘I've got a son, a 5-year-old that she [participant's mother] takes care of now, he's my world. I'm not allowed him in the hostel. (Father of child) is always in and out of jail, things like that. He's just not the best role model.
(YP14, female)
Many of the participants expressed concerns over the location and the state of the hostels, and type of people around them. The hostels were situated in a part of central London with extremes of poverty on the one hand and of affluence on the other. Observations included:
This hostel (no 1) is very shabby looking with litter in the streets. In the early evening darkness, you feel quite vulnerable as a woman being there.
(observation session 1)
In addition, the living quarters were insanitary and unkempt, which troubled those living there. UK policy states that local authorities have a duty to place homeless young people in secure accommodation (DfE, 2017), and yet the standard of where they are placed is unsatisfactory.
‘To make sure it's clean. To make sure it's clean. That's all I can say, to be honest. I don't really know, to be honest. Make sure there's somewhere suitable, no rats, nothing like that and it will be alright.
Interviewer: Did you find there were some rats?
Yes.’
(YP10, male)
The instinct to survive in a culture where basic and emotional needs were hard to meet took precedence for these young people.
‘[sexual health is] the lowest priority if you're homeless.’
(YP25, female)
Discussion
This study demonstrates how community professionals can play a pivotal role in the sexual healthcare of YP experiencing homelessness. This can be achieved by understanding the factors preventing this group from engaging with sexual healthcare services and facilitating care and support in this vital area of their wellbeing.
The findings have highlighted that sexual health among this group of individuals takes a secondary position to the most fundamental of needs of daily living as identified by Maslow (1943a). As in other studies (Ensign, 2001), this one shows that YP experiencing homelessness have suffered trauma and abuse and are surrounded by risks and dangers. These dangers (for example, FGM, mental health problems and county lines) can impact on their and sexual health outcomes. It is also noteworthy that 49% of the participant population were from black or Caribbean backgrounds. Given that this group faces systemic discrimination and exclusion in all spheres of life, including healthcare, and poorer health outcomes than their white counterparts, enhancing cultural sensitivity among healthcare professionals is important (Alexander, 2016). Of particular concern was safeguarding issues, which was a thread that ran throughout the research study and was likely to affect every area of their lives. The culmination of this complicated mesh of circumstances represents extreme vulnerability with recognisable influence on sexual health.
A history of, as well as current danger, risks and violence, was demonstrated both within and between the genders. Masculinity is of importance to boys in peer group settings, and it is common for males to be viewed as the main perpetrators of violence (Ott, 2010). However, males may also be the victims in a complex way; there is often a tension between needing to display masculinity or power against the need for love and intimacy (Ott, 2010). These complexities are often acted out by males as fear, aggression, depression, suicidal feelings and confusion. This contradiction in feelings experienced by males was evident in this study, where there were stories involving knives and fights on the one hand and the need for intimacy and tenderness on the other. Many would be at risk of county lines, where vulnerable YP can be subjected to sexual violence and forced into sex work through becoming addicted to drugs and the necessity to pay off debts (National Crime Agency, 2017).
For females, danger, violence and risk were associated with transactional sex, described as sex in exchange for gifts or money, which was identified directly or indirect by the YP and key workers. It is more common among younger people than older people, affecting both males and females, and is linked to poverty. Females may be at greater risk because of their poor negotiating power in economic situations (Formson and Hilhorst, 2016). This relates closely to risk of coercion, unintended pregnancy and STI.
There was testament to lack of contraceptive use, which indicated a risk of unintended pregnancy. Evidence on unintended pregnancy among women experiencing homelessness in the UK is sparse. Gorton's (2000) survey of London's homeless hostels revealed that 24% of females aged 16–25 years had been pregnant in the previous year. Studies in the US evidenced that the infants of homeless women were found to have considerably more adverse outcomes compared with the general population, in terms of lower birth weight. Births were more frequently pre-term, and homeless women from ethnic minorities had poorer outcomes compared with those who were white. Stein et al (2000) found that homeless women have higher rates of pregnancy as well as unintended pregnancy and that the poor outcomes were also linked to substance use, which continued during pregnancy. The lack of contraceptive use among the participants in the present study highlighted an urgent need to address contraceptive use with YP in hostels.
FGM may be a concern among this study population; although only one young female brought this up in her interview, this highly sensitive issue is worthy of further investigation. Overall, these highly sensitive issues indicate a need for excellent communication skills among healthcare professionals and the need to take time to build positive self-regard on an equal footing (Rogers, 1995). This technique can be used to help alleviate the shame, guilt and lack of trust that was repeatedly alluded to and expressed by the participants.
Forming relationships with professionals and healthy relationships with each other was particularly difficult, and this was impacted by past experiences. YP who needed sexual healthcare were found to prefer to use their GP service rather than the mainstream sexual health services, which they found intimidating. This was especially so with the male participants, who said that they felt more comfortable with a GP whom they knew already. Seeing a GP does not necessarily mean the consultation will be about sexual health issues. General practice has an important role to play in the management of sexual health (Royal College of General Practitioners, 2016); this may also indicate that healthcare professionals in general practice are key figures in ensuring a less traumatic visit to deal with sexual health matters. Recommendations from the National Institute for Health and Care Excellence (NICE) (2019) stipulated that additional, targeted support should be offered to socially disadvantaged young people for their sexual health needs through outreach services. It may be appropriate to meet the needs of YP experiencing homelessness by developing services in their hostels run by local GPs who are known to the hostel residents and with whom they have established relationships.
The culture that emerges because of experiencing homelessness is made up of multiple complex issues as described and revealed through this investigation. It was identified that YP experiencing homelessness constantly find themselves unsettled and moving from one harsh environment to another. These environments are in dangerous, fearful, unkempt and desperate conditions. This, in turn, may cause extra challenges to staff in communicating and managing relationships and sexual health among YP experiencing homelessness. This study found similar environments (in varying degrees across hostels) to those described by Barnardo's (2014) in their research on accommodation for young people who had been in the care of local authorities.
Maslow's (1943b) hierarchy of needs pyramid demonstrates the need for basic physiological needs, such as shelter, hydration and hunger, to be satisfied before the higher ones, such as specialist sexual health needs, can be met. There is an opportunity to implement into sexual health the care model, transferrable to other homeless groups arising from this research. It addresses the fulfilment of basic needs (Maslow, 1943a) working through the pyramid to managing sexual health care through good communication and trust (Figure 1); integrated with this model is a cycle building trust and reducing shame (Figure 2).
Strengths and limitations
This study was conducted by a highly experienced nurse working with vulnerable populations with multiple safeguarding needs. This allowed for collection and awareness of sensitive data. There was an even distribution of gender across participants, which allowed for more representation from males than seen in other sexual health research involving YP. One limitation was that YP who are less confident may be under-represented due to self-selected participation.
Recommendations for future research
Findings from this study suggest the need for the development of training courses and support for community nurses working with YP experiencing homelessness.
A randomised controlled study (using cluster randomisation) in YP's hostels is proposed, which could involve providing sexual healthcare and support on site versus standard clinic based sexual healthcare, for the measurement of sexual health outcomes. With further research, there will be a strong case for implementing robust policy for the care of this vulnerable population, which aims to be transformative for their outcomes and their lives.
Conclusion
Many YP experiencing homelessness are living fearful lives in desperate conditions, having suffered from, and continuing to experience, trauma and abuse. In many cases, they do not prioritise sexual health while trying to live from day to day and serve their most basic physiological needs to survive. Together with this, they require continuing support to build trusting relationships and reduce negative emotions, such as guilt and shame and enhance communication. There is a real need for policy to address the chaos and vulnerability, so that meaningful and satisfactory sexual health outcomes can be achieved. Specialist interventions will identify needs, reduce shame, enhance relationships among YP and with healthcare professionals and enable growth towards self-care.
KEY POINTS
- Trust and confidentiality concerning access to sexual health provision is extremely important to young people experiencing homelessness
- Past and current trauma and safety issues influence how young people experiencing homelessness address their sexual health needs
- Previous and current experiences of danger, fear and trauma influence the ability to communicate and to form lasting and meaningful relationships
- Sexual health care is best managed in the community by health professionals having a trusting relationship with young people
CPD REFLECTIVE QUESTIONS
- What are the factors that might contribute to poor sexual health among young people experiencing homelessness?
- How might you address the subject of sexual health in a consultation with a young person experiencing homelessness?
- What are the key issues in forming and sustaining trusting professional relationships with young people experiencing homelessness?