Experience of Violence During Homelessness

Anita S Hargrave; Cheyenne M Garcia; Jennafer A Birkmeyer; Angelica DeGaetano; Margot Kushel

doi:10.1001/jamainternmed.2024.5336

. 2024 Oct 14;184(12):1474–1477. doi: 10.1001/jamainternmed.2024.5336

Experience of Violence During Homelessness

Anita S Hargrave ^1,^2,^3,^✉, Cheyenne M Garcia ^2,³, Jennafer A Birkmeyer ^2,³, Angelica DeGaetano ^2,³, Margot Kushel ^2,³

¹Department of Internal Medicine, University of California, San Francisco (UCSF), San Francisco

²Center for Vulnerable Populations, University of California, San Francisco, San Francisco

³UCSF Benioff Homelessness and Housing Initiative at Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California

Accepted for Publication: August 13, 2024.

Published Online: October 14, 2024. doi:10.1001/jamainternmed.2024.5336

^✉

Corresponding Author: Anita S. Hargrave, MD, MAS, Department of Internal Medicine, University of California, San Francisco, 505 Parnassus Ave, San Francisco, CA 94143 (anita.hargrave@ucsf.edu).

Author Contributions: Drs Hargrave and Kushel had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Hargrave, Garcia, Kushel.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Hargrave, Birkmeyer.

Obtained funding: Hargrave, Kushel.

Administrative, technical, or material support: Hargrave, Garcia, DeGaetano, Kushel.

Supervision: Hargrave, Kushel.

Conflict of Interest Disclosures: Dr Hargrave reported receiving grants from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) of the National Institutes of Health (NIH); Blue Shield of California Foundation (BSCF); University of California, San Francisco (UCSF) Benioff Homelessness and Housing Initiative (BHHI); California Healthcare Foundation (CHCF); and Department of Health Care Services during the conduct of the study. Ms Garcia reported receiving grants from the National Institute on Aging, BHHI, BSCF, and CHCF during the conduct of the study. Ms Birkmeyer reported receiving grants from BHHI, BSCF, and CHCF during the conduct of the study. Mrs DeGaetano reported receiving grants from BHHI, BSCF, and CHCF during the conduct of the study. Dr Kushel reported receiving grants from the National Institute on Aging, BHHI, BSCF, and CHCF during the conduct of the study and being a board member of Housing California, National Homelessness Law Center, and Steinberg Institute outside the submitted work.

Funding/Support: This research was supported by the BSCF, BHHI, and CHCF (Dr Hargrave); grant K12AR084219 from the NIAMS of NIH (Dr Hargrave); grant 21-10317 from the UCLA-UCSF ACEs Aware Family Resilience Network through a contract with the Department of Health Care Services (Dr Hargrave); and grant 2K24AG046372 from the National Institute on Aging (Dr Kushel). The BSCF organized feedback sessions with community domestic violence organizations, violence prevention advocates, and people with lived experience of homelessness prior to data collection and at the midpoint of the data analysis.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The content of this manuscript is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or other funders.

Meeting Presentation: This work was presented at the 2023 Annual Conference of the Society of General Internal Medicine; May 12, 2023; Aurora, Colorado.

Data Sharing Statement: See Supplement 2.

Additional Contributions: We thank the people who participated in CASPEH (California Statewide Study of People Experiencing Homelessness), the study staff who conducted the research, and the members of the community advisory boards who guided our work. The following individuals provided guidance: Dez Martinez, BHHI; Tiana Moore, PhD, MS, MA, Brilliant Corners; Dave Graham-Squire, PhD, BHHI; and Kara Young Ponder, PhD, BHHI. The named individuals were financially compensated by the BHHI for their contributions.

^✉

Corresponding author.

PMCID: PMC11474486 PMID: 39401025

Abstract

This cross-sectional study reports the prevalence and odds of physical and/or sexual violence among unhoused adults in California.

Experiencing violence and homelessness has compounding deleterious implications for health.^1,2,3,4 The most recent large representative study of exposure to violence during homelessness was conducted 30 years ago, before the increase in unsheltered homelessness.⁴ We examined factors associated with experiencing violence while homeless, with a primary independent variable of violence experienced prior to homelessness.

Methods

As part of CASPEH (California Statewide Study of People Experiencing Homelessness), we conducted a cross-sectional study of a representative sample of adults (aged ≥18 years) experiencing homelessness in California from October 2021 to November 2022.⁵ We purposively selected 8 counties and sampled from locations including homeless shelters, domestic violence shelters, and encampments, partnering with community advisory boards to collect data. Research staff sampled individuals randomly and completed in-person structured interviews (eFigure in Supplement 1). The University of California, San Francisco Institutional Review Board approved the study. Oral informed consent was obtained. We followed the STROBE reporting guideline.

We assessed for physical and sexual violence during current homelessness episode (primary outcomes) and for additional types of violence across the life course. Participants self-reported sociodemographics, health status (number of chronic diseases, alcohol use, drug use), and features of homelessness (sleeping location, homelessness duration, social support) (eTable in Supplement 1).

We performed bivariable analyses stratified by sexual violence and physical violence during current homelessness episode and adjusted for survey weights to generate representative statewide estimates. We conducted multivariable logistic regression models to examine the association of sexual or physical violence during homelessness with experience of violence within 6 months prior to homelessness (primary exposure), after adjusting for sociodemographics, health status, features of homelessness, and childhood violence. Data analysis was performed with Stata 16.1 (StataCorp LLC).

Results

The 3200 CASPEH participants had a median (IQR) age of 47 (36-56) years and included 1965 cisgender men (67.2%), 1148 cisgender women (31.2%), and 57 transgender individuals (1.6%). Seventy-four percent of participants experienced lifetime violence. During current homelessness, 37.9% of participants experienced physical or sexual violence (36.1% physical, 9.8% sexual) (Table 1).

Table 1. Sample Characteristics by Violence Type During the Current Episode of Homelessness^a.

Characteristic	Participants stratified by violence type, No. (weighted %)
Characteristic	Physical	Sexual	Physical or sexual
Study participants experiencing homelessness	992 (36.1)	254 (9.8)	1045 (37.9)
Age, median (IQR), y	43 (35-52)	41 (34-49)	43 (35-52)
Age group, y
18-24	66 (34.0)	18 (11.8)	70 (36.3)
25-49	562 (44.3)	167 (13.1)	596 (46.3)
≥50	364 (26.6)	69 (5.6)	379 (28.2)
Race and ethnicity^b
Asian American or Pacific Islander	11 (23.0)	2 (4.0)	12 (26.4)
Black	189 (29.1)	53 (9.8)	211 (31.8)
Latinx or Hispanic	209 (37.6)	48 (10.4)	214 (38.6)
Native American, Alaskan, or Indigenous	35 (36.3)	12 (9.9)	37 (36.9)
White	374 (39.4)	84 (8.6)	386 (41.1)
Multiracial	160 (40.8)	50 (12.0)	169 (42.7)
Other races and ethnicities^c	2 (14.5)	1 (3.3)	3 (17.7)
Gender identity
Cisgender men	626 (36.2)	72 (6.1)	642 (37.5)
Cisgender women	343 (35.6)	170 (17.5)	378 (38.5)
Transgender and all other gender identities^d	21 (40.3)	12 (23.3)	23 (45.8)
Sexual orientation
Heterosexual	852 (35.5)	184 (8.2)	888 (36.9)
All other sexual orientations^e	132 (43.1)	67 (25.0)	149 (48.5)
Partnered status
Single, never married	511 (34.7)	134 (9.7)	540 (36.7)
In a relationship or married	242 (37.6)	60 (7.7)	251 (38.8)
Divorced or separated	192 (39.0)	45 (12.6)	204 (41.3)
Widowed	42 (32.7)	13 (11.5)	45 (35.3)
No. of chronic diseases
0-2	842 (36.0)	196 (9.3)	883 (37.8)
≥3	149 (36.5)	56 (13.3)	160 (39.1)
Heavy episodic alcohol use
None	792 (35.3)	205 (9.4)	833 (37.1)
Heavy episodic alcohol use	185 (41.0)	45 (12.0)	194 (42.7)
Regular drug use
None	505 (26.1)	125 (6.9)	541 (28.0)
Regular drug use	472 (52.2)	124 (14.1)	487 (53.8)
Sleeping location
Sheltered	246 (24.8)	68 (6.2)	266 (27.1)
Unsheltered: outdoors	575 (40.2)	157 (12.9)	601 (42.1)
Unsheltered: vehicle	167 (37.8)	29 (6.1)	174 (39.0)
Duration of this episode of homelessness, median (IQR), mo	31 (12-63)	24 (10-55)	30 (12-62)
Social support
None	365 (35.2)	109 (11.3)	394 (38.3)
1-5 Persons	505 (37.1)	117 (9.2)	523 (38.4)
≥6 Persons	112 (34.3)	27 (8.4)	118 (35.2)
Childhood violence
No physical or sexual violence	377 (27.0)	71 (5.3)	389 (27.5)
Physical or sexual violence	609 (46.2)	182 (15.0)	649 (49.4)
Violence 6 mo prior to homelessness
No physical or sexual violence	574 (27.2)	111 (5.2)	595 (27.9)
Physical or sexual violence	405 (61.2)	141 (22.8)	436 (65.2)

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^{^a}

Homelessness was defined by the HEARTH (Homeless Emergency Assistance and Rapid Transition to Housing) Act of 2009 as individuals and families who lack a fixed, regular, and adequate nighttime residence; who will lose their primary nighttime residence imminently (ie, within 14 days); or who are fleeing domestic violence, dating violence, stalking, or similar threatening situations. This table presents stratified row percentages to highlight the prevalence of violence in each subgroup; therefore, a row does not add up to 100%. Survey weights were applied to obtain the weighted percentages.

^{^b}

Race and ethnicity were self-reported by participants.

^{^c}

Other races and ethnicities primarily included Middle Eastern or North African.

^{^d}

Transgender and all other gender identities included transmale or transman, transfemale or transwoman, genderqueer or gender nonconforming, different gender identity, or gender identity not matching sex assigned at birth.

^{^e}

Other sexual orientations included nonheterosexual or nonstraight, including gay or lesbian, bisexual, asexual, same gender–loving, pansexual, queer, or not listed.

In adjusted models, experience of violence prior to homelessness was associated with increased odds of physical or sexual violence (adjusted odds ratio [AOR], 3.33; 95% CI, 2.53-4.38) during homelessness. Factors associated with increased odds of experiencing physical or sexual violence while homeless were regular drug use (AOR, 2.41 [95% CI, 1.82-3.18] or 1.84 [95% CI, 1.17-2.90], respectively), unsheltered sleeping outdoors (AOR, 1.39 [95% CI, 1.08-1.78] or 2.53 [95% CI, 1.51-4.23], respectively), and childhood abuse (AOR, 1.75 [95% CI, 1.28-2.41] or 1.96 [95% CI, 1.08-3.56], respectively) (Table 2).

Table 2. Exposure to Violence During Homelessness: Multivariable Results.

Variable	Violence type, AOR (95% CI)
Variable	Physical	Sexual	Physical or sexual
Physical or sexual violence 6 mo prior to homelessness (primary exposure)
No violence	1 [Reference]	1 [Reference]	1 [Reference]
Violence	2.95 (2.22-3.91)	3.96 (2.77-5.67)	3.33 (2.53-4.38)
Age group, y
18-24	1.73 (1.08-2.79)	1.36 (0.45-4.08)	1.69 (1.05-2.70)
25-49	2.10 (1.68-2.62)	1.73 (1.10-2.71)	2.07 (1.67-2.57)
≥50	1 [Reference]	1 [Reference]	1 [Reference]
Race and ethnicity^a
Black	0.85 (0.64-1.13)	1.73 (1.04-2.88)	0.93 (0.70-1.22)
Latinx or Hispanic	0.89 (0.67-1.19)	1.55 (0.90-2.69)	0.90 (0.67-1.19)
White	1 [Reference]	1 [Reference]	1 [Reference]
Multiracial	0.94 (0.63-1.40)	1.52 (0.85-2.69)	0.97 (0.63-1.47)
Other races and ethnicities^b	0.60 (0.37-0.96)	0.67 (0.36-1.25)	0.62 (0.40-0.98)
Gender identity
Cisgender men	1 [Reference]	1 [Reference]	1 [Reference]
Cisgender women	0.99 (0.73-1.35)	5.13 (3.66-7.18)	1.08 (0.78-1.49)
Transgender and all other gender identities^c	0.63 (0.34-1.16)	2.06 (0.70-6.07)	0.70 (0.36-1.35)
Sexual orientation
Heterosexual	1 [Reference]	1 [Reference]	1 [Reference]
All other sexual orientations^d	1.17 (0.79-1.73)	2.64 (1.41-4.96)	1.33 (0.88-2.01)
Partnered status
Single	1 [Reference]	1 [Reference]	1 [Reference]
In a relationship or married	1.13 (0.89-1.44)	0.45 (0.27-0.75)	1.08 (0.84-1.39)
Divorced or separated	1.54 (1.17-2.03)	1.57 (0.83-3.00)	1.52 (1.14-2.02)
Widowed	0.87 (0.48-1.56)	0.99 (0.42-2.34)	0.90 (0.50-1.62)
No. of chronic diseases
0-2	1 [Reference]	1 [Reference]	1 [Reference]
≥3	1.13 (0.85-1.50)	1.61 (1.04-2.47)	1.19 (0.90-1.57)
Heavy episodic alcohol use
None	1 [Reference]	1 [Reference]	1 [Reference]
Heavy episodic alcohol use	1.27 (0.96-1.67)	1.23 (0.66-2.28)	1.27 (0.97-1.68)
Regular drug use
None	1 [Reference]	1 [Reference]	1 [Reference]
Regular drug use	2.41 (1.82-3.18)	1.84 (1.17-2.90)	2.37 (1.78-3.17)
Sleeping location
Sheltered	1 [Reference]	1 [Reference]	1 [Reference]
Unsheltered: outdoors	1.39 (1.08-1.78)	2.53 (1.51-4.23)	1.35 (1.04-1.74)
Unsheltered: vehicle	1.47 (1.08-2.00)	0.67 (0.35-1.30)	1.40 (1.02-1.92)
Duration of this episode of homelessness, median (IQR), mo	1.01 (1.00-1.01)	1.00 (1.00-1.00)	1.01 (1.00-1.01)
Social support
<1 Person	1 [Reference]	1 [Reference]	1 [Reference]
≥1 Persons	1.06 (0.84-1.35)	0.75 (0.50-1.12)	1.0 (0.79-1.27)
Childhood physical or sexual violence
No physical or sexual violence	1 [Reference]	1 [Reference]	1 [Reference]
Physical or sexual violence	1.75 (1.28-2.41)	1.96 (1.08-3.56)	1.89 (1.39-2.59)

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Abbreviation: AOR, adjusted odds ratio.

^{^a}

Race and ethnicity were self-reported by participants.

^{^b}

Asian American or Pacific Islander and Native American, Alaska Native, or Indigenous groups were included in the other category because of small cell sizes.

^{^c}

^{^d}

Other sexual orientations included nonheterosexual or nonstraight, including gay or lesbian, bisexual, asexual, same gender–loving, pansexual, queer, or not listed.

Discussion

Thirty-eight percent of CASPEH participants experienced violence during their current episode of homelessness, compared with 1% of the US population annually.⁶ The high prevalence of violence against people experiencing homelessness necessitates a clinical and policy response. Exposure to violence immediately preceding homelessness was associated with higher odds of experiencing violence during homelessness. Clinicians who care for people experiencing homelessness should use best practices, including early detection of violence occurrence, universal provision of violence-related treatment resources, and trauma-informed care that emphasizes survivor safety and self-agency. Clinician knowledge and provision of housing resources can help break the cycle of violence that is exacerbated by homelessness.³ Policymakers should prioritize improving access to noncongregate shelter, affordable and supportive permanent housing with services appropriate for those with behavioral health conditions and survivors of violence, and long-term funding for violence prevention and recovery that supports populations highly affected by violence.

Study limitations include our inability to investigate violence among gender or sexual minoritized individuals. Additionally, this research may be affected by unmeasured confounding and social desirability bias. However, to our knowledge, this was the first representative study to evaluate experience of violence during homelessness in the past 3 decades and the first to evaluate such violence in the homeless population regardless of health care, case management, or other service use.⁴ The results support the urgent need to address violence against people experiencing homelessness.

Supplement 1.

eFigure. Flow Diagram of Participant Recruitment

eTable. California Statewide Survey of People Experiencing Homelessness (CASPEH) Questions Used in Analysis

jamainternmed-e245336-s001.pdf^{(194.7KB, pdf)}

Supplement 2.

Data Sharing Statement

jamainternmed-e245336-s002.pdf^{(12.6KB, pdf)}

References

1.Meinbresse M, Brinkley-Rubinstein L, Grassette A, et al. Exploring the experiences of violence among individuals who are homeless using a consumer-led approach. Violence Vict. 2014;29(1):122-136. doi: 10.1891/0886-6708.VV-D-12-00069 [DOI] [PubMed] [Google Scholar]
2.Broll R, Huey L. “Every time I try to get out, I get pushed back”: The role of violent victimization in women’s experience of multiple episodes of homelessness. J Interpers Violence. 2020;35(17-18):3379-3404. doi: 10.1177/0886260517708405 [DOI] [PubMed] [Google Scholar]
3.Tong MS, Kaplan LM, Guzman D, Ponath C, Kushel MB. Persistent homelessness and violent victimization among older adults in the HOPE HOME study. J Interpers Violence. 2021;36(17-18):8519-8537. doi: 10.1177/0886260519850532 [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Lee BA, Schreck CJ. Danger on the streets: marginality and victimization among homeless people. Am Behav Sci. 2005;48(8):1055-1081. doi: 10.1177/0002764204274200 [DOI] [Google Scholar]
5.Wesson P, Graham-Squire D, Perry E, Assaf RD, Kushel M. Novel methods to construct a representative sample for surveying California’s unhoused population: the California Statewide Study of People Experiencing Homelessness. Am J Epidemiol. 2024;kwae323. Published online September 11, 2024. doi: 10.1093/aje/kwae323 [DOI] [PMC free article] [PubMed] [Google Scholar]
6.Thompson A, Tapp SN. Criminal victimization, 2022. Office of Justice Programs, Bureau of Justice Statistics, US Department of Justice. Accessed February 1, 2024. https://bjs.ojp.gov/document/cv22.pdf

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplement 1.

eFigure. Flow Diagram of Participant Recruitment

eTable. California Statewide Survey of People Experiencing Homelessness (CASPEH) Questions Used in Analysis

jamainternmed-e245336-s001.pdf^{(194.7KB, pdf)}

Supplement 2.

Data Sharing Statement

jamainternmed-e245336-s002.pdf^{(12.6KB, pdf)}

[ild240024r1] 1.Meinbresse M, Brinkley-Rubinstein L, Grassette A, et al. Exploring the experiences of violence among individuals who are homeless using a consumer-led approach. Violence Vict. 2014;29(1):122-136. doi: 10.1891/0886-6708.VV-D-12-00069 [DOI] [PubMed] [Google Scholar]

[ild240024r2] 2.Broll R, Huey L. “Every time I try to get out, I get pushed back”: The role of violent victimization in women’s experience of multiple episodes of homelessness. J Interpers Violence. 2020;35(17-18):3379-3404. doi: 10.1177/0886260517708405 [DOI] [PubMed] [Google Scholar]

[ild240024r3] 3.Tong MS, Kaplan LM, Guzman D, Ponath C, Kushel MB. Persistent homelessness and violent victimization among older adults in the HOPE HOME study. J Interpers Violence. 2021;36(17-18):8519-8537. doi: 10.1177/0886260519850532 [DOI] [PMC free article] [PubMed] [Google Scholar]

[ild240024r4] 4.Lee BA, Schreck CJ. Danger on the streets: marginality and victimization among homeless people. Am Behav Sci. 2005;48(8):1055-1081. doi: 10.1177/0002764204274200 [DOI] [Google Scholar]

[ild240024r5] 5.Wesson P, Graham-Squire D, Perry E, Assaf RD, Kushel M. Novel methods to construct a representative sample for surveying California’s unhoused population: the California Statewide Study of People Experiencing Homelessness. Am J Epidemiol. 2024;kwae323. Published online September 11, 2024. doi: 10.1093/aje/kwae323 [DOI] [PMC free article] [PubMed] [Google Scholar]

[ild240024r6] 6.Thompson A, Tapp SN. Criminal victimization, 2022. Office of Justice Programs, Bureau of Justice Statistics, US Department of Justice. Accessed February 1, 2024. https://bjs.ojp.gov/document/cv22.pdf

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Experience of Violence During Homelessness

Anita S Hargrave, MD, MAS

Cheyenne M Garcia, BA

Jennafer A Birkmeyer, MPH

Angelica DeGaetano, MPhil, LLM

Margot Kushel, MD

Abstract

Methods

Results

Table 1. Sample Characteristics by Violence Type During the Current Episode of Homelessness^a.

Table 2. Exposure to Violence During Homelessness: Multivariable Results.

Discussion

References

Associated Data

Supplementary Materials

ACTIONS

PERMALINK

RESOURCES

Cite

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PERMALINK

Experience of Violence During Homelessness

Anita S Hargrave, MD, MAS

Cheyenne M Garcia, BA

Jennafer A Birkmeyer, MPH

Angelica DeGaetano, MPhil, LLM

Margot Kushel, MD

Abstract

Methods

Results

Table 1. Sample Characteristics by Violence Type During the Current Episode of Homelessnessa.

Table 2. Exposure to Violence During Homelessness: Multivariable Results.

Discussion

References

Associated Data

Supplementary Materials

ACTIONS

PERMALINK

RESOURCES

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Table 1. Sample Characteristics by Violence Type During the Current Episode of Homelessness^a.