Canadian street youth: Who are they? What are their needs?

‘Homeless youth’, ‘out-of-the-mainstream youth’ and ‘street youth’ are some of the many terms that are used to describe a heterogeneous group of young people who live and work on the streets of urban centres across Canada (1–3). The actual number of street youth in Canada is unknown, and estimates vary from 45,000 to 150,000 youths, depending on the source (4). The youth come from rural, suburban and urban areas, are from all socioeconomic classes and have diverse cultural backgrounds. For different reasons, these adolescents are thrown out of their homes or run away to inner city streets in search of identity, independence or a better life.

Many have suffered emotional, physical and/or sexual trauma or parental neglect during their childhood (5–7). Others have underlying behavioural, emotional or mental health problems, which are often undiagnosed and exacerbated by substance misuse that began in early adolescence (2,7,8). Over time, these teens become increasingly detached from their families, the educational system and society, and adopt a street-involved lifestyle that compromises their personal development, and physical and mental well-being. Many street youth become involved in illicit drug use, survival sex and criminal activities, which further alienate them socially and legally (2,5,7). In Canada, 12% to 26% of street youth have exchanged sex for money, shelter, drugs or other needs, and 17% to 36% of them have injected drugs (9,10).

Living on the streets in an unstable and predatory environment puts these young people at risk of developing many health problems (2,3,7,9–14). Studies carried out among Canadian street youth report high rates of sexually transmitted diseases and blood borne infections; for example, chlamydia infection was found in more than 20% (12), hepatitis B markers in 7% to 9% (9,13), hepatitis C infection in more than 12% (9) and human immunodeficiency virus infection in 1.8% to 2.2% (5,10) of street youth. For many youth, alcohol and/or drug dependency, and mental health problems lead to increased morbidity and premature death. In a cohort of Montreal street youth, severe depression, attempted suicides and drug overdoses were frequent (15). The mortality rate among these youths was 12 times higher than that of other young people their age; suicides and drug and/or alcohol problems were the leading causes of death (15).

WHAT CAN PHYSICIANS DO TO HELP THESE YOUTH?

Identify youth at risk of marginalization

Many street youth report a long history of serious personal and family problems that began years before they ended up on the streets. Some were living with abusive families, or had parents with addiction and/or mental health problems. Others had unresolved gender identity issues, mental health problems or substance use disorders (1,5,7,8). In early adolescence, most street youth began engaging in multiple risk-taking behaviours, such as truancy, illicit drug use, unsafe sexual activities and delinquency (4,5). Despite the fact that many of these youth were referred to health care, social service or child protection professionals to address overt school or behavioural difficulties, very few disclosed their underlying personal problems (2). Even fewer youth felt that they were given the support that they needed when family or personal problems were identified (2).

Certain behavioural and school problems are known to precede and be associated with substance use and mental health problems (16); family physicians and paediatricians are ideally situated to identify youth at risk of marginalization and to provide early intervention. Multiple risk-taking behaviours and severe mood swings in a child or adolescent should alert caregivers that the child may not just be going through ordinary adolescent ‘angst’ but may be showing signs of more serious problems. Physicians’ privileged relationship with youth during medical visits enables them to learn about a young patient’s personal and family life, and explore the underlying causes of his or her problems. Although such history-taking may often be difficult and time-consuming in a busy clinical practice, it is essential if caregivers are to help youth and their families receive the services that they require. The physician can play a pivotal role by developing an intervention plan for a troubled youth with his or her family, school officials, social services and even the police, that can help him or her avoid further social alienation and ultimately street involvement.

Develop accessible clinical services for street youth

Once youth become street-involved, they often have a difficult time obtaining the health care services that they need for their numerous physical and psychological problems. Several personal barriers prevent them from accessing the health care system (14,17,18). Many have difficulty establishing trusting relationships with adults; they also suffer from high levels of psychological distress, often exacerbated by alcohol and drug use that make it difficult for them to seek help. Perceived discrimination by health care workers, worries about confidentiality and a fear of being reported to the police or child protection authorities are also common reasons why street youth avoid medical services, especially when they are minors (14,17,18).

Several organizational barriers also limit their access to medical care. Youth living without a fixed address or identity papers cannot obtain services in many hospitals and clinics. If they do receive care, they often cannot afford the cost of the medication or treatments prescribed. Flexibility regarding these issues, as well as adapted hours and locations of medical services have been shown to improve access, and engage street youth in their health care. In a community-based hepatitis B vaccination outreach project in Montreal, over 1000 youth presented for hepatitis vaccination; during the first year, follow-up rates were over 80% for the second dose and 50% for the third dose (19). The project’s success was due to the active participation of street youth and community workers in the organization of the outreach clinics in their environment.

Another example of successful programs reaching street youth are the multiservice clinics that have been set up over the past decade in several cities to respond to the diverse medical, psychosocial and legal needs of street youth (20–25). These centres provide clinical services where street youth congregate, and are open when they seek care and need it the most. In collaboration with community organizations, health professionals establish contact and trust with youth by responding to their health concerns and to their basic needs for survival and security. A wide range of other services are offered as needed, such as family mediation, legal aid, and mental health and addiction referrals. By providing basic ambulatory health care to street youth where they live, on their terms and in a stepwise fashion, health care professionals are able to connect street youth with the many services that they need to improve their well-being and assist them in their social reintegration.

Provide alternatives to street life

Most street youths want to get off the streets but need support and help in reorienting their lives (2,5,14). For many adolescents who have substance abuse and mental health problems, and who are isolated from their families, getting off the streets seems insurmountable. Stable and structured social housing is essential so that youth can develop the organizational and social skills necessary to take control of their lives. Once the basic needs of food, shelter and security are met, these young people can benefit from other services or special programs. Social reinsertion projects, adapted educational programs and job training are necessary for adolescents who left school early and have lived on the streets for several years. Many of them also need addiction services, trauma recovery programs and mental health care to alleviate their suffering and decrease their marginalization.

Unfortunately, these programs and services are not available to street youth in most Canadian cities because of drastic cuts in health and social services over the past decade. Addiction services and mental health resources for adolescents are seriously strained or simply nonexistent. Consequently, many street youth who want help dealing with their problems of past abuse, addiction or mental illness are not able to access the services that they need.

CONCLUSIONS

Physicians can contribute in many ways to improve the health care and social integration of marginalized youth. For example, we can identify youth at risk in our practices and refer them to the services that they need; for young people already on the streets, we can develop adapted, accessible clinical services. And finally, as child advocates, we can lobby all levels of government for the increased addiction and mental health services that are so urgently needed for many adolescents and their families.

In every community, physicians and professionals in education, social and judiciary services must work together to address the needs of troubled youth before they arrive on the streets and while they live on the streets. Concrete, long term solutions are needed to help at-risk youth remain connected emotionally and socially. None of our children or adolescents should have only the streets to call home.