Out on the Street: A Public Health and Policy Agenda for Lesbian, Gay, Bisexual, and Transgender Youth Who Are Homeless

Abstract

A disproportionate number of lesbian, gay, bisexual and transgender (LGBT) youth experience homelessness each year in the United States. LGBT youth who are homeless have particularly high rates of mental health and substance use problems, suicidal acts, violent victimization, and a range of HIV risk behaviors. Given the intense needs of LGBT youth experiencing homelessness, it is imperative that we understand their unique experiences and develop responsive practices and policies. The range and severity of health risks vary across subgroups of all homeless LGBT youth, and since the population is nonhomogeneous their particular needs must be identified and addressed. Thus the purpose of this article is to review the causes of homelessness among LGBT youth, discuss the mental health and victimization risks faced by this population, address differences among homeless LGBT subgoups, and recommend effective interventions and best practices. We conclude by discussing promising future research and public policy directions.

A disproportionate number of lesbian, gay, bisexual and transgender (LGBT) persons experience homelessness each year in the United States, although the exact number is unknown. Among these persons are approximately 320,000 to 400,000 youth (Quintana, Rosenthal, & Kehely, 2010).¹ For example, in Massachusetts public high schools more than one-third of homeless students have either a minority sexual orientation or are unsure of their sexual orientation (Corliss, Goodenow, Nichols, & Austin, 2011). It has also been documented that LGBT youth comprise approximately 30–45% of clients served by homeless youth agencies, drop-in centers, outreach, and housing programs (Durso & Gates, 2012).

LGBT youth who are homeless have particularly high rates of mental health and substance use problems, suicidal acts, violent victimization, and a range of HIV risk behaviors (Cochran, Stewart, Ginzler & Cauce, 2002; Tyler, 2013; Whitbeck, Chen, Hoyt, Tyler & Johnson, 2004). Many have histories of academic difficulties and high rates of school dropout. Despite the size of this population and the concomitant risks, little is known about the causes, correlates and consequences of homelessness among youth who are LGBT. Promising practices are beginning to emerge, but evidence-based interventions and strategies for working with LGBT subpopulations remain very limited.

The issue of homelessness among LGBT youth in the United States has remained largely unacknowledged until recently when this subgroup became part of a broader national conversation about how to prevent and end homelessness. In 2010, the United States Interagency Council on Homelessness (USICH), representing 10 federal agencies, including the cabinet secretaries, published Opening Doors: Federal Strategic Plan to Prevent and End Homelessness (United States Interagency Council on Homelessness [USICH], 2010). Up until this time, federal policies were focused on ending chronic homelessness among single adult individuals. Opening Doors expanded the Federal agenda, setting a goal of ten years to end homelessness for youth, children and families, and veterans (USICH, 2010, p. 7). The plan specifically mentions LGBT youth facing homelessness, referring rather guardedly to studies that suggest “youth who are gay, lesbian, bisexual, transgender, and questioning represent a larger proportion when compared to the overall population” (USICH, 2010, p. 15). Opening Doors also cites “gay, lesbian, bisexual and transgender populations” as a focus in its efforts to make information about how to work with special populations readily available (USICH, 2010, p. 34). As part of this federal initiative, attention is now being spotlighted on developing best practices and improving outcomes for LGBT youth experiencing homelessness.

Given the intense needs of LGBT youth who are homeless, it is imperative that we understand their unique experiences and develop responsive practices and policies. The range and severity of health risks vary across subgroups of all homeless LGBT youth, and since the population is nonhomogeneous their particular needs must be identified and addressed. Thus the purpose of this article is to review the causes of homelessness among LGBT youth, discuss mental health and victimization risks faced by this population, address differences among homeless LGBT subgoups, and recommend effective interventions and best practices. We conclude by discussing promising research and policy directions.

Background

High Rates of Homelessness

The literature on homelessness among LGBT youth varies considerably in the age parameters used to recruit participants, with some studies setting one end of this age range as low as 10 years (Walls & Bell, 2011) and others as high as 28 years (Clatts, Goldsamt, Yi & Gwads, 2005). Depending on the age of the study sample, developmental needs and the reported experience of homelessness vary dramatically. The most commonly cited reason among LGBT youth for becoming homeless is running away from families who reject them due to sexual orientation or gender identity (Durso & Gates, 2012). The second most commonly cited reason is being forced out by their family, despite preferring to stay at home, after disclosing their sexual orientation or gender identity. Another common reason for becoming homeless is aging out of or running away from the foster care system, where harassment and violence of LGBT youth frequently occur (Durso & Gates, 2012; Mallon 1997a; Mallon 1997b; Ray 2007).

Among lesbian, gay and bisexual youth, the mean age of becoming homeless for the first time is 14 years, and many of these youth do not disclose their sexual identity to another person until after becoming homeless (Rosario, Schrimshaw & Hunter, 2012b). This suggests that running away from home may be a coping strategy during the stressful process of lesbian, gay, and bisexual identity development in early adolescence, and that these teenagers may be evicted by caretakers who reject them for gender-nonconforming behaviors even before they have verbally disclosed their sexual identity to another person (Rosario et al., 2012b).

The long-term trajectory of homelessness from youth into adulthood for LGBT individuals remains largely unknown. Risk factors influencing whether homelessness among transitional age LGBT youth evolves into chronic homelessness in adulthood are poorly understood, and prospective studies of homeless LGBT adolescents transitioning into adulthood are mostly lacking.

Increased Mental Health Risks

Lesbian, gay or bisexual homeless adolescents are more likely than homeless heterosexual adolescents to have a current major depressive episode (41.3% versus 28.5%), PTSD (47.6% versus 33.4%), suicidal ideation (73% versus 53.2%), and have made at least one suicide attempt (57.1% versus 33.7%) (Whitbeck et al., 2004). Lesbian adolescents are more likely than heterosexual females to meet criteria for alcohol abuse (61.4% versus 35.5%) and drugs (47.7% versus 32.5%). LGBT homeless youth 13 to 21 years are more likely than non-LGBT homeless youth to use cocaine, crack or methamphetamines and to report depressive symptoms (Cochran et al., 2002).

Even after controlling for childhood sexual abuse and early sexual orientation development in lesbian, gay and bisexual youth, becoming homeless is related to future depressive symptoms, anxiety symptoms, disorderly conduct, and substance use disorders (Rosario, Scrimshaw & Hunter, 2012a). The association between homelessness and psychiatric symptoms is mediated by stressful life events, negative social relationships, and lack of social support from friends. LGBT status in runaway and homeless youth is a significant predictor of recent stress, and LGBT youth are more likely to engage in self-harm and attempt suicide over a 3-month period (Moskowitz, Stein & Lightfoot, 2012). In adolescent runaways between the ages of 12 and 19 years, identifying as gay predicts suicidality (Leslie, Stein & Rotheram-Borus, 2002). Lesbian-, gay-, bisexual-identified and unsure homeless youth 13 to 20 years are more likely to have been in a locked mental heath treatment facility, used amphetamines and intravenous drugs, and reported recent depression and suicidal ideation (Noell & Ochs, 2001). While lesbian, gay and bisexual youth initiate alcohol and illicit drug use earlier than heterosexual youth, substance use behavior most often begins after becoming homeless, suggesting that substance abuse may be a coping strategy for the numerous stressors of adolescent homelessness (Rosario et al., 2012b).

Increased Survival Sex and Sexual Victimization

LGBT homeless adolescents have increased rates of high-risk survival strategies, such as survival sex. They also are at greater risk of being physically or sexually victimized on the streets. Homeless lesbian, gay, and bisexual youth between the ages of 10 and 25 years are 70% more likely than homeless heterosexual youth to engage in survival sex (Walls & Bell, 2011). Similarly, LGBT homeless youth 13 to 21 years are more likely than non-LGBT homeless youth to experience physical or sexual victimization, have a greater number of perpetrators, and have unprotected sexual intercourse (Cochran et al., 2002).

In the Los Angeles Unified School District, compared with heterosexual students, the location of homelessness for LGBT or unsure students is less likely to be a homeless shelter (Rice et al., 2013) and greater than three times as likely to be a stranger’s home (14.5% versus 4.2%, P<0.001; Rice et al., 2012), which may indicate higher rates of sexual exploitation among these youth (Rice et al., 2013). LGBT homeless youth are more likely than their heterosexual counterparts to trade sex with a stranger, have more than 10 sexual partners who are strangers, have sex with a stranger who uses IV drugs, have anal sex with a stranger, have unprotected sex with a stranger, and have sex with a stranger after using drugs (Tyler, 2013).

Differences Among Subpopulations

Existing research and direct service programs often group lesbian, gay, bisexual and transgender youth together into a single, homogeneous category. In reality, LGBT subpopulations have unique challenges, experiences and needs depending upon age, sex, ethnicity, geographic region, sexual behavior, self-identified sexual orientation, and gender identity. For example, more homeless male youth self-identify as homosexual and more homeless female youth self-identify as bisexual (Rew, Whittaker, Taylor-Seehafer & Smith, 2005). Efforts to distinguish these subpopulations from one another have identified striking differences in their experiences.

Differences in violent victimization

Homeless youth between 16 and 20 years who self-identify as gay and lesbian are more likely to report a history of sexual abuse, and either being tested or treated for HIV, than bisexual youth (Rew et al., 2005). Lesbian runaways are more likely than heterosexual runaways to have been physically abused by caretakers, and lesbian, gay, and bisexual runaways are more likely than heterosexual runaways to have been sexually abused by caretakers (Whitbeck et al., 2004).

Moreover, the types of violence experienced among homeless male and female LGBT youth differ. Among homeless and LGBT youth, 35% of females and 65% of males report a history of violence (Marsiglia, Nieri, Valdez, Gurrola & Mars, 2009). Among homeless/LGBT males, family violence and stranger violence are more commonly experienced than partner violence, while partner violence and stranger violence are more common than family violence among homeless/LGBT women.

Differences in substance use behaviors

Lesbian, gay and bisexual homeless subpopulations exhibit distinct substance use patterns. Among homeless or unstably housed HIV-seropositive individuals 18 years or older, gay and bisexual males are more likely to engage in speed/methamphetamine and alcohol use than females (Friedman et al., 2009). Use of two drugs, powder cocaine, heroin, speed/methamphetamine, and alcohol are each correlated with increased sexual risk behaviors only among gay/bisexual males.

High-risk behaviors among young men who have sex with men

Another distinct homeless subpopulation with specific health risks and needs consists of young men who have sex with men (MSM), defined as males with one or more male sexual partner(s) regardless of whether they identify as gay/bisexual or heterosexual. Research that focuses on participants’ sexual behavior without asking how they self-identify cannot distinguish MSM in the sample who are also gay- or bisexual-identified. Homelessness is consistently a significant risk factor among young MSM for HIV-risk behaviors. Homelessness among young MSM between 17 and 28 years is highly correlated with an increased likelihood of lifetime and current exposure to high-risk drug use and sexual behavior (Clatts et al., 2005). Onset of these high-risk exposures is earlier in young MSM with a history of unstable housing compared with those who have no history of homelessness; in most cases drug use did not occur prior to becoming homeless.

Differences in patterns and rates of high-risk substance use and sexual behaviors exist among runaway compared to non-runaway homeless young MSM. Runaway MSM between the ages of 15 and 22 years first experience oral and anal sex one year younger than non-runaway MSM (LaLota, Kwan, Waters, Hernandez & Liberti, 2005). Runaways, who are significantly younger when they first “come out,” report a greater number of male or female partners throughout their lifetime, are more likely to experience forced sexual contact or be diagnosed with an STD, and are more likely to ever have used drugs, including intravenous drugs. Runaways have 3.3 times the risk of HIV infection compared to non-runaways and are more likely to have unprotected vaginal or anal sex with female partners. Thus runaway MSM require focused care to help reduce HIV risk behaviors.

Transgender persons

Homeless transgender youth are among the most vulnerable of LGBT subpopulations. The unique challenges encountered by homeless female-to-male and male-to-female transgender youth are understudied and often unaddressed. Transgender youth often initially identify as gay or lesbian before identifying as transgender, resulting in an even more complex developmental process (Ryan, 2003; Wilber, Ryan & Marksamer, 2010). These youth face higher victimization rates in school than nontransgender gay and lesbian youth (Gay, Lesbian, and Straight Education Network, 2009). Issues for homeless transgender youth include the humiliation and physical or sexual victimization that occur at shelters, where transgender clients are most often obliged to stay in quarters and use bathrooms or showers based on birth sex among people of a gender with which they do not identify (Mottet & Ohle, 2010). Often, they are not even welcomed into a shelter in the first place (Mottet & Ohle, 2010; Quintana et al., 2010). Additionally, homeless transgender youth transitioning to the gender with which they identify often face health complications from unmonitored hormone and silicone injections obtained from street suppliers.

Recommendations

Standardized Assessment

Programs providing care for homeless youth should conduct basic standardized assessments to identify LGBT individuals and their associated mental health, substance use, and HIV risks. Standardized assessments should include questions for all homeless youth regarding their sexual behavior, sexual orientation, and gender identity. LGBT homeless youth should then be carefully screened for risk of developing depression and anxiety, PTSD, substance use disorders, suicidal ideation, suicide attempts, violent victimization, and HIV risk behaviors. This assessment and screening should be conducted by staff who have undergone sensitivity training in order to be attuned to the needs of these youth.

Best Practices for Serving LGBT Homeless Youth

In 2009, a coalition of organizations supporting LGBT homeless youth published a set of guidelines entitled, “National Recommended Best Practices for Serving LGBT Homeless Youth” (National Alliance to End Homelessness, 2009). They recommend that employees serving homeless LGBT youth should:

• Treat them respectfully and ensure their safety;

• Appropriately address LGBT identity during the intake process;

• Support their access to education, medical care, and mental health care;

• Support transgender and gender-nonconforming youth participants;

• Inform LGBT youth participants about local LGBT programs and services. (p. 4–7).

The guidelines suggest improving organizational culture by recommending that program administrators and supervisors:

• Create a safe and inclusive environment;

• Adopt and implement written nondiscrimination policies;

• Adopt confidentiality policies;

• Provide LGBT competency training to all agency employees and volunteers;

• Establish sound recruitment and hiring policies regarding LGBT competency;

• Develop agency connections to LGBT organizations and the LGBT community;

• Collect and evaluate data on the numbers of LGBT youth accessing services to educate key decision makers and guide programmatic expansion (p. 8–11).

Finally, the coalition’s outlined best practices include recommendations for administrators and youth workers to improve residential services by ensuring safety in shelters and other residential settings (National Alliance to End Homelessness, 2009, p.12).

These recommended best practices should be expanded and adapted to accommodate the unique challenges and needs of specific subpopulations of LGBT homeless youth based on sex, ethnicity, geographic region, sexual behavior, self-identified sexual orientation, and gender identity. While more research is needed to adequately characterize subgroup-specific concerns in order to configure best practices that reflect the diversity of their experiences, areas where there are already compelling data include: gender differences among homeless LGBT youth in the experience of interpersonal violence, patterns of substance abuse in HIV-positive homeless gay/bisexual males, and high-risk substance use and sexual behavior in runaway MSM. The lack of research about the needs of specific high-risk subgroups, particularly homeless transgender persons and minority youth, is notable.

Best Practices for Integrating Mental Health Services

Mental health services for LGBT youth who are homeless would ideally be age-, gender- and culture-specific, grounded in principles of trauma-informed care (Roberts, Rosario, Corliss, Koenen & Austin, 2012; Roberts, Austin, Corliss, Vandermorris & Koenin, 2010; Hopper, Bassuk & Olivet, 2010), and integrated across housing, medical, substance use and social services (Drake, Mueser, Brunett & McHugo, 2004). Given the reality of limited services and resources for homeless youth, it is imperative that at the very least a minimum care package of mental health services be adopted for LGBT youth experiencing homelessness. This would include focused evaluation, and, depending on the availability of mental health training and expertise among staff, referrals for counseling, psycho-education, psychotherapy, and psychopharmacology for mood disorders, trauma and PTSD, and substance use disorders, as well as behavioral interventions such as case management for HIV risk behavior reduction.

Promoting HIV Testing and Condom Use

For youth, ongoing promotion of HIV testing is likely to reduce HIV risk. Among sexually active homeless youth aged 13 to 24 years, being gay is directly associated with increased HIV/STI testing in the past three months (Ober, Martino, Ewing & Tucker, 2012). Thus existing HIV prevention efforts and promotion of testing among homeless gay youth may help to increase their perception of susceptibility to HIV.

HIV education/prevention efforts targeting homeless LGBT youth between 18 and 26 years have engendered more consistent use of condoms (Ream, Barnhart & Lotz, 2012). However, these youth still report that depression, grief, poor self-esteem, purposelessness and social isolation in the context of homelessness can diminish their ability to enforce boundaries related to condom use. Homelessness has been found to indirectly decrease condom use in this population because of the pervasiveness of depressed and anxious feeelings. Additionally, condom use is commonly decreased with primary partners despite the pervasive belief among HIV- and HCV-infected homeless LGBT youth that they acquired infections from their long-term partners (Ream et al., 2012). Thereofre, programs should focus on both HIV risk in the context of long-term romantic relationships and the provision of mental health services that treat anxiety, depression and other negative mood states.

Internet-Based Initiatives

Internet-based initiatives aimed at reducing HIV risk behaviors are an important educational stategy and potentially a treatment vehicle for LGBT homeless youth. Among homeless adolescents and young adults aged 13 to 24 years, gay males search for sexual health information online with significantly greater frequency than other participants (Barman-Adhikari & Rice, 2011). Homeless youth who are actively in touch with their parents on the Internet are more likely to search for HIV/STI information online, and homeless youth to whom health information is delivered online are more likely to seek HIV and HIV-testing information on their own (Barman-Adhikari & Rice, 2011).

Promising Research Directions

Future research should focus on the unique challenges and risks that arise among homeless youth through the interaction of LGBT identity with other aspects of life experience. For example, evidence exists among sexual minority male youth indicating that greater isolation, less connectedness, and lower status within a social network are linked to depressive symptoms, and the correlation between social isolation and depression in this population is stronger than for non-sexual minority youth (Hatzenbuehler, McLaughlin & Xuan, 2012). Thus additional research should be conducted that investigates whether the combination of social isolation and homelessness in a sexual minority intensifies mental health risks among these youth. It is also essential that an accurate national count of LGBT youth who are homeless in the United States be conducted so that much-needed federal funding and crucial clinical services are provided (Ray, 2007).

Understudied populations

Understanding the interplay of LGBT experience with other meaningful identity-related factors, such as aging into adulthood and ethno-cultural identity, has the potential to reveal opportunities for better serving a range of LGBT youth subpopulations that are homeless.

Transition into adulthood

Researchers should assess the differential impact of acute, episodic, and chronic homelessness, as well as the impact of various life milestones, such as high school graduation, on limiting future choices for LGBT youth experiencing homelessness. Additional longitudinal research would assist in developing interventions to mitigate the risk of homelessness among transitional age LGBT youth and then prevent it from progressing into a long-term condition in adulthood.

More studies are also needed to investigate the longitudinal experiences and needs of older LGBT adults experiencing homelessness, given that existing efforts have more often focused on youth. Little is known about LGBT homeless adults, despite the fact that they are also at high risk of mental health problems, substance abuse, HIV, and violent victimization (Newman, Rhodes & Weiss, 2004; Ober, Shoptaw, Wang, Gorbach & Weiss, 2009; Reback, Shoptaw & Downing, 2012; Fuqua et al., 2012).

Ethnic and racial minorities

Given that African Americans and Latino Americans are overrepresented among homeless persons in the United States (estimated at 42% and 13%, respectively) (The United States Conference of Mayors [US Mayors], 2007; US Mayors, 2006; National Coalition for the Homeless, 2009), additional research is needed that focuses on the complex interplay of sexuality, gender, and both ethnic and racial identity. One example of the value of this research is in Arizona, where a community-based study of 32 homeless and/or LGBT youth in a multi-ethnic, majority Latino sample found that higher ethnic identification and linguistic acculturation may be protective against HIV risk among homeless and/or LGBT youth (Marsiglia et al., 2009).

Critical Policy Directions

To our knowledge, an explicitly articulated federal health policy agenda does not yet exist to address homelessness among LGBT youth in the United States. The Center for American Progress (CAP), a leading public policy research and advocacy organization in Washington, D.C., has recommended that federal governmental agencies involved in addressing homelessness specifically recognize LGBT youth who are homeless as a special needs population (Quintana et al., 2010). CAP has also suggested prohibiting discrimination against these youth by all federal agencies.

The Runaway and Homeless Youth Act (RHYA) (Administration for Children and Families, 2008) is the existing federal legislation that funds street outreach programs, drop-in centers, basic needs such as food and clothing, and counseling services for homeless youth. The CAP proposal includes a possible reauthorization of RHYA with nondiscrimination policies for sexual orientation and gender identity, as well as congressional hearings focused on the issue of homelessness among LGBT youth. Future RHYA-funded program development could reflect the caveat from USCIH’s Opening Doors proposal, that “in many cases, youth have become homeless because of hostile and dangerous conditions at home and that reunification with families may not be appropriate for […] many gay, lesbian, bisexual and transgender youth” (USICH, 2010, p. 16).

The CAP recommendations include the option for USICH to develop policies focused specifically on LGBT youth that could be informed by research evidence as well as input from service providers, LGBT community leaders and actual LGBT youth who are homeless. New USICH policies might include nondiscrimination initiatives as well as cultural competency training for service providers focused on sexual and gender identity, and their interaction with ethnicity and race. These initiatives might be financed under RHYA. Finally, the CAP proposal advocates for new research funding, possibly through RHYA, to study the incidence and prevalence of LGBT homeless youth, as well as their diverse service needs, in order to tailor programs accordingly.

Conclusions

LGBT youth are disproportionately represented among homeless persons in the United States and are at high risk for mental health and substance use problems, HIV, and violent victimization. LGBT youth subpopulations have varying needs depending upon age, sex, ethnicity, geographic region, sexual behavior, self-identified sexual orientation, and gender identity. Transgender youth are at particularly high risk. Interventions targeting well-defined LGBT youth subgroups are effective in decreasing behavioral and mental health risks through HIV testing and condom use promotion, Internet-based initiatives, and interventions focused on the needs of specific ethnic/racial LGBT subpopulations are also necessary.

Best practices for serving the mental health needs of LGBT individuals in programs for homeless youth should include staff training in LGBT competency, standardized initial assessment of clients’ sexual orientation, sexual behavior and gender identity, and brief screening for mental health and substance use problems. These assessments can then guide referrals for case management, counseling, psycho-education, psychotherapy, and psychopharmacology for mood disorders, trauma, and substance use disorders, as well as behavioral interventions such as contingency management for HIV risk behavior reduction.

Organizations serving LGBT homeless youth should refer to the existing best practice recommendations for volunteers, employees and administrators in order to help improve mental health among the LGBT youth. Future research should focus on the unique challenges and risks that arise among homeless youth through the interplay of LGBT identity with other sociocultural factors, including the transition into adulthood as well as both ethnic and racial identity. In addition to developing evidence-based practices that are supported by robust outcome research, it is essential that non-discrimination policies be developed. Given the myriad challenges faced by LGBT homeless youth, policy initiatives would ideally involve prohibiting discrimination against LGBT youth, reauthorizing RHYA, and dissemination of explicit LGBT cultural competency training for all providers of services for homeless youth. Finally, USICH might develop evidence-based and community-informed policies focused on LGBT youth. Without further supports, LGBT youth who are homeless will continue to be a lost generation.