Homeless Adolescents: Common Clinical Concerns Jennifer Feldmann, MD and Amy B. Middleman, MD, MPH, MSED Homeless youth are at alarmingly high risk for a myriad of physical and psychological problems as a result of both the circumstances that prededed their homelessness, and as a direct consequence of life on the streets. Sexually transmitted infections (STIs), pregnancy, trauma, tuberculosis, uncontrolled asthma, and dermatologic infestations are a few of the health problems with which these youth commonly present. These somatic problems are compounded by high rates of drug and alcohol abuse as well as depression and suicide. Despite the obvious need for medical services, homeless youth often do not receive appropriate medical care due to numerous individual and systems barriers impeding health care access by this population. In addition to the barriers experienced by the adult homeless population, homeless adolescents confront further hurdles stemming from their age and developmental stage. Some of these impediments include a lack of knowledge of clinic sites, fear of not being taken seriously, concerns about confidentiality, and fears of police or social services involvement. Improved access to appropriate health care is necessary if we are to better support and care for this population of young people. To effectively manage and treat homeless youth, individual providers must be aware of the diagnoses associated with homelessness, as well as the community resources available to these youth. Finally, providers need to be the voices advocating for improved services for this disadvantaged and silent population. © 2003 Elsevier Inc. All rights reserved.
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n caring for adolescents, physicians must remember that unaccompanied homeless youth (“street youth”) merit special concern and attention. This hidden population is at uncommonly high risk for developing a variety of negative social and health outcomes. Homeless youth are a heterogeneous group, and include: 1) “situational runaways,” youth who leave home for short periods of time (1 to 2 days) and then usually return home; 2) “runaways” who leave home and stay away for long periods of time, typically as a result of problems with parents such as neglect, abuse, or serious conflict; 3) “throwaways,” youth who have left home because of severe abuse and/or neglect, parental abandonment, or being “kicked out”; and 4) “systems youth,” youth who have spent a large portion of their lives in public institutions or foster care.1 All are included in the definition of homeless youth in this article.
From the Baylor College of Medicine, Department of Pediatrics, Adolescent and Sport Medicine Section, Texas Children’s Hospital, Houston, TX Supported by Project #MCJ-489501 from the Maternal and Child Health Bureau (Title V, Social Security Act), Health Resources and Services Administration, Department of Health and Human Services. Address correspondence to Jennifer Feldmann, Fellow in Adolescent Medicine, Baylor College of Medicine, Department of Pediatrics, Adolescent and Sport Medicine Section, Texas Children’s Hospital, Houston, TX 770302399; e-mail:
[email protected] © 2003 Elsevier Inc. All rights reserved. 1045-1870/03/1401-0002$30.00/0 doi:10.1053/spid.2003.127211
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Estimates of the size of this growing at-risk population vary widely from 500,000 to 2 million.2,3 Although these estimates are staggering, they most likely are conservative estimates because of the multiple confounding factors that prevent accurate quantification. Their high residential mobility, living in areas that often are inaccessible to typical survey methodologies (ie, hotels, abandoned buildings, and the streets), and mistrust of authority figures are some of the factors that impede accurately assessing the size of this “hidden” population.1,4 Both the factors that lead an adolescent to become homeless and the problems homeless youth encounter living on the street place them at great risk for development of a host of negative health outcomes. In comparing the health histories of homeless youth with the general adolescent population of Minnesota, a greater percentage of homeless youth report medical problems in every health category surveyed.5 Lack of access to adequate hygiene, crowded shelters, exposure to the elements, drug abuse, violence, poor sanitation, and engaging in survival sex (exchanging sex for food, shelter, drugs, security or money) all contribute to the health issues faced by homeless youth. Our personal experience working at Covenant House, Texas, a shelter with clinic facilities for shelter residents and street youth in Houston, Texas, as well as experience reported in several studies reveal that sexually transmitted infections (STIs), respiratory problems, dermatologic infection and infestations, gastrointestinal complaints, dental disease, drug abuse, trauma, and psychiatric disease are conditions commonly encountered among this population.5-8
Seminars in Pediatric Infectious Diseases, Vol 14, No 1 ( January), 2003: pp 6-11
Clinical Concerns of Homeless Adolescents These clinical findings mirror the concerns of homeless teenagers who identify the most common health problems they face to be STIs, human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), pregnancy, depression, drug use, and injuries–all realities of life on the streets.6 This paper discusses the health effects that result from or are exacerbated by the circumstances and behaviors of homeless teens. Access to care is inextricably bound to health consequences and is discussed in the context of barriers to providing care for this homeless adolescent population.
Physical Problems STIs STIs, including gonorrhea, chlamydia, herpes, trichomonas, HIV, and syphilis, are one of the primary sources of morbidity for homeless youth. Many studies have demonstrated that homeless youth initiate sexual activity earlier and exhibit more risky sexual behaviors than do their domiciled peers. The mean age of onset of sexual activity for homeless youth is 12 to 13 years, approximately one year earlier than that of their home-based peers.5,9-11 These early initiators are less likely to have used condoms at first intercourse; consequently, the prevalence of STIs has been found to be higher among the younger members of this cohort.5,12 Additionally, greater than one-third of homeless youth report having been victims of sexual abuse,1,9 often a significant contributing factor to their homelessness. In a study of homeless youth in Baltimore, sexually abused teens were 3.8 times more likely to have been forced to have sex than were their school-based peers.5,10 Individuals with a history of victimization also are more likely to engage in survival sex.13 Findings vary, with 10 to 54 percent of homeless young people reporting involvement in survival sex; teenagers who have been pregnant, are gay or bisexual, are street-based (versus shelter based), and have participated in criminal activity and drug use are more likely to have participated in prostitution.5,9,13 With this enormous burden of sexual risk-taking behavior, it is not surprising that STIs are a common diagnosis among this population. Among the general adolescent population in Minnesota, 8 percent of respondents reported “ever having had an STI.” This figure is in contrast to the 40 percent of homeless youth in San Francisco who report having had an STI.5 Studies among homeless youth have found the following STI prevalences: 4.7 to 27 percent for chlamydia14,15; 1.1 to 4.2 percent for gonorrhea5,12; 7.9 percent for trichomoniasis5; 0.5 percent for syphilis5; and 5.5 percent for herpes type-2 with an annual incidence of 11.7 percent.14 Although risk clearly is excessive for all homeless youth, street-based youth as compared with shelter-based youth are 4.5 times more likely to report having had an STI, putting them at even greater risk.11
HIV/AIDS Rates of HIV infection among homeless youth are two to ten times higher than the rates reported for other samples of U.S. adolescents.16 Comparing prevalence rates across age-matched groups with different risk profiles clearly il-
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lustrates the gravity of the situation faced by “street youth.” Among military recruits, prevalence rates of 0.03 to 0.06 percent have been found.1,17 This rate is in contrast to the 5.3 to 12 percent prevalence rates at sites providing services to homeless youth.1,5,18 The primary risk factors for HIV infection include a history of STI infection, intravenous drug use (IVDU), crack cocaine use, prostitution, older partners, and homosexual and bisexual activity.1 Further, infection rates are higher among African Americans than whites, with the highest risks found among older male street youth, the group least likely to be in contact with prevention services.18,19 Immediate survival needs often supercede the long-term threat of HIV, which, in the face of hunger and victimization, often seems irrelevant.6 Condom use among street youth tends to be inconsistent and dependent on the context of the relationship. Although condoms often are used with clients for oral, anal, and vaginal sex and with casual partners for vaginal and anal sex, condoms often are not used among “main” partners. An awareness of transmission prevention methods varies, with young men who have sex with men demonstrating the greatest knowledge of protective strategies compared with heterosexual youth, who have the weakest knowledge.20
Hepatitis Given the high prevalence of HIV infection and associated risk factors, one is not surprised that the prevalence and incidence of hepatitis B (HBV) and hepatitis C (HCV) are 10 to 12 times higher among homeless youth than among the general adolescent population.14 Prevalence rates of 3.6 to 9.2 percent for HBV and 5 to 12.6 percent for HCV have been reported.14,21,22 A study of 150 homeless youth found 22 percent of the subjects to be positive for serum markers of either HBV or HCV.9 Factors predicting HBV or HCV positivity are much the same as for HIV, with lifetime crack cocaine use, homosexual/bisexual orientation, IVDU, and prostitution all predictive. Tattooing has been found to be marginally predictive, whereas the data are divided on the predictive value of body piercing.21,22 Although hepatitis A (HAV) infection is not sexually transmitted, the living circumstances of homeless youth leave them vulnerable to acquisition of it as well. Two Canadian studies found serologic evidence of prior HAV infection in 4.7 percent and 6.3 percent of homeless youth. Birth in a country with high rates of HAV, increased age, IVDU, and insertive anal penetration all were associated with prior infection.23,24 Given the risk and morbidity of the various hepatidities and the availability of vaccines for both HBV and HAV, providers should offer routine immunization to this highrisk cohort of youth.
Pregnancy The high-risk sexual activity in which many homeless youth participate also puts them at risk for pregnancy. When comparing shelter-based youth with school-based youth, the
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shelter-based population was found to be 2.3 times more likely to have been pregnant.10 This risk is further amplified for street-based youth who are 7.8 times more likely than are shelter-based youth to have ever had a child.11 This high risk is echoed in the concerns of homeless female youth who ranked pregnancy as the second most important health problem facing homeless teens; STIs were first, and AIDS ranked third. In explaining why pregnancy was more concerning than AIDS, the group reported “more teens get pregnant than get AIDS, so even though AIDS can kill you, pregnancy messes up more kids’ lives.”6 Factors including poor general health, dietary restrictions and limited prenatal care contribute to the increased risk of having low-birth weight infant and to high infant mortality rates.1
Dermatology Thirty-one percent of homeless teens receiving care at a primary care clinic in San Francisco had dermatologic findings including acne, atopic dermatitis, old scars, and burns.5 Dermatologic concerns including sunburn and frostbite are not uncommon sequelae of prolonged exposure to the elements. Impetigo as well as infestations of scabies and lice occur frequently among this population because of the crowded conditions and poor hygiene.8 Tinea, particularly tinea pedis, is seen frequently, because these teens may go for extended periods of time without removing their damp shoes and socks. Treatment can be difficult as readily available shower facilities necessary to utilize shampoos, soaps, and creams cannot be assumed to be available. Further, prevention of recurrence is troublesome because their avoiding the outdoor elements and crowded conditions is nearly impossible for these teens.
Respiratory Tuberculosis. With regard to tuberculosis (TB), homeless youth encounter many of the same risks as do homeless adults, and with the rates of TB being as much as 20 times higher for homeless individuals than for the general population, the risk is significant.25 The prevalence of latent TB among the homeless has been found to be as high as 40 to 67 percent, and not surprisingly, skin test positivity rates are much greater in the inner-city.25,26 The homeless population is an important reservoir of infection for the general population given their high mobility, and homeless youth are at high risk of becoming infected and contributing to the spread of TB. Risk factors for TB skin test positivity relevant to homeless youth include living in crowded conditions, long-term homelessness, and prior psychiatric hospitalization.26 HIV also plays an important role in the prevalence of TB among the homeless, and a positive TB skin test should be followed by an HIV test, because treatments for HIV-positive and HIV-negative individuals vary Asthma. Asthma affects a significant number of homeless youth. Asthma triggers such as mold, cockroaches, rodents, psychosocial stress, and upper respiratory infections are frequent fixtures of homeless life.27 Combining the numerous triggers with limited availability and affordability of medications, one is not surprised that shelter-based teens with a
history of asthma are 2.2 times more likely to have visited an emergency room (ER) in the last 12 months than are their school-based peers.10 In our experience at Covenant House, asthma is a common problem and many teenagers with asthma have been without medications since leaving home.
Dental In looking at dental disease among homeless youth, one must extrapolate from the literature on both homeless adults and children. As compared with the general public, homeless children have 10 times the rate of poor dentition. Further, 28 percent of children have visible caries on examination.27 This baseline risk is augmented by other contributors of dental disease, including poor hygiene, smoking, alcohol use, and lack of regular dental care.8
Trauma/Violence As discussed earlier, homeless youth often experience victimization. Violence perpetrated by them, toward them, or toward those around them is prevalent. As compared with youth accessing care at a school-based clinic, homeless youth were 5 times more likely to have been beaten, 2.5 times more likely to have witnessed a shooting or stabbing, and 4 times more likely to have ever thought of killing someone else.10 The odds for all these violence-related risks are 2 to 3 times higher still for street-based youth.11 Although females are more likely to be sexually assaulted and to fear further victimization, males and females have comparable levels of exposure to violence; males tended to be perpetrators of violence more often than were females.28
Mental Health Issues Drug and Alcohol Use Substance abuse is one of the most concerning health-risk behaviors among the homeless population. As with other highrisk behaviors, a continuum of risk appears to exist, with street-based youth being at highest risk, shelter-based youth at significant but comparatively less risk than street-based youth, and home-based youth encountering the least risk. A recent study utilizing three national samples found that for nearly every substance, street-based youth reported the greatest use.4 Examination of substance use among this highestrisk stratum reveals that three-quarters of subjects reported marijuana use; one-third reported using analgesics, stimulants and hallucinogens; and one-quarter acknowledged using cocaine and/or crack cocaine, inhalants, and/or sedative during the 30 days preceding leaving home until the day of the interview.4 Shelter-based youth reported substance use patterns that are much like those reported in household youths with recent runaway or homeless experience. Notable exceptions are for the use of marijuana, which was more common among shelter-based youth, and the use of alcohol, which was more common among housed but recently homeless youth.4 In comparing use histories of street youth, shelter-based youth, and randomly selected home-based youth, the differences are striking. Of the twelve substances included on one
Clinical Concerns of Homeless Adolescents survey, the average number of drugs used from 30 days before leaving home to the day of the interview for street youth was 4.6 and for shelter-based youth was 2.2. These figures are in contrast to a mean lifetime use of 1.7 substances for homebased youth. These data translate into 71 percent of streetbased youth and 46 percent of shelter-based youth having used 3 or more substances during the 30 days before leaving home until the day of the interview, and 25 percent of home-based youth ever having used 3 or more substances.4 Studies have found rates of IVDU from 15.1 percent to as high as 33.8 percent among the homeless youth.4,5,14 Despite these extremely high use rates, one study based in San Francisco found that only 6.5 percent of homeless teenagers have been in drug treatment, and only 9.3 percent feel that drugs are a problem for them.5 In fact, youth report drug use to have functional value as an escape from the difficulties and uncertainties that are part of homelessness.6 Not surprisingly, the longer individuals are on the street, the more they become involved in substances abuse.1
Depression/Suicide Homeless youth suffer from a wide range of mental health problems that often coexists with physical and substance abuse problems. Rates of formally defined disorders including major depression, conduct disorder, and posttraumatic disorder are at least three times higher than those among nonhomeless controls.29 Depression is the diagnosis most commonly reported. One study found a current DSM-IV diagnosis of major depression in 12.2 percent of homeless youth and dysthemia in 6.5 percent. Rates were higher in older adolescents and among females. Rather than following homelessness, depression appeared to precede it. A diagnosis of depression or dysthymia was found to be associated with other risk factors, including infrequent condom use, nonheterosexual orientation, and a current diagnosis of an STI.30 Another study found that 44 percent of homeless young people reported “feeling depressed or sad often.” Among those that reported a history of sexual abuse, 62 percent endorsed feeling depressed. Forty-two percent of the surveyed population had considered or attempted suicide.5 In comparison with schoolbased youth, the shelter-based youth are 3.7 times more likely to report having considered suicide.10 Consequently, rates of psychiatric hospitalizations are much higher among homeless adolescents than among their domiciled peers, in part due to the high number of suicide attempts and high rates of sexual abuse.1
Barriers to Care for Homeless Youth Quality health care for homeless youth is difficult to access. Some barriers are associated with the homeless youth themselves, including distrust of adults and professional agencies, denial of need for care, fear of discrimination, and lack of knowledge about available services. Factors associated primarily with systems of care include lack of transportation for youth to access facilities, few appropriate facilities for obtaining health care, and the lack of knowledge among individual providers regarding optimal treatment for this population. Legislation has been in place to help protect the health and welfare of the homeless, including homeless youth, but more needs to be done to help
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overcome these numerous barriers to providing quality health care to this vulnerable population.
Barriers Associated with Youth Many of the barriers to obtaining health care that homeless youth describe in published reports include factors that are not significantly different from those perceived by all adolescents. Many of the concerns clearly are related to the youths’ cognitive developmental stage. Among a group of 89 street youth served by two community agencies in Minneapolis, Minnesota, 12 percent reported negative impressions of the health care they had received most recently, including a dislike for the doctors or hospitals, “communication problems,” complaints of a long wait for care, and perceived incompetence of the healthcare professionals.31 A subset of youth who had had serious health problems within the past several years were asked what they saw as barriers to obtaining health care. One-half of the youth reported that they did not even receive health care for their problems, and they listed the following reasons: 31 percent felt that the problem did not warrant a health care visit, 11 percent chose self-care, 11 percent “toughed it out,” 8 percent stated that they were not yet ready to address the problem, and 8 percent were concerned that they did not have the resources to pay for care.31 Less commonly cited were that youth preferred talking to friends, were embarrassed or afraid to seek care, were dissatisfied with a prior experience, prayed that things would improve, or simply “didn’t feel like it.”31 Some other barriers youth endorsed when presented with a list of potential barriers included fear of racial discrimination, fear of returning to clinic if money was owed, transportation issues, a dislike of doctors telling them how to lead their lives, lack of knowledge of where to go for care, clinic not open when they can go, fear of finding out what is wrong, fear of not being taken seriously, not trusting adults, fear of pain, concerns about the maintenance of confidentiality, embarrassment, and others.31 Other reports cite similar concerns on the part of youth.1,6 Youth who are homeless often have come from homes that do not value them. They have been victimized and exploited by adults in many cases. Trusting other adults and professionals is very difficult for many homeless youth. In addition, homeless youth may be involved in illegal activities for survival in the streets, including prostitution, drug dealing, drug abuse, and stealing. Fear of involvement by police or social services may serve as barriers to accessing health care.1 Importantly, the time and energy required to find safe shelter and adequate food on the streets renders accessing health care difficult, especially during the times when most clinics are operating.32 Ensign and Gittelsohn confirm this concern in their qualitative study of homeless youth in Baltimore.6 Youth identified the ERs of the major academic hospitals in town as the primary source of health care because “they are always open.”6 In a study of 109 homeless youth who had lived on the street or in temporary arrangements with friends versus in foster care, youth who lived on the streets were significantly more likely than were youth in foster care to report having used a hospital ER within the past year.11 In another study, homeless youth were twice as
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likely as were youth using a school-based health clinic to report using an ER in the past 12 months.10 Only an estimated 1 in 12 runaway youth are served by federally funded shelters,1 and only one-quarter of homeless youth seen by shelter workers receive medical services.5 Homeless youth often identify themselves as being very different from homeless adults– or “bums,” thus making clear that this perception serves as a barrier to accessing some traditional sites of health care for the homeless.6 Some youth complain that shelters such as Covenant House, Texas in Houston have rules that are too strict; homeless youth often have become accustomed to abiding by few rules and boundaries on the streets; they often have difficulty adjusting to curfews, wake-up times, and work/study requirements.
Systems of Care Barriers Many healthcare facilities not accustomed to treating homeless youth present barriers to homeless youth needing health care. Providers seeing a largely middle class group of patients may discourage homeless access because of bias against indigent patients who may have cleanliness issues and be poorly clothed.33 However, not all patients are obviously homeless in their appearance. Many youth will not volunteer that they are homeless, and the astute provider will need to formulate the possible diagnosis of homelessness from the patient’s health issues. In a study of street youth in San Francisco, 98.6 percent of street youth presenting for an examination initially appeared healthy to the provider; despite this initial appearance, many exhibited medical problems common to the homeless that required diagnosis and treatment.5 Frequent patient relocation renders continuity of care very difficult to establish with homeless youth and complicates providing appropriate care. Very importantly, the lack of coordination of health services among social, educational, vocational, and legal services for these youth renders seeking health care at most sites less desirable for homeless adolescents who would need to access separate sites for multiple services.1 Also helpful is for healthcare facilities to be familiar with their state’s guidelines on a minor’s ability to consent for care. Youth who are financially independent from parents may consent for their own care. This includes youth living apart from their parents and “managing their own financial affairs.”34 Providers may treat these minors based on the minors’ own consent. Being able to allow youth to sign for their own confidential care is critical to achieving optimal care for this population of youth. Many model programs have been developed to provide quality health care to homeless adolescents. These programs, not unlike services ideal for all adolescents, allow for adolescent-centered care where the care plan is adapted to the patient, provide comprehensive care by drawing on community resources in collaboration to care for the patient in a way that promotes the dignity of patients, empower youth, serve all runaway and homeless youth, provide services that attract youth, are flexible in service provision and funding, are culturally sensitive, are family-focused when able, and target youth strengths.1
The Solution? Federal or community support to provide these ideal services to homeless youth is very limited. The Stewart B. McKinney Homeless Assistance Act, signed into law in July of 1987, was the first major federal legislative response to homelessness. The act has been amended several times during the ensuing years, but it remains the only major response to homelessness on the part of the government of the United States. The act currently contains nine titles that provide for multiple government programs or program expansions to help the homeless obtain food, shelter, education, and health care. Several programs for healthcare services for the homeless are administered by the Department of Health and Human Services and include Health Care for the Homeless (HCH), a Community Mental Health Services block grant program, and two demonstration programs providing mental health and alcohol and drug abuse treatment services.35,36 HCH grants and distributes funds to community resources that implement services targeted for the homeless. The goals of the programs are to provide for primary health care and substance abuse services at locations accessible to the homeless, provide emergency care with referrals to hospitals for inpatient care services and/or to needed mental health services, provide outreach services to access homeless persons who are difficult to reach, and provide aid in establishing eligibility for entitlement programs and housing.37 A listing of the programs receiving support in your area are available on the HCH website. This federal funding, which for HCH in the year 2001 was approximately $101 million, has helped support much needed health care for the homeless in all 50 of the United States, the District of Columbia, and the Commonwealth of Puerto Rico. From the concerning figures of the health status of the homeless stated within this article, however, clearly more work needs to be done. Individual providers can help by being cognizant of the medical diagnoses that may indicate homeless status among patients and by working to address all of the patients’ concerns. Systems of care can address concerns regarding continuity of care and ensure availability of transportation and accessible hours of operation for homeless patients. Communication systems that take into account limited phone access for patients are needed. Most important is that providers be aware of the resources available for referrals for homeless youth, including nearby HCH sites of care. Resources that are available to providers include information and strategies to increase access to health care by the homeless.27,35,36 Advocating for additional funding and the full authorization of healthcare programs that provide important school-based services such as the Healthy Schools/Healthy Communities program currently in existence would be of help to all homeless youth.27 Phone numbers and website addresses for resource information are provided in the reference section of this paper.
Summary Street and sheltered youth are particularly vulnerable to a myriad of health problems directly resulting from their homeless status. They develop greater rates of STIs, including HIV and AIDS, dermatologic issues, respiratory prob-
Clinical Concerns of Homeless Adolescents lems exacerbated by homeless life, and trauma and violence. Not surprisingly, higher rates of mental illness exist among the homeless population of youth. To support and care for this population of youth, youth access to appropriate health care is required. Individual providers can be aware of the diagnoses associated with homelessness to effectively manage and treat this population, but an awareness of further community resources, accessible on line at various websites, would further aid in providing optimal care. Finally, advocacy for improved care of street and “throwaway” youth in this country might help improve the health outcomes of a new generation of troubled teens.
References 1. Farrow JA, Deisher RW, Brown R, et al: Health and health needs of homeless and runaway youth. A position paper of the Society for Adolescent Medicine J Adolesc Health 13:717-726, 1992 2. Center for Population Options. Out of the Shadows: Building an Agenda and Strategies for Preventing HIV/AIDS in Homeless Youth. 1990. Washington, DC, Center for Populations Options. 3. Ringwalt CL, Greene JM, Robertson M, et al: The prevalence of homelessness among adolescents in the United States. Am J Public Health 88:1325-1329, 1998 4. Greene JM, Ennett ST, Ringwalt CL: Substance use among runaway and homeless youth in three national samples. Am J Public Health 87:229-235, 1997 5. Sherman DJ: The neglected health care needs of street youth. Public Health Rep 107:433-440, 1992 6. Ensign J, Gittelsohn J: Health and access to care: perspectives of homeless youth in Baltimore City, U.S.A. Soc Sci Med 47:2087-2099, 1998 7. McNamee MJ, Bartek JK, Lynes D: Health problems of sheltered homeless children using mobile health services. Issues Compr Pediatr Nurs 17:233-242, 1994 8. Usatine RP, Gelberg L, Smith MH, et al: Health care for the homeless: a family medicine perspective. Am Fam Physician 49:139-146, 1994 9. Beech BM, Myers L, Beech DJ: Hepatitis B and C infections among homeless adolescents. Fam Community Health 25:2836, 2002 10. Ensign J, Santelli J: Health status and service use. Comparison of adolescents at a school- based health clinic with homeless adolescents Arch Pediatr Adolesc Med 152:20-24, 1998 11. Ensign J, Santelli J: Shelter-based homeless youth. Health and access to care Arch Pediatr Adolesc Med 151:817-823, 1997 12. Poulin C, Alary M, Bernier F, et al: Prevalence of Chlamydia trachomatis and Neisseria gonorrhea among at- risk women, young sex workers, and street youth attending community organizations in Quebec City, Canada Sex Transm Dis 28:437-443, 2001 13. Greene JM, Ennett ST, Ringwalt CL: Prevalence and correlates of survival sex among runaway and homeless youth. Am J Public Health 89:1406-1409, 1999 14. Noell J, Rohde P, Ochs L, et al: Incidence and prevalence of chlamydia, herpes, and viral hepatitis in a homeless adolescent population. Sex Transm Dis 28:4-10, 2001 15. Bunnell RE, Dahlberg L, Rolfs R, et al: High prevalence and incidence of sexually transmitted diseases in urban adolescent females despite moderate risk behaviors. J Infect Dis 180:16241631, 1999 16. Rotheram-Borus MJ, Koopman C, Haignere C, et al: Reducing HIV sexual risk behaviors among runaway adolescents. JAMA 266:1237-1241, 1991
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17. Burke DS, Brundage JF, Goldenbaum M, et al: Human immunodeficiency virus infections in teenagers. Seroprevalence among applicants for US military service. The Walter Reed Retrovirus Research Group. JAMA 263:2074-2077, 1990 18. Allen DM, Lehman JS, Green TA, et al: HIV infection among homeless adults and runaway youth, United States, 1989-1992. Field Services Branch AIDS 8:1593-1598, 1994 19. Clatts MC, Davis WR, Sotheran JL, et al: Correlates and distribution of HIV risk behaviors among homeless youths in New York City: implications for prevention and policy. Child Welfare 77:195-207, 1998 20. Wagner LS, Carlin PL, Cauce AM, et al: A snapshot of homeless youth in Seattle: Their characteristics, behaviors and beliefs about HIV protective strategies. J Community Health 26:219-232, 2001 21. Roy E, Haley N, Lemire N, et al: Hepatitis B virus infection among street youths in Montreal. CMAJ 161:689-693, 1999 22. Roy E, Haley N, Leclerc P, et al: Risk factors for hepatitis C virus infection among street youths. CMAJ 165:557-560, 2001 23. Ochnio JJ, Patrick D, Ho M, et al: Past infection with hepatitis A virus among Vancouver street youth, injection drug users and men who have sex with men: Implications for vaccination programs. CMAJ 165:293-297, 2001 24. Roy E, Haley N, Leclerc P, et al: Seroprevalence and risk factors for hepatitis A among Montreal street youth. Can J Public Health 93:52-53, 2002 25. Brewer TF, Heymann SJ, Krumplitsch SM, et al: Strategies to decrease tuberculosis in us homeless populations: A computer simulation model. JAMA 286:834-842, 2001 26. Gelberg L, Panarites CJ, Morgenstern H, et al: Tuberculosis skin testing among homeless adults. J Gen Intern Med 12:2533, 1997 27. National Health Care For The Homeless. National Health Care for the Homeless Council 2002 Policy Statement. 2002. http://www.nhchc.org/ 28. Kipke MD, Simon TR, Montgomery SB, et al: Homeless youth and their exposure to and involvement in violence while living on the streets. J Adolesc Health 20:360-367, 1997 29. Shaffer D, Caton CLM. Runaway and homeless youth in New York City: A report of the Ittleson Foundation. 1984. New York, Division of Child Psychiatry, New York State Psychiatric Institute, and Columbia University College of Physicians and Surgeons. 30. Rohde P, Noell J, Ochs L, et al: Depression, suicidal ideation and STD-related risk in homeless older adolescents. J Adolesc 24:447-460, 2001 31. Geber GM: Barriers to health care for street youth. J Adolesc Health 21:287-290, 1997 32. Bureau of Primary Health Care. HRSA Fact Sheet. 1998 33. Scharer LK, Conanan BA, Savarese M, et. al: Under the safety net: The health and social welfare of the homeless in the United States. United Hospital Fund Bookpub, 1990 34. English A: Treating adolescents. Legal and ethical considerations Med Clin North Am 74:1097-1112, 1990 35. Department of Health and Human Services. Homeless. http:// aspe.os.dhhs.gov/progsys/homeless/ 36. National Coalition For The Homeless. Homeless Youth: NCH Fact Sheet #18. 1999. National Coalition For The Homeless. http://nch.ari.net/direct1.html 37. Health Resources and Service Administration, Bureau of Primary Health Care. Health care for the homeless information resource center–The comprehensive response. Health Resources and Service Administration, Bureau of Primary Health Care, 2002
