Sexual health care for people experiencing homelessness

Additional barriers and unique challenges to accessing sexual and reproductive health care services.

by Mari Lowe, NP-C

published 04/15/20

People experiencing homelessness face several challenges that affect their access to sexual health care. Unstable housing makes communication, transportation, and safety more difficult, affecting a patient’s ability to come to appointments, receive test results, fill prescriptions, and manage follow-up appointments. However, homeless patients often have the same questions about their sexual health as people with more stable housing, and they are often eager to make healthy, well-informed choices for themselves.

Here are a few tips for providing care to this patient population:

Use a Trauma-Informed Approach to History Taking

The first step to providing high-quality sexual health care is often taking a detailed social and sexual health history. This information is key to providing client-centered care and gives us a more nuanced picture of our patients’ lives outside of the exam room. Since rates of physical violence, sexual violence, substance misuse, and mental illness are higher in the homeless population compared to the general population, it’s also important to ask about these issues so that they can be connected to support and treatment as needed.

When taking a health history, use a trauma-informed approach by asking questions in a sensitive and non-judgmental manner. For example, clarifying preferred pronouns allows you to address patients with the language they use to identify themselves. Asking your patients where they live with an open-ended question such as, “Where are you staying?” allows your patient to define their housing status instead of assuming they are housed. Follow up questions can be helpful to clarify if this a temporary space or a recent move for them, as well as with whom they live.

When it comes to getting a sexual health history, ask your homeless patients the same questions that you would ask all of your patients, including sexual practices, partner history, sexually transmitted infection (STI) history and protective behaviors, current contraception use and history, and reproductive history.

Use Explicit Consent to Approach Physical Exams in a Sensitive Manner

Due to higher rates of stress and trauma, physical exams can be nerve-wracking for people experiencing homelessness. So, first consider if a physical exam is even necessary. If a physical exam is necessary, use the principles of explicit consent to get permission from your patient prior to examining them. Explain why a physical exam is helpful to their health and what the exam will entail. Offer to have a chaperone present for emotional support and as an additional calming presence. Proceed with the exam at a speed that feels comfortable for the patient, making sure to leave space for patients to ask questions when they want. When the exam is done and prior to stepping out of the room, make sure they have access to anything they would need to clean up.

Discuss Birth Control and Pregnancy Desires

Asking One Key Question® to all of your patients capable of becoming pregnant is an excellent way to kick off a conversation about their pregnancy desires. If your patient answers “no,” follow-up questions include asking if they are currently using or are interested in starting birth control, assessing their contraceptive needs, and reviewing methods that can help them meet their reproductive well-being goals.

Access to contraception as well as correct and consistent use is a challenge for most people using birth control. However, patients experiencing homelessness face additional barriers including the risk of having their medications stolen in a shelter setting, including birth control pills. When starting a homeless patient on a birth control method that requires a prescription, such as the pill or the patch, ask patients how often they prefer to pick up their medications, since your patient may feel better knowing they can access their medications from the pharmacy each month, rather than trying to protect a larger supply from theft. On the other hand, they may prefer fewer trips to the pharmacy to save on travel expenses, so let the patient make the choice for what works best for them. For patients who choose the ring, be mindful that some people who are homeless do not have access to refrigeration, so consider Annovera or a monthly prescription for NuvaRing may lessen the burden of storing extra rings.

Offer STI Testing, Treatment, and Counseling

All patients, regardless of housing status, should be offered STI testing, treatment, and counseling based on their individual risks and the CDC guidelines. While point-of-care lab testing is the simplest option for getting patients their results, it’s not available for all STIs and can be costly for providers and patients. To help your patients get their STI test results, ask them how they want to be contacted, since not everyone has an address or access to a phone or email, and confirm their personal and emergency contact information. If needed, assist the patient with scheduling a follow-up visit for a few days later so that you can review any outstanding test results in person.

Talk to patients about STI protective behaviors like using condoms to reduce the risk of STIs and taking pre-exposure prophylaxis (PrEP) for those at high risk of HIV infection. If condoms are available on-site, giving them out in small plastic bags can protect them from water damage if patients don’t have a dry place to store their belongings.

Bottom Line:

Patients, regardless of their housing status, likely have the same questions about their sexual health and have the same needs for testing, treatment, and counseling as everyone else. However, they do face some additional barriers and unique challenges in accessing sexual and reproductive health care services. And just like with any patient, use a trauma-informed approach to start conversations about potentially sensitive topics, like sexual and reproductive health, and during physical exams.

Mari Lowe, NP-C, works as a family nurse practitioner in Washington, D.C., serving in respite care and medical outreach for people experiencing homelessness. She previously spent several years incorporating sexual and reproductive health into primary care at Unity Health Care. In her free time, you’ll find her reading the latest non-fiction book or practicing yoga.
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