Pediatricians are in a prime position to identify and support youth experiencing homelessness in both clinic and hospital settings, and to respond to their myriad health needs. Youth homelessness can be invisible, as their common forms of homelessness, such as couch-surfing, can be challenging to accurately quantify, and thus most counts are considered to be underestimates.1,2 Surveys in this population have identified parental rejection as a primary driver of youth homelessness.3 It is not surprising, then, that youth homelessness disproportionally affects lesbian, gay bisexual, transgender, questioning + (LGBTQ+) individuals, as well as racial and ethnic minorities and other structurally marginalized groups.2 Understanding the unique social barriers and health needs faced by this population is critical in designing clinically responsive programs as well as effective policy.4
In this issue of Pediatrics, Deal and Gonzalez provide an analysis of Youth Risk Behavioral Survey data from 21 states, finding that sexual minority youth were 3 times more likely to have experienced homelessness in the past month.5 Further, sexual minority youth who had experienced homelessness reported higher-risk sexual practices and more mental health symptoms. The authors highlight the need for tailored public health and clinical services, eg, sexually transmitted infection testing and treatment and offering of pre-exposure prophylaxis, to mitigate harms of higher risk behaviors among youth experiencing homelessness.
Astonishingly, in this national sample comprising hundreds of thousands of individuals, almost 50% of all sexual minority youth who had experienced homelessness reported having attempted suicide. This astoundingly high rate speaks to the trauma burden of unhoused sexual minority youth, but also the risk of incurring further trauma while homeless,6 and accordingly, the need for access to trauma-informed, comprehensive mental health treatment. Although any community health center or academic practice would be able to offer such services, we would argue that Health Care for the Homeless programs—which share a core set of principles, including meeting patients where they are, offering judgment-free, trauma-informed care, and “1-stop shopping” integrated care7 —are uniquely positioned to create outreach programs that meet the needs of sexual minority youth. A collaborative approach inclusive of shelter-based medical programs is one recommended by the American Academy of Pediatrics (AAP) to best meet the needs of unhoused youth and families.6
The eye-opening findings in this study underline the vital importance of screening for homelessness and other social drivers of health to identify at-risk adolescents as recommended by the AAP.8 The findings highlight the importance of capturing sexual orientation and gender identity data for every patient as well. The National LGBTQIA+ Education Center has a number of helpful toolkits and webinars designed to support clinical practices in implementing the collection of sexual orientation and gender identity data.9 This data collection, along with race, ethnicity, and other demographic factors, allow us as pediatricians to tailor care to reduce inequities.
In this study, state-level policy environments were not associated with increased risk for homelessness. The authors posit that this may be because of a data lag reflecting policy environments several years behind public attitudes toward LGBTQ+ populations. They also note that policy may need to prioritize a focus on addressing stigma to be most effective in keeping youth safe. They make this recommendation because of the critical finding that state-level acceptance of homosexuality was associated with lower risk of homelessness, not only for sexual minority youth but across all youth. This finding about state-level acceptance suggests that in states with broader support of the LGBTQ+ community and thus broader family acceptance, there are fewer youth driven into homelessness. Additionally, programs in these states may be more responsive and accepting across the intersectional identities of gender, race, and ethnic minoritized youth. Although further research is needed, we implore state and national officials to ensure that such research is action-oriented, testing policy and clinical interventions aimed at keeping sexual minority youth alive.
We applaud the authors on this important paper examining the association between sexual minority status, health, and homelessness in adolescents. Unhoused sexual minority youth are at an incredibly high risk of suicide. The finding that state-level acceptance of sexual diversity is protective, however, is a powerful call to action. To ensure the well-being of all young people, clinicians and policy makers should pursue tailored clinical and social programs, but also strive to make states and communities more safe and supportive places for sexual and gender minority youth. Their lives depend on it.
Drs Chatterjee and Obando both conceived of and designed this commentary and equally contributed to writing the piece.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2023-062227.
FUNDING: No external funding.
CONFLICT OF INTEREST DISCLOSURES: The authors have no potential conflicts of interest to disclose.