Risk Behaviors and Sexual Health in The Context of Homelessness Discrimination in an Urban Sample of Youth Experiencing Homelessness

Risk Behaviors and Sexual Health in The Context of Homelessness Discrimination in an Urban Sample of Youth Experiencing Homelessness | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Risk Behaviors and Sexual Health in The Context of Homelessness Discrimination in an Urban Sample of Youth Experiencing Homelessness Amanda Sisselman-Borgia, Mia Budescu, Gina Torino This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5333348/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Homelessness among youth in urban areas carries specific challenges because so many come from different geographic regions hoping for opportunities, but instead encounter added problems. Discrimination based on homelessness is a problem that has only recently been explored in youth experiencing homelessness (YEH). Discrimination based on different facets of one’s identity, including homelessness, is associated with health disparities, like sexually transmitted infections (STIs), including HIV. Our study explores the relationship between homelessness discrimination and risky sexual health behaviors among 147 urban YEH. Primarily non-white, YEH in our sample were an average age of 21 years old. We defined risky sexual behaviors as lack of contraceptive use and substance use. There was a significant direct path between discrimination and risky sexual behavior, with those reporting more discrimination also reporting being less likely to use contraception. There was also an indirect effect of discrimination on contraceptive use through depressive symptoms, suggesting that discrimination is associated with more risky sexual behavior by way of depressive symptoms. Higher levels of discrimination were directly associated with lower levels of risky substance use, as were higher levels of depressive symptoms. The direct path between discrimination and risky substance was moderated by age. In light of these findings, we argue that urban communities should be focused on reducing acts of discrimination and stigma around homelessness and improving access to housing. Resolving these urban social problems may go a long way in reducing large public health problems like STIs and the HIV epidemic. Figures Figure 1 Figure 2 Figure 3 Introduction and Literature Review It is estimated that approximately 4 million youth experience homelessness (YEH) in the United States every year, with approximately 100,000 YEH in New York City (NYC) alone. 1,2 Urban areas often attract YEH from other regions due to perceived opportunities and acceptance, particularly in major urban centers like NYC. However, the housing affordability crisis and high cost of living in urban areas, including NYC, have led to high levels of homelessness, disproportionately impacting those with greater health disparities, such as HIV infections. Between 2018-2022, rates of HIV infection sky-rocketed 129% among young people aged 13-29 and people who were homeless were 10 times more likely to be infected with HIV compared to their housed counterparts. 3 Moreover, YEH who identify as LGBTQ+ are over-represented in the homelessness population. 2 The Brookings Institute emphasizes the importance of understanding the unique needs of individuals facing homelessness in urban settings, as well as the factors that lead to health disparities, such as discrimination and stigma. 4 This study investigates the complex relationship between discrimination due to homelessness and risky sexual health behaviors, including substance use and unsafe sex, as well as overall wellbeing and health-seeking behaviors. It also explores whether this relationship differs according to age within a sample of urban youth experiencing homelessness. Discrimination and Health HIV risk factors and health disparities among marginalized groups, including YEH, are linked to institutionalized racism and structural inequities. 5 Structural inequalities encompass issues of institutionalized racism but also include issues around income inequality, poverty, and homelessness. Moreover, the aforementioned disparities are exacerbated by individual experiences of subtle forms of discrimination or microaggressions, which can elevate stress levels and contribute to poor health outcomes (Nadal, 2016; Sue, 2010a, 2010b). 6–8 Limited research explores the association between individual experiences of racial and ethnic discrimination or microaggressions and HIV risk. 9 Research indicates that YEH regularly report racial and ethnic discrimination in the form of microaggressions, which are associated with anxiety, depression, somatic symptoms, chronic illness, and sleep problems. 10 More recently, microaggressions based on homelessness have been explored and described in urban youth who experience homelessness. 11,12 Homelessness based microaggressions were associated with mood disorders, sleep problems, and somatic complaints like headaches and gastrointestinal problems in two samples of YEH in NYC 11–14 . It is estimated that up to 40 percent of YEH identify as LGBT+. 15,16 LGBT+ people who are Black and brown are at a higher risk for discrimination based on multiple intersecting identities. 17 LGBT+ youth, particularly those identifying as trans gender, are also at a higher risk for homelessness and associated health disparities. 18,19 Sexual and gender minority (SGM) youth are more likely to leave home during adolescence and less likely to find safety in the streets due to discrimination and victimization. 18 YEH who identify LGBT+ are more likely to become homeless because of lack of support from family of origin, abuse, financial and emotional neglect, and aging out of the foster care system. 19 Stress and Risky Health Behaviors. Minority stress theory maintains that minority groups have cumulative stress caused by discrimination and increasing vulnerability to mental health disorders. 20 Individuals with more than one marginalized identity are more likely to have higher levels of anxiety, depression, substance use issues, and suicidal ideation. 21 Transgender youth experience depression, suicidal ideation, and self-harming behaviors at a rate three times higher than their cisgender counterparts. 22 Stigma related stress has also been associated with risky sexual behaviors and substance abuse, such that YEH were 6-12 times more likely to be diagnosed with HIV infection than their non-homeless counterparts. 23–25 Emerging Adults: Development and Experience of Urban Homelessness Developmentally, YEH are adolescents, many of whom are also emerging adults. Emerging adulthood is a period of transition that includes learning to manage supporting oneself financially, including the responsibilities associated with work and living independently. Adolescents who are considered emerging adults are learning to identify themselves separately and independently from their families, and are learning about who they are as individuals. 26 Youth who don't have critical support from adult caregivers, including those who are housing instable and lacking these relationships may be at an additional risk for mental health problems and diagnoses. 27 Because of the importance of identity formation during this time, youth with multiple marginalized intersecting identities (i.e., LGBTQIA, race, age, homelessness) are at a particularly high disadvantage in creating a life for themselves, including looking for and maintaining stable housing and employment. 26 Existing literature connects risk behaviors in this age group and poor health and mental health. 28 There are gaps in the literature, though, about how discrimination experiences based on intersecting identities, including homelessness, contribute to risk behaviors in YEH. Current study: The current investigation had two primary research goals: To describe the wellbeing, risky sexual and substance use behaviors and health-seeking behaviors of urban youth experiencing homelessness To examine the association between experiences with homelessness discrimination, depressive symptoms, and risky behaviors and health seeking behaviors. This goal consists of two primary research questions: Is the association between discrimination and risky/health-seeking behaviors mediated by depressive symptoms? Is the direct path between discrimination and health behaviors moderated or changed by age? Methods Sample and Design This was a cross-sectional study, with survey data collected once from each participant. We collected data from 147 youth experiencing homelessness, approximately half of whom identified as LGBT+, which mirrors the NYC youth homelessness population (N = 69; 48%). 29 Our participants were between the ages of 16 and 24, with an average age of M = 20.8 (SD = 2.01). Half of the participants (N = 73; 50%) had a high school diploma or equivalent and 26% (N = 38) had less than high school diploma. Our sample was primarily non-white with 41% identified as Black or African American, 20% identified as Latino, 22% multi-racial, 10% white and 6% other. Procedures Data was collected from 147 youth experiencing homelessness from drop in centers, shelters, transitional housing, and crisis centers across the five boroughs of NYC. Youth were offered a $20 gift card to compensate them for their time in completing the survey. Survey completion was done with paper and pencil on site at the drop in centers, shelters, and transitional residences. Research staff introduced the study and read the informed consent form to small groups of youth. There were a total of 10 sites that participated in the study, across four boroughs of NYC, however youth from all five boroughs were included as the drop in centers serve youth that travel from each borough. Youth completed the survey on their own and study staff were nearby if they had questions. If a youth had difficulty with reading level or comprehension, a research assistant read the questions to them. All procedures were approved by the CUNY Institutional Review Board. Measures Discrimination. The Homelessness Microaggressions, Assumptions of Mental Inferiority sub-scale (AMI) was used to measure homelessness microaggressions. 11 Examples of items include, “People think I am stupid”, “People expect me to take handouts regardless of whether or not I want them”, and “People have called me lazy”. Response options ranged from 0 ( never happened ) to 5 ( happened 5 times in the last 6 months ). Depressive Symptoms: Measured using the CES-D. 30 This scale consists of 20 items assessing the degree to which respondents felt symptoms of depression in the last week. Participants endorsed items such as “I felt depressed” and “People were unfriendly to me” on a scale of 0 ( rarely or none of the time ) to 3 ( most or all of the time; 5 – 7 days ). Scores were averaged across, such that they ranged from 0 to 3 for each participant. The scale had good internal reliability in the current sample ( α = .88) Risky Sexual Behavior: Was measured using a series of questions created specifically for the current study. Participants were asked to report how often they use contraceptives when sexually active with scores ranging from 0 ( never ) to 5 ( always ). Respondents were also asked to report whether they were currently sexually active ( yes/no ) and whether they used contraception in their latest sexual encounter ( yes/no ). The contraceptive question was used as the outcome variable for the regressions presented below. Risky Substance Use: Drug risk behavior was measured using the two subscales of the CRAFFT brief measure for alcohol and drug use, which is commonly used with adolescents. The CRAFFT includes six questions that assess risk associated with alcohol and drug use, with yes/no responses. 31 The responses are added for a total score ranging from 0 (no risk) to 6 (indicating serious risk and dependence on drugs or alcohol). Items included, “Have you ever ridden in a car driven by someone (including yourself) who was “high” or had been using alcohol or drugs?” and “Do you ever use alcohol or drugs when you are by yourself or alone?”. Trust in Medical Professionals: Was measured using the following three questions which were created for the purpose of this study: “Do you trust your doctors to provide you with adequate medical care?” “Do you talk to your doctor about your feelings, such as depression or anxiety?” and “Do you talk to your doctor about sexually transmitted diseases?”. Each item was scored as yes (1) or no (0). Health Seeking Behavior: Was calculated by taking the average of the following three questions: “how likely are you to visit the doctor if you are sick?”., “How likely are you visit the doctor to follow up on a mental health issue?”, and “How likely are you to visit the doctor for regular checkups?” Each of the questions was measured on a scale of 1 ( very unlikely ) to 5 ( very likely ). These items had strong internal consistency with α=.84. In addition, participants were asked whether they have a primary care physician (PCP), and when they had their last physical Results Information about health-seeking behaviors and trust in doctors is presented in Table 1. The majority of the sample ( n = 101 or 68%) reported getting a physical in the last month or 6 months. When asked where they would go if they were not feeling well, 42 participants picked a walk-in clinic, n = 29 said primary care doctor, and n = 41 said they would go to the emergency room. More than half ( n = 93 or 63%) said there has been a time in the past year they thought they should seek medical care but did not. Also, when asked how likely are you to visit a doctor if feeling sick 45% ( n = 63) responded very unlikely or unlikely while 33% ( n = 48) responded likely or very likely. Overall, more than half the sample agreed they trust their doctors (n = 115 or 78%), talked to their doctors about their feelings ( n = 83 or 56.5%), and talked to their doctors about sexually transmitted diseases ( n = 90 or 61.2%). Detailed information about risky behaviors and wellbeing is presented in Table 2. The majority of the sample ( n = 105) reported being sexually active, and less than half ( n = 55) reported using contraception in their last sexual encounter. In response to how often they use contraception (not necessarily in the last encounter), n = 74 reported never or rarely, while only 14 responded always . Higher levels of discrimination were associated with higher levels of contraceptive use ( r = .41, p < .001) and higher levels of depressive symptoms ( r = .60, p < .001). Higher levels of depressive symptoms were also associated with higher levels of substance use ( r = .41, p < .001). Youth who reported trusting doctors were significantly more likely to visit the doctor when sick ( t (133)=-4.03, p < .001), go to the doctor for a mental health follow-up ( t (131) = -4.62, p < .001) and go to the doctor for regular check-ups ( t (133) = -4.56, p < .001). Youth who reported trusting their doctors were more likely to report talking to their doctor about STDs (χ 2 = 7.21, p < .001) and their feelings (χ 2 = 14.99, p < .001). Youth who reported talking with doctors about feelings also reported significantly higher levels of depressive symptoms (t(137) = -3.34, p = .001). Respondents who reported talking to their doctors about STDs were more likely to use contraception in their most recent sexual encounter (χ 2 (df = 1) = 4.84, p = .028). Chi square and t-tests were conducted to look for differences in key study variables based on gender and sexual identity. LGBT + youth were more likely to report going to see the doctor if feeling sick ( t (135) = -2.88, p = .005), follow up on a mental health issue with the doctor ( t (135) = -2.75, p = .007) and visit the doctor for regular checkups ( t (134) = -2.98, p = .003). LGBT + youth also reported higher levels of depressive symptoms ( t (138) = -4.19, p < .001) and discrimination ( t (138) = -2.45, p = .016) based on homelessness than their non-LGBT + counterparts. LGBT + identity was not associated with risky substance-use or contraceptive use, trust in medical professionals (χ 2 = 1.53, p = .215), talking to doctors about feelings (χ 2 = 3.41, p = .065), or talking about STDs (χ 2 = 2.82, p = .09). There were gender differences in depressive symptoms ( F (2, 141) = 3.54, p = .032), the likelihood of going to see a doctor when sick ( F (2, 136) = 3.63, p = .029) and likelihood of seeing a doctor for a regular checkup ( F (2, 135) = 5.40, p = .006). For all three variables males reported lower scores than females, while transgender non-conforming youth reported higher scores than both males and females on all three variables. There were no gender differences in trust in doctors (χ 2 = 2.46, p = .293), talking to doctors about ones feelings (χ 2 = 1.98, p = .371), or talking about STDs (χ 2 = 1.48, p = .478). There were no racial differences on any of the key variables. Primary Analyses : The primary research question was whether discrimination based on homelessness was associated with risky sexual behaviors (contraceptive use), risky drug/alcohol use (CRAFFT) and health seeking behaviors. We tested this mediation using the Hayes PROCESS macro in R which uses a bootstrapping approach. We also examined whether the direct and indirect paths (c ' and ab, respectively) between discrimination and these outcomes were moderated was moderated by age (see Fig. 1). The model was tested separately for each outcome variable and all models controlled for the covariates of gender, race, sexual orientation, and education level. Results are presented in table 3. Risky Sexual Behavior : There was a significant direct path between discrimination and risky sexual behavior (c ' = -2.82, SE = .88, t = 3.20, p = .002), with those reporting more discrimination also reporting being less likely to use contraception (path c). Path b, between depressive symptoms (M) and contraceptive use was not significant ( b = .07, SE = .29, p = .823). Similarly, the path between discrimination and depressive symptoms (path a) was not significant ( a = .42, SE = .28, p = .136). Finally, there was an indirect effect of discrimination on contraceptive use through depressive symptoms ( ab = .-14, SE = .08, 95% bootstrap CI: − .30to − .01), suggesting that discrimination is associated with more risky sexual behavior by way of depressive symptoms. Moderation by Age : The direct effect between discrimination and contraceptive use was moderated by age (ΔR 2 = .07, F (1, 115) = 9.10. p = .003). This latter interaction was probed by calculating the conditional effect of discrimination at -1SD, the mean, and + 1SD on contraceptive use at three levels of the moderator (age): -1SD, the mean, and + 1SD. This effect is plotted in Fig. 2. At age 19 there was a significant association between discrimination and risky sexual behavior ( b = .33, SE = .13, p = .009), such that higher levels of discrimination was associated with more risky behavior. The association between discrimination and contraceptive use was not significant at age 21 ( b = − .09, SE = .09, p = .335) or age 23 ( b = .16, SE = .12, p = .190). A Johnson-Neyman probe of the interaction suggests that significance region for the moderator is between ages 16 and 20.12, while for older ages, the association between discrimination and contraceptive use is null. The mediation was not moderated by age (index of moderated mediation = .003, SE = .007, 95% CI: − .009 to 0.12) Risky Drug/Alcohol Use : Higher levels of discrimination were directly associated with lower levels of risky substance use (c' = -2.24, SE = 1.07, p = .039), as were higher levels of depressive symptoms (b = .81, SE = .33, p = .015). The path between discrimination and depressive symptoms was not significant (a = − .05, SE = .29, p = .861). Finally, there was an indirect effect of discrimination on risky substance use through depressive symptoms (ab = .20, SE = .08, 95% bootstrap CI: .05 to .62). Moderation by Age : The direct path between discrimination and risky substance was moderated by age (ΔR 2 = .04, F (1, 122) = 6.96, p = .009). A probe of the interaction showed that at lower ages (19), the association between discrimination and risky substance use was not significant ( b = .27, SE = .15, p = .080), but the association was positive at ages 21 ( b = .54, SE = .11, p < .001) and 23 ( b = .81, SE = .14, p < .01). A Johnson-Neyman probe found that the significance region was between ages 19.16 and 24. This interaction is plotted in Fig. 3. The mediation was not moderated by age (index of moderated mediation = .01, SE = .01, 95% CI: − .01 to .04). Health Seeking Behaviors : Neither the path between discrimination and health seeking (c'=.18, SE = .82, p = .830) nor the path between depressive symptoms and health seeking (b = ..32, SE = .25, p = .213) were significant. There was also no significant indirect effect between discrimination and health seeking (ab = .08 SE = .06, 95% bootstrap CI: − .04 to .22). Finally, the direct path between discrimination and health seeking was not moderated by age ( F (1, 122) = .09, p = .761, and the index of moderated mediation was not significant. Discussion In summary, we found direct effects between homelessness discrimination experiences and substance misuse as well as discrimination and depression. We also found a direct path between discrimination and risky sexual behavior (lack of contraceptive use). However, we did not find a direct effect between discrimination and health seeking behaviors. Interestingly, we observed that age moderated the relationship between discrimination and contraceptive use, particularly for YEH aged 19 to 21, who reported lower contraceptive use with higher discrimination experiences. This association was no longer significant by age 21. While LGBT + youth were more likely to visit doctors and discuss their feelings compared to their heterosexual peers, cisgender males were less likely to seek medical help than females or LGBT + youth. Despite these findings, LGBT + identity did not moderate any of the associations between discrimination and risky health behaviors. Importantly, no direct or indirect relationship was observed between homelessness-related discrimination and medical trust or health-seeking behaviors. Our study corroborates previous work suggesting that discrimination experiences among YEH are associated with poor mental health 10 , 11 . However, few studies have specifically examined the relationship between homelessness discrimination and risky behaviors. Our study contributes new insights by demonstrating that homelessness discrimination is directly associated with increased substance use and indirectly related to lower contraceptive use through depressive symptoms. In addition, we found that age moderated the relationship between contraceptive use and discrimination experiences, such that YEH between the ages of 19 and 21 were less likely to use contraceptives. As YEH age, they may develop better coping mechanisms and risk awareness, leading to increased contraceptive use. However, structural barriers associated with homelessness, such as limited access to condoms and contraceptives, contribute to risky behaviors. This underscores the need for structural interventions to address homelessness and health inequities. Lisa Bowleg stresses the importance of framing this finding within an anti-racist perspective, understanding that adolescents with privilege or fewer structural barriers might not be placed in such situations and would have better access to health care, condoms, and other buffers to keep them healthy or mitigate STI. 32 Furthermore, it is essential that we are careful to consider the stereotypes associated with adolescence and risk and understand that for YEH between the ages of 19 and 21, discrimination was associated with lower contraceptive use. The age in which discrimination was related to contraceptive use (between the ages of 19 to 21) is a very vulnerable time for adolescents and emerging adults, particularly for those experiencing homelessness. Identity development is of increased importance at this age and acts of discrimination related to any identity points, such as homelessness, can impact coping and ability to mitigate risk. 26 YEH in this age range may experience feelings of omnipotence and lower perceived risk, just as their housed peers do. 26 This combined with circumstantial risk associated with homelessness (i.e., survival sex for basic needs, sexual assault) could lead to situations in which the youth do not have access to contraception. Good mentoring along with peer support are important tools to address risk perception. 33 , 34 Even more important, is advocating for structural change that has potential to shift circumstantial risk and provide more stable lives for YEH. Program staff and administrators should be actively involved in campaigning for local, state, and federal representatives who place housing and better shelter for YEH on their agendas. Petitioning existing law makers is also important and can be done collectively with youth. We also speculate that YEH beyond 21 may have been receiving services for a period of time and have better access to contraception and a better understanding of risk mitigation. Implications and Suggestions for Urban Practitioners Although the suggestions above regarding mentoring and peer support are helpful to YEH for many reasons, we also and perhaps more importantly have to better educate the community and those working in organizations addressing urban homelessness about the detrimental impact of microaggressions. We should be focusing on reducing acts of microaggressions and shifting public opinion and attitudes about homelessness and youth. Homelessness is often most visible in cities where people sleep in public areas or on public transportation. Providers working in human services and social work positions may still hold negative attitudes about homelessness, believing YEH are somehow to blame for their circumstances and less capable than their housed counterparts. 35 We should find creative ways, including use of virtual reality technology, to develop empathy and provide education that moves people enough to shift attitudes and change behaviors toward YEH. Further, discrimination has an impact on the lives of YEH because of existing structural problems in society that lead to homelessness and inequities, like affordable housing and shelter bed shortages. Experiencing discrimination and associated poor contraceptive use can lead to pregnancies and further hardships for YEH and their children. Limitations and Suggestions for Future Research First, our sample was cross sectional, which makes it difficult to make assumptions about causation. Our sample was also limited to urban YEH and our findings may not be generalizable to youth who are in different geographic regions. Third, our sample did not include as many younger adolescents and was on the older end of adolescence, with an average age of 21. So, we don’t know if these findings would hold with a younger group of YEH. Thus, it is imperative that studies investigate the longer-term impacts of discrimination on YEH. The transient nature of YEH and associated problems make longitudinal work more difficult, but studies that investigate youth at risk for homelessness in school settings might be more feasible and produce meaningful findings that would apply to YEH in the community. Efforts should also be made to include YEH in the design of research projects, including through use of participatory action research methods, allowing them to provide advice about best practices for reducing attrition and maintaining longitudinal contact. In conclusion, our study highlights the importance of addressing both the developmental and structural contexts of homelessness. For YEH between the ages of 19 and 21, discrimination was associated with lower contraceptive use, suggesting that this age group may be particularly vulnerable to the negative effects of discrimination. Interventions that target both individual coping skills and structural barriers, such as improving access to healthcare and reducing discrimination, are necessary to improve outcomes for YEH. Declarations The authors have no conflicts of interest to disclose. The study described in this manuscript was funded by a grant from the American Psychological Foundation. References Student homelessness in New York city. 2022–23. Advocates for Children of New York. November 1, 2023. Accessed October 24, 2024. https://advocatesforchildren.org/policy-resource/student-homelessness-data-2023/ Morton MH, Dworsky A, Matjasko JL, et al. 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The new life stage of emerging adulthood at ages 18–29 years: implications for mental health. Lancet Psychiatry. 2014;1(7):569–76. Barman-Adhikari A, Bowen E, Bender K, Brown S, Rice E. A social capital approach to identifying correlates of perceived social support among homeless youth. Child Youth Care Forum. 2016;45(5):691–708. Bender K, Ferguson K, Thompson S, Langenderfer L. Mental health correlates of victimization classes among homeless youth. Child Abuse Negl. 2014;38(10):1628–35. 2023_Youth_Count_Report. Published online. 2023. https://www.nyc.gov/assets/dycd/downloads/pdf/2023_Youth_Count_Report.pdf Radloff LS, The CES-D, Scale. A Self-Report Depression Scale for Research in the General Population. Appl Psychol Meas. 1977;06/(3):385–401. Knight JR, Sherritt L, Shrier LA, Harris SK, Chang G. Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Arch Pediatr Adolesc Med. 2002;156(6):607–14. Bowleg L. The Problem With Intersectional Stigma and HIV Equity Research. Am J Public Health. 2022;112(S4):S344–6. Erangey J, Marvin C, Littman DM, et al. How peer support specialists uniquely initiate and build connection with young people experiencing homelessness. Child Youth Serv Rev. 2020;119(105668):105668. Thulien NS, Kozloff N, McCay E, Nisenbaum R, Wang A, Hwang SW. Evaluating the effects of a rent subsidy and mentoring intervention for youth transitioning out of homelessness: Protocol for a mixed methods, community-based pilot randomized controlled trial (preprint). JMIR Preprints . Published online July. 2019;19. 10.2196/preprints.15557 . Budescu M, Sisselman-Borgia A, Torino GC. An Experimental Approach to Assessing the Attitudes of Social Service and Healthcare Employees toward the Homeless. J Soc Serv Res. 2021;47(2):245–55. Tables Table 1. Health Seeking Behaviors and Trust in Doctors ( n = 147) Variable n(%) Last physical Never 4 (2.7%) Past month 49 (33.3%) In the past 6 months 52 (35.4%) In the last year 10 (6.8%) 1 to 2 years ago 19 (12.9%) More than 2 years ago 5 (3.5%) Do you have a primary care doctor? (yes) 92 (62.6%) Do you trust your doctors? (yes) 115 (78.2%) Do you talk to doctors about your feelings? (Yes) 83 (56.5%) Do you talk to doctors about STDs? (yes) 90 (61.2%) See doctor if sick M = 3.23 (1.50) Follow up on mental health issue M = 3.23 (1.54) Regular checkups M = 3.32 (1.50) Should have seen a doctor but did not? (yes) 43 (29.3%) Table 2. Risky Behavior and Wellbeing among YEH ( n =147) Variable M (SD) Depressive Symptoms 1.22 (.55) Mental Inferiority 1.42 (1.36) Risky Substance Use 1.29 (1.07) How often do you use contraception? 1.46 (1.40) Never n = 47 (31.9%) Rarely n = 27 (18.4%) Sometimes n = 22 (14.9%) Most of the time n =21 (14.3%) Always n =14 (9.5%) Use contraception in most recent encounter? (yes) n = 55 (37.5%) Table 3. Direct and Indirect Effect between Discrimination and Wellbeing and Health Behaviors (n = 147) Risky Sexual Behavior Risky Substance Use Health Seeking Predictor: b(SE) CI b(SE) CI b(SE) CI Direct effects: Age -.34 (.08)** -.52, -.16 -.17 (.11) -.39, .06 -.12 (08) -28, .05 Education .15 (.18) -.20, .49 .16 (.25) -.26, .58 .27 (.17) -.07, .59 Black .41 (.28) -.14, .96 .65 (.33) -.01, 1.32 .49 (.26) -.03, 1.01 Latinx .14 (.33) -.52, .88 .39 (.40) -.40, 1.19 .41 (.31) -0.21, 1.03 Female .41 (.29) -.18, .99 .02 (.36) -.70, .74 -.15 (.28) -.71, .41 LGBTQ .48 (.29) -.11, 1.06 -0.08 (.36) -.79, .63 .54 (.26) -.007, 1.08 TGNC .52 (.42) -.34, 1.30 -.29 (.50) -1.28, .70 .24 (.38) -.43, 1.007 Depressive Symptoms (path b) -.42 (.28) -.97, .14 .81 (.32)* .16, 1.46 .32 (.25) -.18, .82 Mental Inferiority (path c') 2.92 (.88)* 1.07, 4.56 -2.24 (1.07)* -4.36, -.12 .18 (.82) -1.81, 1.46 Mental Inferiority * Age -.13 (.05)* -.21, -.04 .12 (.05)* .02, .22 .01 (.04) -.07, .09 Direct effect on Mediator (path a) Mental Inferiority .07 (.29) -.52, .65 -.05 (.30) -.65, .54 .04 (.31) -.64, .55 Indirect Effects (ab): Mental Inferiority (indirect) -.14 (.08)* -.30, -.01* .20 (.08)* .05, .62* .08 (.06) -.04, .22 Model fit R 2 =.18 F (10, 112) = 2.41* R 2 =.44 F (10, 120) = 10.65** R 2 =.16 F (10, 117) = 2.31* *p<.05; **p<.01 Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Sisselman-Borgia","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABP0lEQVRIie2RMUvDQBTHX4mcy+mtrxy2XyElcAoV81VyCM1y6SKIYMFCId3aTTrodxCEfIGDZOkHCMShdYhLh7oEp2KqZjCVqptIfvCHx3E/7t57ABUVfxWah6yLWR62+14XGNsVJ0998FMFCsXU3yjsWqezRQ/sfRbNZ1KddC1thI9x7wHYxAsRLtqy/1nBpHPYuglB+qgsUwanZ0IT11JhChh3OwhTt6xA4ghOCTgEKUEZGDLQVHBFNJioBNZ8XVaaiZtxugKbsOjpRQZX8n7AMq5WhbLaUMxECb7nQ80HR0D+hLwzKOGeXyj9DaWVqPP67Qjfesk/FsmJJoJ7I01xurCOnNC1SkojcQNcZMd2cxzNl8/BpRwPBylXmW6woWrFy177oNz+x+A2j9bL2kHny+tbMJa/NSoqKir+I6/BIm2hKZhRqAAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0003-2018-345X","institution":"Lehman College CUNY","correspondingAuthor":true,"prefix":"","firstName":"Amanda","middleName":"","lastName":"Sisselman-Borgia","suffix":""},{"id":371851288,"identity":"f9f30e99-6e38-47f5-940f-5bc3286f31b4","order_by":1,"name":"Mia Budescu","email":"","orcid":"","institution":"Lehman College","correspondingAuthor":false,"prefix":"","firstName":"Mia","middleName":"","lastName":"Budescu","suffix":""},{"id":371851289,"identity":"940d1998-2461-443b-b60c-ff6578d2b75b","order_by":2,"name":"Gina Torino","email":"","orcid":"","institution":"SUNY Empire State College","correspondingAuthor":false,"prefix":"","firstName":"Gina","middleName":"","lastName":"Torino","suffix":""}],"badges":[],"createdAt":"2024-10-25 15:16:57","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-5333348/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5333348/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":73450810,"identity":"2cbbe3df-198a-40b9-81b8-44756ed7d8e3","added_by":"auto","created_at":"2025-01-10 06:03:18","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":38743,"visible":true,"origin":"","legend":"\u003cp\u003eConceptual Model for Direct and Indirect Impact of Discrimination on YEH\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5333348/v1/012d5e89e7b3e13cc742cc9c.png"},{"id":73449589,"identity":"8a2e96d0-7176-4dd4-b551-a5e22d781489","added_by":"auto","created_at":"2025-01-10 05:39:18","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":28891,"visible":true,"origin":"","legend":"\u003cp\u003eInteraction between Age and Discrimination on Risky Sexual Behavior\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5333348/v1/5d6b3515baef6704b05991d4.png"},{"id":73449592,"identity":"4a5ab800-acc1-4708-a378-d926d6971b1d","added_by":"auto","created_at":"2025-01-10 05:39:18","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":29883,"visible":true,"origin":"","legend":"\u003cp\u003eInteraction between Age and Discrimination on Risky Substance Use\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-5333348/v1/95390e76862251d62c7367e7.png"},{"id":73451879,"identity":"e8894be8-e23a-4d23-aaff-5d649457c52e","added_by":"auto","created_at":"2025-01-10 06:11:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":752825,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5333348/v1/d2e7680a-a2e7-4b87-85d5-0f53c4233c6d.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eRisk Behaviors and Sexual Health in The Context of Homelessness Discrimination in an Urban Sample of Youth Experiencing Homelessness\u003c/p\u003e","fulltext":[{"header":"Introduction and Literature Review","content":"\u003cp\u003eIt is estimated that approximately 4 million youth experience homelessness (YEH) in the United States every year, with approximately 100,000 YEH in New York City (NYC) alone.\u003csup\u003e1,2\u003c/sup\u003e Urban areas often attract YEH from other regions due to perceived opportunities and acceptance, particularly in major urban centers like NYC. However, the housing affordability crisis and high cost of living in urban areas, including NYC, have led to high levels of homelessness, disproportionately impacting those with greater health disparities, such as HIV infections. Between 2018-2022, rates of HIV infection sky-rocketed 129% among young people aged 13-29 and people who were homeless were 10 times more likely to be infected with HIV compared to their housed counterparts.\u003csup\u003e3\u003c/sup\u003e Moreover, YEH who identify as LGBTQ+ are over-represented in the homelessness population.\u003csup\u003e2\u003c/sup\u003e The Brookings Institute emphasizes the importance of understanding the unique needs of individuals facing homelessness in urban settings, as well as the factors that lead to health disparities, such as discrimination and stigma.\u003csup\u003e4\u003c/sup\u003e\u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study investigates the complex relationship between discrimination due to homelessness and risky sexual health behaviors, including substance use and unsafe sex, as well as overall wellbeing and health-seeking behaviors. It also explores whether this relationship differs according to age within a sample of urban youth experiencing homelessness.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscrimination and Health\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHIV risk factors and health disparities among marginalized groups, including YEH, are linked to institutionalized racism and structural inequities.\u003csup\u003e5\u003c/sup\u003e Structural inequalities encompass issues of institutionalized racism but also include issues around income inequality, poverty, and homelessness. Moreover, the aforementioned disparities are exacerbated by individual experiences of subtle forms of discrimination or microaggressions, which can elevate stress levels and contribute to poor health outcomes (Nadal, 2016; Sue, 2010a, 2010b).\u003csup\u003e6\u0026ndash;8\u003c/sup\u003e Limited research explores the association between individual experiences of racial and ethnic discrimination or microaggressions and HIV risk.\u003csup\u003e9\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResearch indicates that YEH regularly report racial and ethnic discrimination in the form of microaggressions, which are associated with anxiety, depression, somatic symptoms, chronic illness, and sleep problems.\u003csup\u003e10\u003c/sup\u003e More recently, microaggressions based on homelessness have been explored and described in urban youth who experience homelessness.\u003csup\u003e11,12\u003c/sup\u003e Homelessness based microaggressions were associated with mood disorders, sleep problems, and somatic complaints like headaches and gastrointestinal problems in two samples of YEH in NYC\u003csup\u003e11\u0026ndash;14\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIt is estimated that up to 40 percent of YEH identify as LGBT+.\u003csup\u003e15,16\u003c/sup\u003e LGBT+ people who are Black and brown are at a higher risk for discrimination based on multiple intersecting identities.\u003csup\u003e17\u003c/sup\u003e LGBT+ youth, particularly those identifying as trans gender, are also at a higher risk for homelessness and associated health disparities. \u003csup\u003e18,19\u003c/sup\u003e\u0026nbsp; Sexual and gender minority (SGM) youth are more likely to leave home during adolescence and less likely to find safety in the streets due to discrimination and victimization.\u003csup\u003e18\u003c/sup\u003e YEH who identify LGBT+ are more likely to become homeless because of lack of support from family of origin, abuse, financial and emotional neglect, and aging out of the foster care system.\u003csup\u003e19\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStress and Risky Health Behaviors.\u0026nbsp;\u003c/strong\u003eMinority stress theory maintains that minority groups have cumulative stress caused by discrimination and increasing vulnerability to mental health disorders.\u003csup\u003e20\u003c/sup\u003e Individuals with more than one marginalized identity are more likely to have higher levels of anxiety, depression, substance use issues, and suicidal ideation.\u003csup\u003e21\u003c/sup\u003e Transgender youth experience depression, suicidal ideation, and self-harming behaviors at a rate three times higher than their cisgender counterparts.\u003csup\u003e22\u003c/sup\u003e Stigma related stress has also been associated with risky sexual behaviors and substance abuse, such that YEH were 6-12 times more likely to be diagnosed with HIV infection than their non-homeless counterparts.\u003csup\u003e23\u0026ndash;25\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEmerging Adults: Development and Experience of Urban Homelessness\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDevelopmentally, YEH are adolescents, many of whom are also emerging adults. Emerging adulthood is a period of transition that includes learning to manage supporting oneself financially, including the responsibilities associated with work and living independently. Adolescents who are considered emerging adults are learning to identify themselves separately and independently from their families, and are learning about who they are as individuals.\u003csup\u003e26\u003c/sup\u003e Youth who don\u0026apos;t have critical support from adult caregivers, including those who are housing instable and lacking these relationships may be at an additional risk for mental health problems and diagnoses.\u003csup\u003e27\u003c/sup\u003e Because of the importance of identity formation during this time, youth with multiple marginalized intersecting identities (i.e., LGBTQIA, race, age, homelessness) are at a particularly high disadvantage in creating a life for themselves, including looking for and maintaining stable housing and employment.\u003csup\u003e26\u003c/sup\u003e Existing literature connects risk behaviors in this age group and poor health and mental health.\u003csup\u003e28\u003c/sup\u003e There are gaps in the literature, though, about how discrimination experiences based on intersecting identities, including homelessness, contribute to risk behaviors in YEH.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCurrent study:\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe current investigation had two primary research goals:\u0026nbsp;\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eTo describe the wellbeing, risky sexual and substance use behaviors and health-seeking behaviors of urban youth experiencing homelessness \u0026nbsp;\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eTo examine the association between experiences with homelessness discrimination, depressive symptoms, and risky behaviors and health seeking behaviors. This goal consists of two primary research questions:\u0026nbsp;\u003col style=\"list-style-type: lower-alpha;\"\u003e\n \u003cli\u003eIs the association between discrimination and risky/health-seeking behaviors mediated by depressive symptoms? \u0026nbsp;\u003c/li\u003e\n \u003cli\u003eIs the direct path between discrimination and health behaviors moderated or changed by age?\u0026nbsp;\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eSample and Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was a cross-sectional study, with survey data collected once from each participant. We collected data from 147 youth experiencing homelessness, approximately half of whom identified as LGBT+, which mirrors the NYC youth homelessness population (N = 69; 48%).\u003csup\u003e29\u003c/sup\u003e Our participants were between the ages of 16 and 24, with an average age of M = 20.8 (SD = 2.01). Half of the participants (N = 73; 50%) had a high school diploma or equivalent and 26% (N = 38) had less than high school diploma. Our sample was primarily non-white with 41% identified as Black or African American, 20% identified as Latino, 22% multi-racial, 10% white and 6% other.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProcedures\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData was collected from 147 youth experiencing homelessness from drop in centers, shelters, transitional housing, and crisis centers across the five boroughs of NYC. Youth were offered a $20 gift card to compensate them for their time in completing the survey. Survey completion was done with paper and pencil on site at the drop in centers, shelters, and transitional residences. Research staff introduced the study and read the informed consent form to small groups of youth. There were a total of 10 sites that participated in the study, across four boroughs of NYC, however youth from all five boroughs were included as the drop in centers serve youth that travel from each borough. Youth completed the survey on their own and study staff were nearby if they had questions. If a youth had difficulty with reading level or comprehension, a research assistant read the questions to them. All procedures were approved by the CUNY Institutional Review Board.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMeasures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDiscrimination.\u003c/em\u003e\u003c/strong\u003e The Homelessness Microaggressions, Assumptions of Mental Inferiority sub-scale (AMI) was used to measure homelessness microaggressions.\u003csup\u003e11\u003c/sup\u003e Examples of items include, \u0026ldquo;People think I am stupid\u0026rdquo;, \u0026ldquo;People expect me to take handouts regardless of whether or not I want them\u0026rdquo;, and \u0026ldquo;People have called me lazy\u0026rdquo;. Response options ranged from 0 (\u003cem\u003enever happened\u003c/em\u003e) to 5 (\u003cem\u003ehappened 5 times in the last 6 months\u003c/em\u003e).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDepressive Symptoms:\u0026nbsp;\u003c/em\u003eMeasured using the CES-D.\u003csup\u003e30\u003c/sup\u003e\u0026nbsp; \u0026nbsp;This scale consists of 20 items assessing the degree to which respondents felt symptoms of depression in the last week. \u0026nbsp;Participants endorsed items such as \u0026ldquo;I felt depressed\u0026rdquo; and \u0026ldquo;People were unfriendly to me\u0026rdquo; on a scale of 0 (\u003cem\u003erarely or none of the time\u003c/em\u003e) to 3 (\u003cem\u003emost or all of the time; 5 \u0026ndash; 7 days\u003c/em\u003e). \u0026nbsp;Scores were averaged across, such that they ranged from 0 to 3 for each participant. \u0026nbsp; The scale had good internal reliability in the current sample (\u003cem\u003e\u0026alpha;\u003c/em\u003e = .88)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRisky Sexual Behavior:\u0026nbsp;\u003c/em\u003eWas measured using a series of questions created specifically for the current study. \u0026nbsp;Participants were asked to report how often they use contraceptives when sexually active with scores ranging from 0 (\u003cem\u003enever\u003c/em\u003e) to 5 (\u003cem\u003ealways\u003c/em\u003e). \u0026nbsp; Respondents were also asked to report whether they were currently sexually active (\u003cem\u003eyes/no\u003c/em\u003e) and whether they used contraception in their latest sexual encounter (\u003cem\u003eyes/no\u003c/em\u003e). The contraceptive question was used as the outcome variable for the regressions presented below.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRisky Substance Use:\u0026nbsp;\u003c/em\u003eDrug risk behavior was measured using the two subscales of the CRAFFT brief measure for alcohol and drug use, which is commonly used with adolescents. The CRAFFT includes six questions that assess risk associated with alcohol and drug use, with \u003cem\u003eyes/no\u003c/em\u003e responses.\u003csup\u003e31\u003c/sup\u003e The responses are added for a total score ranging from 0 (no risk) to 6 (indicating serious risk and dependence on drugs or alcohol). Items included, \u0026ldquo;Have you ever ridden in a car driven by someone (including yourself) who was \u0026ldquo;high\u0026rdquo; or had been using alcohol or drugs?\u0026rdquo; and \u0026ldquo;Do you ever use alcohol or drugs when you are by yourself or alone?\u0026rdquo;.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cem\u003eTrust in Medical Professionals:\u003c/em\u003e Was measured using the following three questions which were created for the purpose of this study: \u0026ldquo;Do you trust your doctors to provide you with adequate medical care?\u0026rdquo; \u0026ldquo;Do you talk to your doctor about your feelings, such as depression or anxiety?\u0026rdquo; and \u0026ldquo;Do you talk to your doctor about sexually transmitted diseases?\u0026rdquo;. Each item was scored as yes (1) or no (0). \u003cem\u003eHealth Seeking Behavior:\u0026nbsp;\u003c/em\u003eWas calculated by taking the average of the following three questions: \u0026ldquo;how likely are you to visit the doctor if you are sick?\u0026rdquo;., \u0026ldquo;How likely are you visit the doctor to follow up on a mental health issue?\u0026rdquo;, and \u0026ldquo;How likely are you to visit the doctor for regular checkups?\u0026rdquo; Each of the questions was measured on a scale of 1 (\u003cem\u003every unlikely\u003c/em\u003e) to 5 (\u003cem\u003every likely\u003c/em\u003e). These items had strong internal consistency with \u0026alpha;=.84. \u0026nbsp;In addition, participants were asked whether they have a primary care physician (PCP), and when they had their last physical\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eInformation about health-seeking behaviors and trust in doctors is presented in Table\u0026nbsp;1. The majority of the sample (\u003cem\u003en\u003c/em\u003e = 101 or 68%) reported getting a physical in the last month or 6 months. When asked where they would go if they were not feeling well, 42 participants picked a walk-in clinic, \u003cem\u003en\u003c/em\u003e = 29 said primary care doctor, and n = 41 said they would go to the emergency room. More than half (\u003cem\u003en\u003c/em\u003e = 93 or 63%) said there has been a time in the past year they thought they should seek medical care but did not. Also, when asked how likely are you to visit a doctor if feeling sick 45% (\u003cem\u003en\u003c/em\u003e = 63) responded very unlikely or unlikely while 33% (\u003cem\u003en\u003c/em\u003e = 48) responded likely or very likely. Overall, more than half the sample agreed they trust their doctors (n = 115 or 78%), talked to their doctors about their feelings (\u003cem\u003en\u003c/em\u003e = 83 or 56.5%), and talked to their doctors about sexually transmitted diseases (\u003cem\u003en\u003c/em\u003e = 90 or 61.2%). Detailed information about risky behaviors and wellbeing is presented in Table\u0026nbsp;2. The majority of the sample (\u003cem\u003en\u003c/em\u003e = 105) reported being sexually active, and less than half (\u003cem\u003en\u003c/em\u003e = 55) reported using contraception in their last sexual encounter. In response to how often they use contraception (not necessarily in the last encounter), \u003cem\u003en\u003c/em\u003e = 74 reported never or rarely, while only 14 responded always .\u003c/p\u003e\u003cp\u003eHigher levels of discrimination were associated with higher levels of contraceptive use (\u003cem\u003er\u003c/em\u003e = .41, p \u0026lt; .001) and higher levels of depressive symptoms (\u003cem\u003er\u003c/em\u003e = .60, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001). Higher levels of depressive symptoms were also associated with higher levels of substance use (\u003cem\u003er\u003c/em\u003e = .41, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001). Youth who reported trusting doctors were significantly more likely to visit the doctor when sick (\u003cem\u003et\u003c/em\u003e(133)=-4.03, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001), go to the doctor for a mental health follow-up (\u003cem\u003et\u003c/em\u003e(131) = -4.62, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001) and go to the doctor for regular check-ups (\u003cem\u003et\u003c/em\u003e(133) = -4.56, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001). Youth who reported trusting their doctors were more likely to report talking to their doctor about STDs (χ\u003csup\u003e2\u003c/sup\u003e = 7.21, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001) and their feelings (χ\u003csup\u003e2\u003c/sup\u003e = 14.99, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001). Youth who reported talking with doctors about feelings also reported significantly higher levels of depressive symptoms (t(137) = -3.34, \u003cem\u003ep\u003c/em\u003e = .001). Respondents who reported talking to their doctors about STDs were more likely to use contraception in their most recent sexual encounter (χ\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e (df = 1) = 4.84, \u003cem\u003ep\u003c/em\u003e = .028).\u003c/p\u003e\u003cp\u003eChi square and t-tests were conducted to look for differences in key study variables based on gender and sexual identity. LGBT + youth were more likely to report going to see the doctor if feeling sick (\u003cem\u003et\u003c/em\u003e(135) = -2.88, \u003cem\u003ep\u003c/em\u003e = .005), follow up on a mental health issue with the doctor (\u003cem\u003et\u003c/em\u003e(135) = -2.75, \u003cem\u003ep\u003c/em\u003e = .007) and visit the doctor for regular checkups (\u003cem\u003et\u003c/em\u003e(134) = -2.98, \u003cem\u003ep\u003c/em\u003e = .003). LGBT + youth also reported higher levels of depressive symptoms (\u003cem\u003et\u003c/em\u003e(138) = -4.19, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001) and discrimination (\u003cem\u003et\u003c/em\u003e(138) = -2.45, \u003cem\u003ep\u003c/em\u003e = .016) based on homelessness than their non-LGBT + counterparts. LGBT + identity was not associated with risky substance-use or contraceptive use, trust in medical professionals (χ\u003csup\u003e2\u003c/sup\u003e = 1.53, \u003cem\u003ep\u003c/em\u003e = .215), talking to doctors about feelings (χ\u003csup\u003e2\u003c/sup\u003e = 3.41, \u003cem\u003ep\u003c/em\u003e = .065), or talking about STDs (χ\u003csup\u003e2\u003c/sup\u003e = 2.82, \u003cem\u003ep\u003c/em\u003e = .09).\u003c/p\u003e\u003cp\u003eThere were gender differences in depressive symptoms (\u003cem\u003eF\u003c/em\u003e(2, 141) = 3.54, \u003cem\u003ep\u003c/em\u003e = .032), the likelihood of going to see a doctor when sick (\u003cem\u003eF\u003c/em\u003e(2, 136) = 3.63, \u003cem\u003ep\u003c/em\u003e = .029) and likelihood of seeing a doctor for a regular checkup (\u003cem\u003eF\u003c/em\u003e(2, 135) = 5.40, \u003cem\u003ep\u003c/em\u003e = .006). For all three variables males reported lower scores than females, while transgender non-conforming youth reported higher scores than both males and females on all three variables. There were no gender differences in trust in doctors (χ\u003csup\u003e2\u003c/sup\u003e = 2.46, \u003cem\u003ep\u003c/em\u003e = .293), talking to doctors about ones feelings (χ\u003csup\u003e2\u003c/sup\u003e = 1.98, \u003cem\u003ep\u003c/em\u003e = .371), or talking about STDs (χ\u003csup\u003e2\u003c/sup\u003e = 1.48, \u003cem\u003ep\u003c/em\u003e = .478). There were no racial differences on any of the key variables.\u003c/p\u003e\u003cp\u003e\u003cem\u003ePrimary Analyses\u003c/em\u003e:\u003c/p\u003e\u003cp\u003eThe primary research question was whether discrimination based on homelessness was associated with risky sexual behaviors (contraceptive use), risky drug/alcohol use (CRAFFT) and health seeking behaviors. We tested this mediation using the Hayes PROCESS macro in R which uses a bootstrapping approach. We also examined whether the direct and indirect paths (c ' and ab, respectively) between discrimination and these outcomes were moderated was moderated by age (see Fig.\u0026nbsp;1). The model was tested separately for each outcome variable and all models controlled for the covariates of gender, race, sexual orientation, and education level. Results are presented in table 3.\u003c/p\u003e\u003cp\u003e\u003cem\u003eRisky Sexual Behavior\u003c/em\u003e:\u003c/p\u003e\u003cp\u003eThere was a significant direct path between discrimination and risky sexual behavior (c ' = -2.82, SE = .88, \u003cem\u003et\u003c/em\u003e = 3.20, \u003cem\u003ep\u003c/em\u003e = .002), with those reporting more discrimination also reporting being less likely to use contraception (path c). Path b, between depressive symptoms (M) and contraceptive use was not significant (\u003cem\u003eb\u003c/em\u003e = .07, SE = .29, \u003cem\u003ep\u003c/em\u003e = .823). Similarly, the path between discrimination and depressive symptoms (path a) was not significant (\u003cem\u003ea\u003c/em\u003e = .42, SE = .28, \u003cem\u003ep\u003c/em\u003e = .136). Finally, there was an indirect effect of discrimination on contraceptive use through depressive symptoms (\u003cem\u003eab\u003c/em\u003e= .-14, SE = .08, 95% bootstrap CI: − .30to − .01), suggesting that discrimination is associated with more risky sexual behavior by way of depressive symptoms.\u003c/p\u003e\u003cp\u003e\u003cem\u003eModeration by Age\u003c/em\u003e :\u003c/p\u003e\u003cp\u003eThe direct effect between discrimination and contraceptive use was moderated by age (ΔR\u003csup\u003e2\u003c/sup\u003e = .07, \u003cem\u003eF\u003c/em\u003e(1, 115) = 9.10. \u003cem\u003ep\u003c/em\u003e = .003). This latter interaction was probed by calculating the conditional effect of discrimination at -1SD, the mean, and + 1SD on contraceptive use at three levels of the moderator (age): -1SD, the mean, and + 1SD. This effect is plotted in Fig.\u0026nbsp;2. At age 19 there was a significant association between discrimination and risky sexual behavior (\u003cem\u003eb\u003c/em\u003e = .33, SE = .13, \u003cem\u003ep\u003c/em\u003e = .009), such that higher levels of discrimination was associated with more risky behavior. The association between discrimination and contraceptive use was not significant at age 21 (\u003cem\u003eb\u003c/em\u003e = − .09, SE = .09, \u003cem\u003ep\u003c/em\u003e = .335) or age 23 (\u003cem\u003eb\u003c/em\u003e = .16, SE = .12, \u003cem\u003ep\u003c/em\u003e = .190). A Johnson-Neyman probe of the interaction suggests that significance region for the moderator is between ages 16 and 20.12, while for older ages, the association between discrimination and contraceptive use is null. The mediation was not moderated by age (index of moderated mediation = .003, SE = .007, 95% CI: − .009 to 0.12)\u003c/p\u003e\u003cp\u003e\u003cem\u003eRisky Drug/Alcohol Use\u003c/em\u003e:\u003c/p\u003e\u003cp\u003eHigher levels of discrimination were directly associated with lower levels of risky substance use (c' = -2.24, SE = 1.07, \u003cem\u003ep\u003c/em\u003e = .039), as were higher levels of depressive symptoms (b = .81, SE = .33, \u003cem\u003ep\u003c/em\u003e = .015). The path between discrimination and depressive symptoms was not significant (a = − .05, SE = .29, \u003cem\u003ep\u003c/em\u003e = .861). Finally, there was an indirect effect of discrimination on risky substance use through depressive symptoms (ab = .20, SE = .08, 95% bootstrap CI: .05 to .62).\u003c/p\u003e\u003cp\u003e\u003cem\u003eModeration by Age\u003c/em\u003e:\u003c/p\u003e\u003cp\u003eThe direct path between discrimination and risky substance was moderated by age (ΔR\u003csup\u003e2\u003c/sup\u003e = .04, \u003cem\u003eF\u003c/em\u003e(1, 122) = 6.96, \u003cem\u003ep\u003c/em\u003e = .009). A probe of the interaction showed that at lower ages (19), the association between discrimination and risky substance use was not significant (\u003cem\u003eb\u003c/em\u003e = .27, SE = .15, \u003cem\u003ep\u003c/em\u003e = .080), but the association was positive at ages 21 (\u003cem\u003eb\u003c/em\u003e = .54, SE = .11, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001) and 23 (\u003cem\u003eb\u003c/em\u003e = .81, SE = .14, \u003cem\u003ep\u003c/em\u003e \u0026lt; .01). A Johnson-Neyman probe found that the significance region was between ages 19.16 and 24. This interaction is plotted in Fig.\u0026nbsp;3. The mediation was not moderated by age (index of moderated mediation = .01, SE = .01, 95% CI: − .01 to .04).\u003c/p\u003e\u003cp\u003e\u003cem\u003eHealth Seeking Behaviors\u003c/em\u003e:\u003c/p\u003e\u003cp\u003eNeither the path between discrimination and health seeking (c'=.18, SE = .82, \u003cem\u003ep\u003c/em\u003e = .830) nor the path between depressive symptoms and health seeking (b = ..32, SE = .25, \u003cem\u003ep =\u003c/em\u003e .213) were significant. There was also no significant indirect effect between discrimination and health seeking (ab = .08 SE = .06, 95% bootstrap CI: − .04 to .22). Finally, the direct path between discrimination and health seeking was not moderated by age (\u003cem\u003eF\u003c/em\u003e(1, 122) = .09, \u003cem\u003ep\u003c/em\u003e = .761, and the index of moderated mediation was not significant.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn summary, we found direct effects between homelessness discrimination experiences and substance misuse as well as discrimination and depression. We also found a direct path between discrimination and risky sexual behavior (lack of contraceptive use). However, we did not find a direct effect between discrimination and health seeking behaviors. Interestingly, we observed that age moderated the relationship between discrimination and contraceptive use, particularly for YEH aged 19 to 21, who reported lower contraceptive use with higher discrimination experiences. This association was no longer significant by age 21.\u003c/p\u003e\u003cp\u003eWhile LGBT + youth were more likely to visit doctors and discuss their feelings compared to their heterosexual peers, cisgender males were less likely to seek medical help than females or LGBT + youth. Despite these findings, LGBT + identity did not moderate any of the associations between discrimination and risky health behaviors. Importantly, no direct or indirect relationship was observed between homelessness-related discrimination and medical trust or health-seeking behaviors.\u003c/p\u003e\u003cp\u003eOur study corroborates previous work suggesting that discrimination experiences among YEH are associated with poor mental health\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. However, few studies have specifically examined the relationship between homelessness discrimination and risky behaviors. Our study contributes new insights by demonstrating that homelessness discrimination is directly associated with increased substance use and indirectly related to lower contraceptive use through depressive symptoms.\u003c/p\u003e\u003cp\u003eIn addition, we found that age moderated the relationship between contraceptive use and discrimination experiences, such that YEH between the ages of 19 and 21 were less likely to use contraceptives. As YEH age, they may develop better coping mechanisms and risk awareness, leading to increased contraceptive use. However, structural barriers associated with homelessness, such as limited access to condoms and contraceptives, contribute to risky behaviors. This underscores the need for structural interventions to address homelessness and health inequities. Lisa Bowleg stresses the importance of framing this finding within an anti-racist perspective, understanding that adolescents with privilege or fewer structural barriers might not be placed in such situations and would have better access to health care, condoms, and other buffers to keep them healthy or mitigate STI.\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e Furthermore, it is essential that we are careful to consider the stereotypes associated with adolescence and risk and understand that for YEH between the ages of 19 and 21, discrimination was associated with lower contraceptive use.\u003c/p\u003e\u003cp\u003eThe age in which discrimination was related to contraceptive use (between the ages of 19 to 21) is a very vulnerable time for adolescents and emerging adults, particularly for those experiencing homelessness. Identity development is of increased importance at this age and acts of discrimination related to any identity points, such as homelessness, can impact coping and ability to mitigate risk.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e YEH in this age range may experience feelings of omnipotence and lower perceived risk, just as their housed peers do.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e This combined with circumstantial risk associated with homelessness (i.e., survival sex for basic needs, sexual assault) could lead to situations in which the youth do not have access to contraception. Good mentoring along with peer support are important tools to address risk perception.\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e,\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e Even more important, is advocating for structural change that has potential to shift circumstantial risk and provide more stable lives for YEH. Program staff and administrators should be actively involved in campaigning for local, state, and federal representatives who place housing and better shelter for YEH on their agendas. Petitioning existing law makers is also important and can be done collectively with youth. We also speculate that YEH beyond 21 may have been receiving services for a period of time and have better access to contraception and a better understanding of risk mitigation.\u003c/p\u003e\u003cp\u003e\u003cb\u003eImplications and Suggestions for Urban Practitioners\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAlthough the suggestions above regarding mentoring and peer support are helpful to YEH for many reasons, we also and perhaps more importantly have to better educate the community and those working in organizations addressing urban homelessness about the detrimental impact of microaggressions. We should be focusing on reducing acts of microaggressions and shifting public opinion and attitudes about homelessness and youth. Homelessness is often most visible in cities where people sleep in public areas or on public transportation. Providers working in human services and social work positions may still hold negative attitudes about homelessness, believing YEH are somehow to blame for their circumstances and less capable than their housed counterparts.\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e We should find creative ways, including use of virtual reality technology, to develop empathy and provide education that moves people enough to shift attitudes and change behaviors toward YEH. Further, discrimination has an impact on the lives of YEH because of existing structural problems in society that lead to homelessness and inequities, like affordable housing and shelter bed shortages. Experiencing discrimination and associated poor contraceptive use can lead to pregnancies and further hardships for YEH and their children.\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitations and Suggestions for Future Research\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFirst, our sample was cross sectional, which makes it difficult to make assumptions about causation. Our sample was also limited to urban YEH and our findings may not be generalizable to youth who are in different geographic regions. Third, our sample did not include as many younger adolescents and was on the older end of adolescence, with an average age of 21. So, we don’t know if these findings would hold with a younger group of YEH. Thus, it is imperative that studies investigate the longer-term impacts of discrimination on YEH. The transient nature of YEH and associated problems make longitudinal work more difficult, but studies that investigate youth at risk for homelessness in school settings might be more feasible and produce meaningful findings that would apply to YEH in the community. Efforts should also be made to include YEH in the design of research projects, including through use of participatory action research methods, allowing them to provide advice about best practices for reducing attrition and maintaining longitudinal contact.\u003c/p\u003e\u003cp\u003eIn conclusion, our study highlights the importance of addressing both the developmental and structural contexts of homelessness. For YEH between the ages of 19 and 21, discrimination was associated with lower contraceptive use, suggesting that this age group may be particularly vulnerable to the negative effects of discrimination. Interventions that target both individual coping skills and structural barriers, such as improving access to healthcare and reducing discrimination, are necessary to improve outcomes for YEH.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eThe authors have no conflicts of interest to disclose.\u003c/p\u003e\n\u003cp\u003eThe study described in this manuscript was funded by a grant from the American Psychological Foundation.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eStudent homelessness in New York city. 2022\u0026ndash;23. Advocates for Children of New York. November 1, 2023. 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Am J Orthopsychiatry. 2016;86(1):79\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSisselman-Borgia A, Budescu M, Torino G. The association of Racial and homelessness microaggressions and physical and mental health in a sample of homeless youth. Urban Soc Work. 2018;2(2):139\u0026ndash;58.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBudescu M, Sisselman-Borgia A, Torino GC. Experience of Homelessness Discrimination Among Emerging Adults: A Qualitative and Quantitative Analysis. Emerg Adulthood. 2021;9(6):690\u0026ndash;701.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSisselman-Borgia A, Menard L, Budescu M, Torino G. Differences in Discrimination Experiences Among Homeless and Nonhomeless Youth. Urban Social Work. 2022;6(1):69\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBudescu M, Reid A, Sisselman-Borgia A, Holbrook N, Valera D, Torino GC. Sleep and mental health among youth experiencing homelessness: A retrospective pilot diary study. Sleep Health. 2024;10(1):54\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlessi EJ, Greenfield B, Manning D, Dank M. Victimization and resilience among sexual and gender minority homeless youth engaging in survival sex. J Interpers Violence. 2021;36(23\u0026ndash;24):11236\u0026ndash;59.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDurso LE, Gates GJ. Serving Our Youth: Findings from National Survey Service Providers Working Lesbian, Gay, Bisexual, Transgender Youth Who Homeless Risk Becoming Homeless. Williams Institute True Colors Fund Palette Fund; 2012.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBalsam KF, Molina Y, Beadnell B, Simoni J, Walters K. Measuring multiple minority stress: the LGBT People of Color Microaggressions Scale. Cultur Divers Ethnic Minor Psychol. 2011;17(2):163\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEastwood EA, Nace AJ, Hirshfield S, Birnbaum JM. Young Transgender Women of Color: Homelessness, Poverty, Childhood Sexual Abuse and Implications for HIV Care. AIDS Behav Published online Dec. 2019;21. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10461-019-02753-9\u003c/span\u003e\u003cspan address=\"10.1007/s10461-019-02753-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcCann E, Brown M. Homelessness among youth who identify as LGBTQ+: A systematic review. J Clin Nurs. 2019;28(11\u0026ndash;12):2061\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull. 2003;129(5):674\u0026ndash;97.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCochran SD, Bj\u0026ouml;rkenstam C, Mays VM. Sexual orientation differences in functional limitations, disability, and mental health services use: Results from the 2013\u0026ndash;2014 National Health Interview Survey. J Consult Clin Psychol. 2017;85(12):1111\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeinhardt LS, Stevens P, Xie H, et al. Transgender and gender nonconforming youths\u0026rsquo; public facilities use and psychological well-being: A mixed-method study. Transgend Health. 2017;2(1):140\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSanta Maria D, Hernandez DC, Arlinghaus KR, et al. Current age, age at first sex, age at first homelessness, and HIV risk perceptions predict sexual risk behaviors among sexually active homeless adults. Int J Environ Res Public Health. 2018;15(2):218.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKeuroghlian AS, Shtasel D, Bassuk EL. Out on the street: a public health and policy agenda for lesbian, gay, bisexual, and transgender youth who are homeless. Am J Orthopsychiatry. 2014;84(1):66\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTyler KA, Schmitz RM. A comparison of risk factors for various forms of trauma in the lives of lesbian, gay, bisexual and heterosexual homeless youth. J Trauma Dissociation. 2018;19(4):431\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArnett JJ, Žukauskienė R, Sugimura K. The new life stage of emerging adulthood at ages 18\u0026ndash;29 years: implications for mental health. Lancet Psychiatry. 2014;1(7):569\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarman-Adhikari A, Bowen E, Bender K, Brown S, Rice E. A social capital approach to identifying correlates of perceived social support among homeless youth. Child Youth Care Forum. 2016;45(5):691\u0026ndash;708.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBender K, Ferguson K, Thompson S, Langenderfer L. Mental health correlates of victimization classes among homeless youth. Child Abuse Negl. 2014;38(10):1628\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e2023_Youth_Count_Report. Published online. 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.nyc.gov/assets/dycd/downloads/pdf/2023_Youth_Count_Report.pdf\u003c/span\u003e\u003cspan address=\"https://www.nyc.gov/assets/dycd/downloads/pdf/2023_Youth_Count_Report.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRadloff LS, The CES-D, Scale. A Self-Report Depression Scale for Research in the General Population. Appl Psychol Meas. 1977;06/(3):385\u0026ndash;401.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKnight JR, Sherritt L, Shrier LA, Harris SK, Chang G. Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Arch Pediatr Adolesc Med. 2002;156(6):607\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBowleg L. The Problem With Intersectional Stigma and HIV Equity Research. Am J Public Health. 2022;112(S4):S344\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eErangey J, Marvin C, Littman DM, et al. How peer support specialists uniquely initiate and build connection with young people experiencing homelessness. Child Youth Serv Rev. 2020;119(105668):105668.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThulien NS, Kozloff N, McCay E, Nisenbaum R, Wang A, Hwang SW. Evaluating the effects of a rent subsidy and mentoring intervention for youth transitioning out of homelessness: Protocol for a mixed methods, community-based pilot randomized controlled trial (preprint). \u003cem\u003eJMIR Preprints\u003c/em\u003e. Published online July. 2019;19. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2196/preprints.15557\u003c/span\u003e\u003cspan address=\"10.2196/preprints.15557\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBudescu M, Sisselman-Borgia A, Torino GC. An Experimental Approach to Assessing the Attitudes of Social Service and Healthcare Employees toward the Homeless. J Soc Serv Res. 2021;47(2):245\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cem\u003eTable 1.\u003c/em\u003e Health Seeking Behaviors and Trust in Doctors (\u003cem\u003en\u003c/em\u003e = 147)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003en(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLast physical\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNever\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4 (2.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePast month\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e49 (33.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIn the past 6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e52 (35.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIn the last year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10 (6.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 to 2 years ago\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19 (12.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMore than 2 years ago\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5 (3.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDo you have a primary care doctor? (yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e92 (62.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDo you trust your doctors? \u0026nbsp;(yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e115 (78.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDo you talk to doctors about your feelings? (Yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e83 (56.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDo you talk to doctors about STDs? (yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e90 (61.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSee doctor if sick\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eM =\u0026nbsp;\u003c/em\u003e3.23 (1.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFollow up on mental health issue\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eM =\u0026nbsp;\u003c/em\u003e3.23 (1.54)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRegular checkups\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eM =\u0026nbsp;\u003c/em\u003e3.32 (1.50)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eShould have seen a doctor but did not? (yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e43 (29.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 2.\u003c/em\u003e Risky Behavior and Wellbeing among YEH (\u003cem\u003en\u003c/em\u003e =147)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eM (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDepressive Symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.22 (.55)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMental Inferiority\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.42 (1.36)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRisky Substance Use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.29 (1.07)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHow often do you use contraception?\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.46 (1.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNever\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e = 47 (31.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRarely\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e = 27 (18.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSometimes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e = 22 \u0026nbsp;(14.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMost of the time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e =21 (14.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAlways\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e=14 (9.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUse contraception in most recent encounter? (yes)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003en\u003c/em\u003e = 55 (37.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 3.\u003c/em\u003e Direct and Indirect Effect between Discrimination and Wellbeing and Health Behaviors (n = 147)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eRisky Sexual Behavior\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003eRisky Substance Use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 177px;\"\u003e\n \u003cp\u003eHealth Seeking\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003ePredictor:\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003eb(SE)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003eCI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003eb(SE)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003eCI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003eb(SE)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003eCI\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDirect effects:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e-.34 (.08)**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e-.52, -.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e-.17 (.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e-.39, .06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e-.12 (08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-28, .05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eEducation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e.15 (.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e-.20, .49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e.16 (.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e-.26, .58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e.27 (.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-.07, .59\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eBlack\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e.41 (.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e-.14, .96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e.65 (.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e-.01, 1.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e.49 (.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-.03, 1.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eLatinx\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e.14 (.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e-.52, .88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e.39 (.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e-.40, 1.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e.41 (.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-0.21, 1.03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e.41 (.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e-.18, .99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e.02 (.36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e-.70, .74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e-.15 (.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-.71, .41\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eLGBTQ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e.48 (.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e-.11, 1.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e-0.08 (.36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e-.79, .63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e.54 (.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-.007, 1.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eTGNC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e.52 (.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e-.34, 1.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e-.29 (.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e-1.28, .70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e.24 (.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-.43, 1.007\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eDepressive Symptoms (path b)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e-.42 (.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e-.97, .14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e.81 (.32)*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e.16, 1.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e.32 (.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-.18, .82\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eMental Inferiority (path c\u0026apos;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e2.92 (.88)*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e1.07, 4.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e-2.24 (1.07)*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e-4.36, -.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e.18 (.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-1.81, 1.46\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eMental Inferiority * Age\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e-.13 (.05)*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e-.21, -.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e.12 (.05)*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e.02, .22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e.01 (.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-.07, .09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDirect effect on Mediator (path a)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eMental Inferiority\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e.07 (.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e-.52, .65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e-.05 (.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e-.65, .54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e.04 (.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-.64, .55\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIndirect Effects (ab):\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eMental Inferiority (indirect)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e-.14 (.08)*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 86px;\"\u003e\n \u003cp\u003e-.30, -.01*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e.20 (.08)*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e.05, .62*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e.08 (.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e-.04, .22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 96px;\"\u003e\n \u003cp\u003eModel fit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eR\u003csup\u003e2\u003c/sup\u003e=.18\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eF\u003c/em\u003e(10, 112) = 2.41*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003eR\u003csup\u003e2\u003c/sup\u003e=.44\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eF\u003c/em\u003e(10, 120) = 10.65**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 177px;\"\u003e\n \u003cp\u003eR\u003csup\u003e2\u003c/sup\u003e=.16\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eF\u003c/em\u003e(10, 117) = 2.31*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 370px;\"\u003e\n \u003cp\u003e*p\u0026lt;.05; **p\u0026lt;.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 87px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-5333348/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5333348/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"Homelessness among youth in urban areas carries specific challenges because so many come from different geographic regions hoping for opportunities, but instead encounter added problems. Discrimination based on homelessness is a problem that has only recently been explored in youth experiencing homelessness (YEH). Discrimination based on different facets of one’s identity, including homelessness, is associated with health disparities, like sexually transmitted infections (STIs), including HIV. Our study explores the relationship between homelessness discrimination and risky sexual health behaviors among 147 urban YEH. Primarily non-white, YEH in our sample were an average age of 21 years old. We defined risky sexual behaviors as lack of contraceptive use and substance use. There was a significant direct path between discrimination and risky sexual behavior, with those reporting more discrimination also reporting being less likely to use contraception. There was also an indirect effect of discrimination on contraceptive use through depressive symptoms, suggesting that discrimination is associated with more risky sexual behavior by way of depressive symptoms. Higher levels of discrimination were directly associated with lower levels of risky substance use, as were higher levels of depressive symptoms. The direct path between discrimination and risky substance was moderated by age. In light of these findings, we argue that urban communities should be focused on reducing acts of discrimination and stigma around homelessness and improving access to housing. Resolving these urban social problems may go a long way in reducing large public health problems like STIs and the HIV epidemic.","manuscriptTitle":"Risk Behaviors and Sexual Health in The Context of Homelessness Discrimination in an Urban Sample of Youth Experiencing Homelessness","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-10 05:39:14","doi":"10.21203/rs.3.rs-5333348/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9b7deb76-64c7-4de9-8ce0-7bcf08afb50c","owner":[],"postedDate":"January 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-01-10T05:39:14+00:00","versionOfRecord":[],"versionCreatedAt":"2025-01-10 05:39:14","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5333348","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5333348","identity":"rs-5333348","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}