The present study has provided reports of cisgender and transgender women living on the streets who have experienced episodes of sexual violence, risky sexual practices and exposures to STI. The reports in this study show that physical, psychological, sexual and symbolic violence are routinely experienced by the participating women. A study conducted in Los Angeles, United States, found that the main forms of violence experienced for homeless women, in the last six months, were psychological violence (87%), physical violence without weapons (48%), physical violence involving weapons (18%), and sexual violence (18%) [21]. A higher rate of sexual assault and forced sex is found among the homeless population, to the detriment of race/ethnicity and sexual orientation, with higher rates among mixed race people, cisgender women and lesbian, gay, bisexual and transsexual populations [11]. Young transgender/expansive genders, living longer on the streets and with an earlier age of homelessness, are significantly associated with living with sexual assault and forced sex [11].
Transactional sexual practices were reported as a strategy for survival and obtaining resources by this group, including food, drugs, money, or shelter. Accordingly, the literature has estimated that the practice of transactional sex is a common and may reach 50% among homeless people [22, 23]. However, many of these people perform transactional sex against their own will, motivated by desperation and a lack of alternatives [23], as suggested in the speeches of the participants in this study.
Thus, many homeless women submit to sexual intercourse to ensure security, even if this costs them the traits of utility and obedience in terms of their bodies [24]. Transactional sex is therefore highly stigmatizing and has negative effects on the health of homeless people, increasing the risk of sexual aggression, suicide attempts, depression, criminal behavior, STIs acquisition, unplanned pregnancy, etc. [22].
Violence against women living on the streets is anchored, above all, in social sex relations in which patriarchy, power relations and the hierarchical constructions of masculinity and femininity are the predominant and generalized drivers [14]. Thus, we find that women living on the streets are even more exploited in this condition. The burden imposed by their stigma and marginalization by society, plus the socially constructed class and racial conditions, perpetuate the most diverse expressions of violence [25] that these women experience in their daily lives, from insults to the serious forms of violence seen in the testimonies described above. In addition, higher rates of STIs and substance use are found among homeless women with a history of intimate partner violence than women who have not suffered violence [1]. A body that is already systematically appropriated as a thing, as a commodity, is seen even more as a public commodity when exposed in a space expressed by pauperization and racialization, such as living on the streets.
The vulnerability of women on the streets contributed significantly to the risky sexual practices and STIs exposures in the study population. We found a higher exposure to STIs in transgender women than cisgender women. A Brazilian study showed that transgender women was eight and five times more likely to test positive for HIV and syphilis, respectively, than cisgender women and men [19]. The STIs can contribute to higher morbidity and mortality in the homeless population due the lack of care and access to health services [26].
Exchanging sex for money, food, drugs, shelter or other unmet needs contributes to an increased risk of exposure to STI/HIV [27]. A greater association between unprotected sexual practices and the risk of acquiring STIs has been detected among women with a history of sexual abuse in childhood and adulthood [1], in homelessness, with psychiatric disorders, or amid alcohol and drug use [1, 19, 27], including habits of sharing injectables, and incarceration history [1]. The practices of unprotected anal sex are also more likely among homelessness, as well as drug abuse/alcohol binging and exchanging sex for money/drugs [1].
The vulnerability of homeless women in relation to lower condom use highlights an historically unfavorable gender inequality, while their exposure to sexual violence hinders their autonomy to make decisions, including in the negotiation of protected sex. These facts do not occur in isolation and are based on the patriarchal system, which gives sexual rights to men over women, practically without restrictions; it is embodied and represents a power structure based on both ideology and physical force [16]. Women, then, are “reified”, and their bodies are appropriated by men, who have social authorization, perpetrated by a pact of social silencing to dispose of them [16].
Homeless women have limitations in their access and use of health services, including sexual and reproductive health care with regard to contraception, prenatal care, appropriate STIs treatment, and access to safe abortion [6, 8]. The nonuse of these services may be related to a lack of knowledge [8, 11], to not knowing where to go to receive assistance [11], or to a lack of health insurance [11], fear, stigma, the possibility of suffering discrimination by health professionals [8] or the fear of becoming involved in the legal system [11].
Thus, when considering the significant barriers to access to sexual and reproductive health, it is essential to develop strategies for welcoming, creating bonds with and promoting the accessibility of the health system among homeless women. The vulnerability of homeless women to STIs highlight the importance of offering HIV/STIs testing, counseling, and HIV risk prevention interventions and suggest that interventions should be tailored to the needs of specific marginalized subgroups of homeless women [28], such as sexual minorities and substance misusers [19].
Addressing STIs prevention needs of homeless women can be enhanced through the integrating sexual health, and other health references services to homeless population [1]. A Brazilian study has found that gynecological care and sexual and reproductive health care in a Street Outreach Office represent an opportunity for welcoming and comprehensive care to the women being assisted, allowing the identification and care of the health needs and different demands of this population [9].
The development of intervention strategies and health education in shelters, foster homes, and drop-in centers [11] can contribute to the recognition and acceptance of the health needs of homeless women through the integration of intersectoral and networked actions. Peer navigators and small group discussions may encourage women to seek health services in the face of the lack of trust and stigma they have experienced and promote a protective network of social support [11]. However, it is also necessary to formulate public programs and policies that promote the possibility of social restructuring in the lives of these women.
The care for homeless women extends from the historicity of welcoming the human being, of the denial of rights throughout or of a good part of life. It is essential to respect people’s subjectivity, uniqueness, suffering, frustrations and desires, especially of women who experience the cascade of power and domination relations that are socially constructed in various aspects. It is essential to understand that the situations that lead women to enter the streets are segments of a social construct that objectively demonstrate the incompetence of the state in managing the problems of social reproduction and the omission and consent of society in the face of physical, economic, psychological, and social violence, namely, the social and symbolic situation in which homeless women live [24].
The present study has limitations because it did not interview the focal women in the context of the streets but in a social shelter. However, the fact that these women were in a shelter provided a safe environment for the researcher and the study participants. We did not had access to medical records to obtain data about the health conditions and STIs. The rates of STIs may be underestimated because of shame and stigma to share this information with the researchers. Despite these limitations, the study has identified deep gender inequities, exposures to violence, abuses, the use of sex as a survival strategy, and conditions that violate the human rights of these women, demonstrating the importance of actions and public policies aimed at this population.
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