Birth Control Access and Selection Among Homeless Youth in the United States: A Review

Background and Purpose: Homeless youth become pregnant at five times the rate of the general population and engage in myriad sexual risk behaviors. Multiple systems of education and care struggle to adequately address their sexual and reproductive health needs. Yet, a growing body of literature exists on the factors affecting homeless youths’ access and selection of birth control, prompting the current review, in order to understand this process and inform development of better attuned sexual and reproductive health approaches.  

Methods: Using a systematic search we retrieved 203 articles from three robust databases: EBSCO, Public Health ProQuest, and PubMed. Keywords used include homeless youth, homeless teenagers, street youth, and birth control. “Homelessness” is defined using a nationally recognized definition provided by the U.S. Department of Housing and Urban Development. “Birth control” is defined broadly, encompassing any form of contraceptive method, and “youth” refers to adolescents and emerging adults aged 12-25 years. To meet the inclusion criteria, articles needed to 1) appear in peer-reviewed journals; 2) report findings from original research pertaining to the experience of accessing and selecting birth control among homeless youth; 3) be written in English; and 4) use data collected in the United States. Of the 203 articles found in our initial search, 23 met criteria for review inclusion.

Results: Key findings emerged across socio-ecological levels. Intrapersonal factors impacting access and selection of birth control include barriers and facilitators to condom use, the differential impact on homeless youth of hormonal birth control side effects, psychosocial characteristics such as social support, and past experiences such as abuse, neglect and substance use. Further, female youth who have never been pregnant or who have anti-pregnancy attitudes are more likely to use contraceptive methods, when compared to those who have not. Interpersonal factors that emerged include one's level of relationship commitment and peer/familial social networks. Youth with a higher relationship commitment report increased sexual risk taking and positive views towards teen pregnancy. Homeless youths’ use of contraception and attitudes towards pregnancy are also influenced by parent-child communication and the presences of peers in their network promoting healthy sexual behaviors. Structural barriers to birth control access emerged, including the lack of culturally competent and adequate sexual and reproductive health care for homeless youth, and the devastating effect of economic insecurity on need for survival sex and on exposure to violence.

Conclusions and Implications: Findings suggest that there are numerous opportunities to decrease sexual risk taking among homeless youth, from reaching them through influencers in their social networks, to providing attuned sexual health education and support around contraceptive use, to giving their parent(s) culturally-tailored support in how to address their children’s sexual health needs prior to and during adolescence. This review also suggests improving broader social and system responsiveness to meet the needs of homeless youth to allow for the prioritization of safe sex practices. Implications of this study include the need for multilevel, comprehensive interventions to assist homeless youth in the process of accessing and selecting birth control.