Blog: Investigating sexual & reproductive health experiences and decision-making of homeless women

This year, I was given the opportunity to present my research on women’s homelessness and sexual reproductive health (SRH) at the HSA Annual Conference 2023. This blog post provides a snapshot of my presentation, which focused on the theoretical lens that I am using to address the issue of women’s homelessness and SRH.

The current context

There is a stark knowledge gap on the lived experiences of homeless women, particularly in regard to their experiences of reproductive health decision-making. The literature that does exist on homeless women foregrounds the challenges that they face at every stage of their reproductive lives. These include adverse reproductive and maternal health outcomes (Corey et al, 2020; Stein et al, 2000), significant unmet need in accessing health services (Shar et al 2019) and difficulties in preparing for motherhood (Murray et al, 2020).

Gordon et al (2019) report that homeless women in the UK are twice as likely to become pregnant than women in the general population yet are less likely to receive antenatal care. Homeless women also face barriers in accessing antenatal care, such as negative stereotyping from healthcare providers and financial constraints (McGeough et al, 2020). Themes of surveillance, infantilisation, and a lack of sensitivity feature heavily in existing literature on homeless individual’s interactions with healthcare (Groundswell, 2022); this has been found to have consequences for how homeless women use services, suggesting that there are obstacles to access that go beyond practical barriers.

A reproductive justice framework

To begin to unpack some of these barriers, I argue for taking a reproductive justice approach to understanding homeless women’s SRH. Articulated by one of the movement’s pioneers Loretta Ross (2017), “reproductive justice is rooted in the belief that systemic inequality has always shaped people’s decision making around childbearing and parenting, particularly vulnerable women” (p291). It connects questions of reproductive justice to other social justice issues including housing stability, economic opportunities, and social care policies, drawing attention to the multiple ways that women are restricted in their decision-making practices (Roberts, 2015).
Originating in women-of-colour (WOC) grassroots health organisations in the 1990s, reproductive justice problematises the notion of ‘free choice’ and draws attention to the structural conditions which limit women’s ability to exercise choice and realise their rights (Morison and Herbert, 2018). It is intersectional at its core and contextualises the decisions that women make within the systems of oppression in which they are located; this makes it a powerful tool for debunking the assertations of neoliberalism and post-feminism that choices are available to all, by offering a more nuanced understanding of the reproductive lives of homeless women.

Structural stigma

My research focuses on stigma as one form of inequality that homeless women face. International and UK-based research suggests that experiences of stigma, social exclusion, marginalisation and dehumanisation characterise homeless people’s healthcare experiences and prevent access to future care (Gunner et al, 2019; Magwood et al, 2019). I take up Imogen Tyler’s (2020) call to adopt a top-down approach to understanding stigma. In particular, drawing upon her theorisation of stigma as a mode of power and form of governmentality. This approach re-politicises stigma by showing how it is deliberately enacted at an institutional level and is perpetuated by structures. Shifting the perspective to focus on stigma as a deliberately produced force allows for stigma to be used as an analytical tool, opening up ways of thinking about how power is enacted upon certain groups in order to devalue them.

In my research context, stigmatising narratives present homeless women as deviant, criminal and ultimately unworthy, having caused their homelessness through personal failures. Through the lens of stigma, the research aims to interrogate the ways in which women’s bodies are controlled by narratives which justify policies that constrain reproductive choices and raise questions about the implications that this has for homeless women, who occupy multiple stigmatised positions.

What could social justice look like?

Discussions on injustice call for a theorising of what justice could look like, in order to begin to create strategies for dismantling inequities in health. I believe that taking a reproductive justice lens, which renders visible the structural causes of ill-health and homelessness, offers the tools to do this. For example, it draws attention to the interconnected nature of issues such as a lack of social housing, poverty, stigma and the reduction of the welfare state.

As emphasised by NICE (2021) “Homelessness is a public health issue, not only a housing issue”; a reproductive justice approach allows for our thinking to go beyond narratives of individualised decision-making, ‘bad choices’ and personal failures. It opens up space for thinking critically about the impacts of structural stigma on decision-making, as one form of injustice that homeless women face. By doing so, we can begin to see effective access to healthcare as more than just whether a service is available, but to think about the resources that women need to make use of services, and the importance of designing and carrying out services so that all individuals are treated with care, dignity and respect.

REFERENCE LIST

Corey, E., Frazin, S., Heywood, S. and Haider, S. (2020) Desire for and barriers to obtaining effective contraception among women experiencing homelessness, Contraception & Reproductive Medicine, 5(12), pp. 1-7.

Gordon, A. C. T., Lehane, D. and Burr, J. (2019). Influence of past trauma and health interactions on homeless women’s views of perinatal care: a qualitative study. British Journal of General Practice, 69(688), p. 760-767.

Groundswell. (2022). Groundswell (2022) #HealthNow Literature Review Update: How has patient experience changed for people who are homeless? Available at: https://groundswell.org.uk/wp-content/uploads/2022/09/Patient-experience-literature-review.pdf.

Gunner, E., Chandan, S. K., Yahyouche, A., Paudyal, V., Marwick, S., Saunders, K., Burwood. (2019). Provision and accessibility of primary healthcare services for people who are homeless: A qualitative study of patient perspectives in the UK. British Journal of General Practice, 69(685), pp. 526-536.

Magwood, O., Leki, V. Y., Kpade, V., Saad, A., Alkhateeb, Q., Gebremeskel, A., Rehman, A., Hannigan, T., Pinto, N. Sun, A. H., Kendall, C., Kozloff, N., Tweed, E.J, Ponka, D., Pottie, K. (2019). Common trust and personal safety issues: A systematic review on the acceptability of health and social interventions for persons with lived experience of homelessness. PLOS ONE, 14(12), pp. 1-30

McGeough, C., Walsh, A. and Clyne, B. (2020). Barriers and facilitators perceived by women whilst homeless and pregnant in accessing antenatal and or postnatal healthcare: A qualitative evidence synthesis, Health Soc Care Community, 26, pp.1380-1393.

Morison, T., and Herbert, S. (2018). Rethinking ‘Risk’ in Sexual and Reproductive Health Policy: the Value of the Reproductive Justice Framework. Sexuality Research and Social Policy, 1(4), pp. 1-12.

Murray, S., Theobald, J., Haylett, F. and Watson, J. (2020). Not Pregnant Enough? Pregnancy and Homelessness, The Social and Global Studies Centre, RMIT University. pp. 1-77.

Roberts, D. (2015). ‘Reproductive Justice, Not Just Rights’, Dissent Magazine, Fall 2015 [Blog], Available at: https://www.dissentmagazine.org/article/reproductive-justice-not-just-rights (Accessed 18th February 2022).

Ross, L, J. (2017) Reproductive Justice as Intersectional Feminist Activism. Souls, 19(3), pp. 286-314.

Shar, P., Koch, T., and Sign, S. (2019). The attitudes of homeless women in London towards contraception, Primary Health Care Research and Development, 20 (131), pp. 1-5.

Stein, J.A, Lu, M. C., Gelberg L. (2000). Severity of homelessness and adverse birth outcomes, Health Psychology, 19 (6), pp. 524-534.

Tyler, I. (2020). Stigma: The Machinery of Inequality. Zed Books.