Boston’s Homeless Women Struggle to Navigate Healthcare System

Last year, the City of Boston said the homeless population had gone down three percent. Despite the decline, homelessness in the city remains at just over six thousand—and most of them eventually will need medical care. Women on the street need specialized medical care. Boston provides an array of medical assistance to help them.

Samantha leans against the entrance to the parking garage adjacent to St. Francis House—the largest day shelter for the homeless in Massachusetts. Samantha lights her cigarette. The 30 year old is originally from New York but has been living in Boston for about a year. Samantha, no last name given, says she has been homeless almost two years.

She’s barely five feet tall, with long, dark, curly hair tied up in a ponytail. Samantha wears a black down vest and a grey hoodie. Although she is not wearing makeup, her face is adorned with a single labret piercing.

Samantha comes to St. Francis House every day. She uses the facilities to shower and get a free meal. Samantha says does not need their medical services, because she has insurance through MassHealth—a public health insurance program similar to Medicaid that provides health care for low-income people with certain criteria, like being HIV positive, having mental health issues or a disability. Samantha does not elaborate on her eligibility. Like many on the street, she can be defensively vague about her personal circumstances.

Anyone entering St. Francis House first has to go through a security checkpoint. The guards scan all bags,  people pass through a metal detector and if the machine beeps the guards make a second pass with a handheld detector checking for anything dangerous. The homeless carry a lot on their person, so the process is slow. Once inside, the general clinic and women’s clinic are located on the second floor.

Rachel Klein is a licensed independent clinical social worker, serving as the Women’s Center supervisor and mental health clinician at St. Francis House. Klein shares her office in the facility with the general clinic. Klein’s office doubles as a storage room stacked with free sanitary napkins and tampons, and a large salad bowl of condoms available to whoever enters.

Most of St. Francis House is covered with informational posters.

“Folks are really marginalized and it’s a really vulnerable population. Folks have a lot of trouble getting from point A to point B,” says Klein, “…the homeless population has a really unique set of needs that are often not met.”

Klein says in many ways the biggest issue homeless women face is not the availability of accessible health care—institutions such as St. Francis House are free, and she says there are enough doctors and other clinics around Boston. The problems are transportation and housing. Homeless people often do not keep doctor appointments simply because they cannot get there.

To encourage participation, St. Francis House offers MBTA passes to its patients with transportation needs.

Housing is important when homeless applicants must undergo certain exams, such as, a colonoscopy, which requires the patient to take laxatives and have ready access to a bathroom for up to 24-hours. For the homeless, this is a considerable obstacle. Often they opt out of the colonoscopy procedure because they do not want to be at a regular homeless shelter for a day with stomach issues that requires both rest and easy access to a bathroom.

St. Francis House does offer housing for both men and women (they can stay as long as they want, but she says people usually transition out once they find a job or other situation,) however; Klein says women rarely use the rooms. The problem is that many women based on past assaults do not feel comfortable sharing housing with men.

“A lot of times in shared living spaces I think women have struggled maybe with their relationships in there and how close quarters it is,” Klein says. “Pretty much all [other] shelters are gendered segregated, and so [for] somebody who has not been around guys for a while…probably less comfortable for the ladies. Which is sad.”

Klein also says there is an underlying mistrust of the medical system. Homeless women, who disclose they are HIV positive or sex workers, feel judged by their attending medical practitioners when they come in for a check-up.

“We try super hard to be low barrier, to be non-judgmental. We serve anyone who comes through the door,” Klein says. “Nobody has to disclose their health status to us if they don’t want to. Anyone can come into the building and get care.”

Tears from the cold wind are running down Saline’s eyes as she stands outside of St. Francis House waiting for a hot meal. Saline comes to St. Francis House frequently, but she says she’s not currently living on the street after being homeless “all her life.” Still she would not say where she currently resides.

Saline has mixed feelings about accepting help, she explained while waiting for a hot meal from St. Francis.

Saline had a heart attack about two years ago; she was treated and then recovered at Tufts Medical Center. Tufts is close to St. Francis and provides a wider range of medical care than available in most other communities around the country. St. Francis House assists patients like Saline, who may  be unable to pay for their care.

Although her initial medical costs appear to be covered, Saline says she cannot afford the ongoing medicine she still requires. “I suffer from high blood pressure…whenever they [prescribe] me medication, they can’t give it to me,” Saline laments that she cannot afford to pay for her prescriptions.

Saline cries as she  talks about her heart attack. She says it is harder to be a homeless woman than to be a homeless man. She broke down, saying “Jesus, God…why take me, if you can’t give me what I need?”

***

Minerva Bolduc works at Women’s Lunch Place on Newbury Street. Bolduc is the program’s Advocacy Manager, and oversees the needs of homeless women who come in from seven in the morning until two in the afternoon.

This includes help accessing food stamps, finding housing, completing job applications, and so on. The space, although focused on the cafeteria, has multiple purposes. Women come to eat, but can also rent a bed to nap, take a shower, do their laundry, create arts and crafts, use the phones or computers, read in the library, or seek other assistance from staff.

Earlier that morning, Bolduc reflected on the importance of women experiencing homelessness being treated well. She described  two women she overheard entering the program speaking on the elevator.

“I don’t know if she was her daughter, but she was cleaning, doing something to [the other woman’s] hair, and she says ‘you know, you look homeless today,’” Bolduc said, ‘it was interesting, because they don’t want to look homeless…even when they use drugs, they use crack, they want to look good.”

Minerva Bolduc holds up a bag filled with toiletries given to the women who come into the center.

The do not just care for their appearance, however. They have to care for their health.

Bolduc thinks the biggest obstacle women face in seeing the doctor is fear of the unknown. For some patients at Women’s Lunch Place, it has been years since they have seen a primary care provider—the stress is heightened when there is a history of drug use or prostitution. Women’s Lunch Place partners with health care Without Walls to provide medical attention to all who enter the shelter.

While helping one woman find housing, Bolduc had to find insurance for her as well.

“Most of the time she did prostitution, stayed on the street. Then I [helped] her with MassHealth…then, I said how about a physical? Then she said, ‘Minerva, who knows what I have,” Bolduc said. “I said [to myself], I don’t know if I’m doing something right [encouraging testing.]”

Although worried the woman might become upset with the knowledge of some physical ailment, Bolduc later accompanied her to every doctor’s appointment.  It turned out, “she…only had a little bit of high cholesterol,” Bolduc said, but she stressed that it is very important the women who come to the shelter are seen by a doctor.

One of the biggest threats to women’s health is from others. An overnight annual homeless census count by the U.S. Department of Housing and Urban Development found that of 554,000 homeless people nationally in 2017, about 87,000 reported they were victims of domestic violence.

Sara Pacelle is the associate director of development at the non-profit Boston Health Care for the Homeless Program. The program operates out of a four-story building across from Boston Medical Center. Pacelle says about one-third of the patients the program treats are women.

The first floor of the agency is bustling like a bus terminal. The main area is mostly an open floor plan; people waiting in the lobby sit and watch all the comings and goings. There is a dental care center, an in-house pharmacy, and a “Supportive Place for Observation and Treatment” for those who come into the clinic overdosing.

Their mission is to only offer primary care—any serious conditions, she says, are referred to Boston Medical, in part, thanks to a relationship they have cultivated over the years. “If a woman came in here and we saw that she was in an advanced stage of cancer…we would send her to the hospital,” says Pacelle.

Although her program treats both men and women, Pacelle says women experience unique health care challenges and must be treated accordingly.

“We find that women experiencing homelessness tend to have a lot of other things on their mind, and health is like one of the last things. They have a greater need to survive on the street. There is a lot of violence on the street,” says Pacelle.

Violence, Pacelle says, is the major reason women do not seek health care or preventive care. Often, the women are intimidated by the possibility they may run into their abusers while at the clinic, or are worried they may be asked to report their abuse to the police. Many homeless people distrust the authorities.

To create a safe environment that encourages women to take care of their medical needs, the program offers a women’s-only event on Saturday mornings at seven called “HER Saturday: Health Empowerment Resources.”

HER Saturdays’ services include lifesaving pre-cancer screenings, such as pap smears and mammograms, as well as, activities to promote better hygiene and well-being like pedicures and yoga. The staff is all women.

“We wanted a safe place where a woman could come, where she could maybe just hang out on Saturday morning,” says Pacelle. “We have coffee and fresh snacks.” HER Saturdays have been offered for a couple years now, with about 100 attendees every week.

With the frigid Boston winters, hypothermia and frostbite are common problems for homeless people.  On HER Saturdays women are offered warm clothing. The staff will ask, “We see that you don’t have winter boots. Do you need boots?  Gloves? Let us get you some gloves,” says Pacelle.

Another setback for women and men entering the facility, Pacelle explains, is the current political climate with regards to the standing of undocumented immigrants. “There’s also…women [who are] undocumented, and so they do not feel comfortable coming here because we ask for their name and information,” says Pacelle.

Their first goal is to encourage care, so they will treat clients anonymously, although that is not ideal, she says. The program needs patient names, so Medicare and Medicaid will reimburse them for the care costs—otherwise, the clinic will have to sustain its treatments  with money they have acquired through private fundraising.

“Some of our female patients have children, and it is really hard to take care of yourself when you are taking care of your child. Your child is your first consideration. That is another reason why moms here put themselves last,” says Pacelle. “They de-prioritize themselves.”

***

Geraldine is on her way to her doctor’s appointment at Tufts. She says she’s lucky she has a home. “People who don’t have a home, I don’t know how they… it’s cold out there…it’s too cold out here,” says Geraldine.

While she doesn’t have to pay for medical services at Tufts, “I don’t get a pap smear anymore, because I’m not going to have any babies, so I don’t get that,” Geraldine reasons.  While health care workers explain to her about the risks of cervical cancer and breast cancer, she attributes her lack of medical needs to the fact that she does have a place to stay.

A study conducted in Boston by the National Center for Biotechnology Information found numerous factors that keep homeless women from getting preventative care, like a pap smear.

A pap smear is a mildly invasive test that checks cells from the cervix for abnormalities. These abnormalities may include or lead to cervical cancer. Certain strands of the human papilloma virus (HPV) are often associated with cervical cancer and can be found through a pap smear. When found early, the chances of the cells turning into cancer are extremely low. A yearly test is recommended.

Many  factors keep women from pap smears, ranging from the “convenience of visit” to the “fear of results.”

Homeless women, according to the study, often have had only one pap smear in their life or are not sure if they have ever had one. Most homeless women will reject a test if a male physician will conduct it. They fear the results of the tests; they fear being judged.

The Woods-Mullen Shelter is an emergency shelter located behind the Boston Health Care for the Homeless Program. It holds 200 beds for women over the age of 18. According to its website, “in the winter months, overflow beds are available.”

Klein says it is ideal that Woods-Mullen is located right behind BHCHP, allowing women who stay there safe housing, clean clothing, toiletries, and the opportunity to speak with a case manager. The women are also encouraged to get a primary care check just next door. They also have an option to go to the clinic in the shelter.

Boston Health Care for the Homeless is one of the country’s largest and most comprehensive health care program for the homeless and runs most of the clinics in Boston. One of the early initiatives of BHCHP was a tracking system for their patients, providing accessibility for homeless women who often are e transient, to show up at any clinic and have their medical history available.

“We have clinics at all these locations around the city, mainly these are shelters. We run the clinic in the shelter,” says Klein pointing to a map of Boston. “We have electronic medical records that are integrated. So, if one of our patients comes here to our clinic one day, and then [goes] and sees [St. Cecilia, our clinic] over at St. Francis House, and then goes to the Woods-Mullen clinic the next day…we know exactly what kind of care they are getting. Which is unique.”

Woods-Mullen is one of the many answers to the issue of accessibility and location homeless women face; still women cannot stay there if they have children.

***

Despite not providing housing, the Cambridge Women’s Center fills an important gap in the housing shelter dilemma-where to go during the daytime. The Center provides women opportunities to heal, learn technical and life skills and resources for housing, employment and health services. It is the oldest community-based center for women in the nation, and the building is a multi-purpose safe space and learning center.

The center offers a variety of resources and programs, such as weekly open luncheons, yoga classes, and rehabilitation and therapy events such as Healing Through Creative Arts for victims of sexual violence and Women’s Narcotics Anonymous meetings for those recovering from drug and alcohol abuse.

Jessye Kass is the Director of Programs, Volunteers, and House Management at Cambridge Women’s Center. The center currently only has two paid staff, so Jessye’s job is to oversee the 70-some weekly volunteers who come to assist and lead groups.

Cambridge Women’s Center is not a housing shelter, but functions as a resource for women “experiencing homelessness.” While they can’t spend the night, homeless women can bathe, cook, use computers and find solace from the streets. All services are free. There are regular events at the center open to any self-identifying women in the community. Jessye emphasizes that the women who come into the center should not be defined by their current situation.

The Cambridge Women’s Center  functions out of a three-story house that has served women since 1971. There’s a living room on the ground floor that radiates female empowerment, with books for those visiting to read such as “I am Malala” and “My Body, My Choice.”

“We are a space only, we meet people where they are at. We are two paid staff…we simply do not have the capacity to do more than provide space and support on a daily management,” Kass says.

“Because of the ways women are [sexually] victimized at a much higher rate than male-bodied…individuals,” Kass says, “we often have women who choose not to shower and to keep themselves with a really intense smell so that it wards off other people.”

Chronic homelessness, as defined by Housing and Urban Development, is when an individual either has been homeless continuously for a year or has had at least four instances of homelessness in the past three years.

“Being homeless is expensive. Another thing is access to feminine hygiene products. That is something that is expensive and adds up,” says Kass. She says supplemental security income is $733 a month, and nowhere near enough for women to survive on.

Unlike government-subsidized programs, the Cambridge Women’s Center is completely donor based. And it’s not sustainable.

“[We are] in desperate need of funds. We are in survival mode. No one has lasted in my position more than 11 months in the last seven years…I work at least 60 hours a week. I’m not going anywhere. I knew what I was getting myself into,” Kass says, “We have seen incredible change in the last year…but two paid staff is just not enough…[but] that’s all we the funds for.”

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